Burdensome bones: Optimising the approach to osteoporosis in primary care

an overview of osteoporosis, including fragility fractures, how to identify at-risk populations, the impact of osteoporosis and current gaps in osteoporosis care.

1. Understand the link between osteoporosis and fragility fractures
2. Recognise the health and economic impact of osteoporosis
3. Identify the unmet need in primary care regarding osteoporosis

Definition of osteoporosis

Osteoporosis is a disease characterised by low bone mass and structural deterioration of bone tissue leading to an increase in bone fragility and susceptibility to fracture.

It is a progressive and asymptomatic disease that usually presents only after a fracture has occurred

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Osteoporosis and fragility fractures

A fragility fracture results from mechanical forces that would not ordinarily result in fracture, known as low level (or ‘low energy’) trauma.¹

An osteoporotic fracture is a fragility fracture that has occurred as a consequence of osteoporosis. It is defined as ‘fracture associated with low bone mineral density’.

 Important! Osteopenia is the stage before osteoporosis when a bone density scan shows lower bone density than the average for the patient’s age, but not low enough to be classed as osteoporosis.⁴ Osteopenia does not always lead to osteoporosis.

  Low level trauma = forces equivalent to a fall from a standing height or less

 Osteoporosis and fragility fractures are very common in those over 50.

Risk factors for fragility fracture

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The impact of fractures on cost and mortality

Osteoporosis affects 3 million people in the UK and over 500,000 people are hospitalised due to fragility fractures every year. 1 in 2 women and 1 in 5 men over the age of 50 are expected to break a bone in their lifetime because of osteoporosis.

Hip fracture is the most common reason for admission to orthopaedic wards with an estimated UK annual incidence of 101,000 in 2020. It is usually caused by an osteoporotic fragility fracture in an older person with osteoporosis and osteopenia.

Hip fractures are associated with high mortality; 6.7% in the first month and approximately 33% at 12 months. This is in part because many of these people have other long-term conditions or may be living with frailty, rather than the hip fracture itself.

Up to 75% of patients are admitted from home and approximately 10–20% of those will move to institutional care. This figure has been projected to be up to 15,000 patients in 2020.

Direct medical costs from fragility fractures to the UK healthcare economy were estimated £1.8 billion in 2000 and are expected to increase to £2.2 billion by 2025, and with most of these costs relating to hip fracture care. 

The rising burden of fragility fractures in the UK

The number of fragility fractures in the UK is expected to increase.

Type of fracture	2010	2025
Hip fractures	79,000	102,000
Vertebral fractures	66,000	84,000
Forearm fractures	69,000	84,900
Other fractures	322,000	411,300
Total fractures	536,000	682,000

 Less than one third of the patients experiencing the estimated 500,000 fragility fractures per year receive bone protecting treatments.

The economic burden of osteoporosis in the UK

The cost of osteoporosis (excluding value of QALYs lost) is estimated to rise from £4.4 billion in 2010 to £5.5 billion in 2025.

The cost of osteoporosis including value of QALYs lost is estimated to increase from approximately £11.5 billion in 2010 to £14.0 billion in 2025.

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NICE recommend those who have experienced a fragility fracture should have their risk of fracture assessed.

In 2016, 97% of hip fracture patients received a bone health assessment. However, treatment was assessed as inappropriate in 21.6% of those patients. 

Most osteoporotic fractures occur in women who do not meet the WHO definition of osteoporosis
The WHO defines osteoporosis as a bone mineral density of 2.5 standard deviations below the mean peak mass (average of young healthy women) as measured by dual-energy X-ray absorptiometry applied to the femoral neck and reported as a T-scoreT-score of -2.5 or below = osteoporosisT-score between -1.0 and -2.5 = low bone density or osteopeniaT-score of -1.0 or above = normal bone density

Patients are not receiving bone protecting treatment
Less than one third of patients in the UK experiencing the estimated 500,000 fragility fractures per year receive bone protecting treatments21% of patients receiving bone health assessments are not being treated with bone protection

Adherence to osteoporosis treatments are low
At 3 months, 74% of patients continue to take their medicinesAt 12 months, only 14% of patients are adhering to their medicines

The proportion of older people is increasing
In 1998, 15.9% of patients were 65 years or olderIn 2018, 18.3% of patients were 65 years or olderIn 2038, 24.2% of patients are expected to be 65 years or olderOne third of over 65s fall at least once each year and 255,000 result in emergency admission

 Important! Identifying patients in a systematic way could prevent up to a quarter of all hip fractures, which equates to almost 20,000 hip fractures a year.

NICE. NICE impact falls and fragility fractures. July 2018.