Economic Impact of Osteoporosis Related Hip Fractures in Bahrain. A Systematic Review
Mir Sadat-Ali1, 2, *
Identifiers and Pagination:Year: 2021
First Page: 332
Last Page: 335
Publisher Id: TOPHJ-21071901
Article History:Received Date: 16/1/2021
Revision Received Date: 13/4/2021
Acceptance Date: 19/4/2021
Electronic publication date: 24/08/2021
Collection year: 2021
open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Fragility fractures are common due to osteoporosis and there is very limited data on hip fractures from the Middle East in general and Kingdom of Bahrain in particular. The aim of this paper is to review the published data of femoral fractures in the Middle East and extrapolate the financial burden of osteoporosis related hip fractures in Bahrain and suggest some course of action for the region in controlling the fragility fractures.
An extensive search was performed on published studies on hip fracture from 1990 to 2020 by a Medline, EMBASE the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews and the Science Citation Index, Bahrain Medical Bulletin, Qatar Medical J, Oman with the key words: Osteoporosis, osteopenia, fragility hip fractures. The inclusion criterion was studies published during 1990-2020 describing the prevalence of osteoporosis and proximal hip fractures in patients with ≥50 years, from the Kingdom of Bahrain, Saudi Arabia, State of Kuwait, Sultanate of Oman, United Arab Emirates, State of Kuwait, Iraq, Iran, Turkey and the State Hashemite Kingdom of Jordan. Based on the fractures per 1000, an average was taken and extrapolated for the Kingdom of Bahrain and direct and indirect costs were assessed.
A total of 19 studies were selected for analysis from 10 countries. The average prevalence of postmenopausal osteoporosis was 29.37±6.97% (Range 20.2 to 38.5). In these 10 countries, 252.411 million people live, with an average of 28.56% suffering from osteoporosis. A total of 72.088 million are at risk of having a fragility fracture. The prevalence of fragility fractures of the proximal femur in six countries means prevalence is 4.41/1000. With this average, it is extrapolated that femoral fractures due to osteoporosis costs Bahrain yearly a total of BD 5.31 million.
The prevalence of Osteoporosis is going to increase in Bahrain as the population is aging. This will further increase the economic impact of taking care of elderly patients with osteoporosis and related fractures. Early intervention to diagnose and treat this aging population will reduce the cost and save lives.
Osteoporosis is a major issue in the developing world, which is causing concerns on the financial as well as social aspects. The reported incidence of post menopausal osteoporosis among Saudi Arabian women was reported to be 33% and men 39% [1, 2]. A recent published report from the Kingdom of Bahrain suggested that the prevalence of osteoporosis is 38% [3, 4]. Osteoporosis has always been under diagnosed hence under treated. Even though the health care authorities and societies have promoted awareness of osteoporosis and its complications but still wide gaps remain in the ideal treatment [4, 5]. These figures did not change much as a recent study showed that only 27.7% women were treated with osteoporosis medications post fragility fractures within 12 months of the index fracture and 72.2% were left untreated . A fragility fracture involving proximal femur is the most devastating injury leading to serious consequences and 28% mortality within the first year. In those surviving the fracture episode, the morbidity is high with loss of independent mobility and 10-12% being assigned to post acute care facility were readmitted within the first 6 weeks .
There is limited literature on the fragility femoral fractures from the Middle-East countries. Bubshait and Sadat-Ali (2007)  reported a prevalence of 5.7 femoral fractures per 1000 population over the age of 50 years and recently, Sadat-Ali et al. (2015)  a prevalence of 5.8/1000 population. The US Preventive Services Task Force (USPSTF) after extensive research and reviews found convincing evidence that bone measurement tests are accurate for predicting osteoporotic fractures in both women and men. The objective of this review is to analyze the prevalence of osteoporosis and related fractures and extrapolate the prevalence of femoral fractures due to osteoporosis in Kingdom of Bahrain and assess the cost and find ways to prevent both.
A meticulous search was performed on published studies on a hip fracture from 1990 to 2020 by a Medline, EMBASE the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews and the Science Citation Index, Bahrain Medical Bulletin, Qatar Medical J, Oman with the key words: Osteoporosis, osteopenia, fragility hip fractures. The inclusion criteria were studies published during 1990-2020 describing the prevalence of osteoporosis and proximal hip fractures in patients with ≥50 years, from Kingdom of Bahrain, Saudi Arabia, State of Kuwait, Sultanate of Oman, United Arab Emirates, State of Kuwait, Iraq, Iran, Turkey and State Hashemite Kingdom of Jordan. Based on the fractures per 1000, an average was taken and extrapolated for the Kingdom of Bahrain and direct and indirect costs were assessed. Data were analyzed using the Statistical Package for the Social Sciences (SPSS), version 23.0 (Chicago, Illinois). Results were expressed as mean ± SD for continuous variables unless stated otherwise
A total of 19 studies were selected for analysis from 10 countries. The average prevalence of postmenopausal osteoporosis was 29.37±6.97% (ranging from 20.2 to 38.5). Table (1) gives the prevalence of individual countries. In these 10 countries, 252.411 million people live with an average of 28.56% suffering from osteoporosis. A total of 72.088 million are at risk of having a fragility fracture. Table 2 gives the prevalence of fragility fractures of the proximal femur in six countries. The mean femoral fracture prevalence is 4.41/1000. It is estimated that in 2020, 7,43901 are Bahraini citizens and 5.32% are ≥50 years of age totaling 39575, and will suffer 177 fractures will have direct costs of BD1.327 million and indirect yearly cost of BD 3.98 for primary first fracture with a total of BD 5.310 million (US$14.07 million) [24-26] (Table 3).
|Authors||Country||Total Population in millions||Prevalence/Incidence (%)|
|1.||Sadat-Ali M &Mattar 20203||Kingdom of Bahrain||0.558||38.5|
|2.||Sadat-Ali et al. 20122||Saudi Arabia||33.7||33.5|
|3.||Al-Shoumer and Nair(2012) ||Kuwait||1.4||20.2|
|4.||Fawsy et al. (2012) ||UAE||1.08||22.3|
|5.||D’Souza et al. (2013) ||Oman||2.3||27.3|
|6.||Hyassat et al. (2017) ||Jordan||10.23||37.5|
|7.||Bener et al. (2007) ||Qatar||0.313||21.3|
|8.||Hamdi et al. (2007) ||Turkey||83.3||30.2|
|9.||Gorial et al. (2013) ||Iraq||38.43||22.8|
|10.||Hemmati et al. (2018) ||Iran||81.1||32|
|1||Al-Nuaim et al. (1995) ||2.9||Saudi Arabia|
|2.||Bubshait and Sadat-Ali (2007) ||5.9||Saudi Arabia|
|3.||Sadat-Ali et al. (2015) ||5.7||Saudi Arabia|
|5.||Memon et al. (1998) ||2.95||Kuwait|
|6.||Kanis et al. (2012) ||2.7||Oman|
|7.||Tuzun S et al. (2012) ||3.28||Turkey|
|8.||Maharlouei et al. (2014) ||9.6||Iran|
This review finds that even with the conservative figures, the economic impact on Bahrain due to osteoporosis and its complications, most commonly proximal femoral fractures is BD5.31 million ($14.07 million) with 28% of the patients dying within a year after the femur fracture. This is for a Bahraini population of <700,000. The ideal way to prevent fractures is to diagnose early and treat appropriately. The gold standard test for such prediction has been dual-energy x-ray absorptiometry (DXA) of the hip and lumbar spine. Based on the DXA, drug therapies can be started to prevent osteoporotic fractures [26-28].
Multiple studies have shown that early diagnosis and drug therapy can reduce fractures in postmenopausal women and men with osteoporosis [26, 27]. The cost of managing osteoporosis related fractures specifically fragility fractures, which increase morbidity and mortality is increasing tremendously all around the world [29, 30]. In the USA in 2005, there were over two million fractures, costing $17 billion, and it is estimated that by 2025, annual fractures and costs are projected to increase by 50% to $25 billion [30-31]. In Europe, the trends are not different from those in the USA, and it was reported that direct costs were estimated at €31.7 billion and are expected to increase to €76.7 billion in 2050 based on the expected changes in the demography of Europe . Giversen  reported that in Denmark, hip fracture incidence increased by 56% during the period 1987–1997, with an increase of 41% among women and 104% among men aged 50 years or older, whereas in Finland, the total number of hip fractures increased by 70% within a 10-year period (1992–2002) . In Saudi Arabia, the data shows the yearly direct costs of treating only one fracture is SR564.75 and indirect costs are SR 1.69 billion making total cost of SR2.359 billion.
There was a recent report that stated that the incidence of osteoporosis is 38% and no literature is found regarding the incidence of osteoporosis nor fragility fractures from Kingdom of Bahrain. We have undertaken this retrospective study to assess the prevalence of osteopenia and osteoporosis among Bahraini citizens, so that appropriate screening can be recommended for early diagnosis and appropriate treatment to prevent fragility fractures. Hip fractures are the most devastating osteoporosis related injury with high morbidity and mortality. In the US, the rate of hip fracture is about 6/1000 , in Saudi Arabia it was 2.8/1000 in 2007, which increased over time to 5.8/1000 in 2015 [4, 8]. It can be extrapolated in 39575 citizens of Bahrain of ≥50 years there could be 177 fractures annually, costing the country a total of BD 5.310 million (US$14.07 million) [23-25]. If these patients can be screened and treated appropriately will cost BD50 per patient yearly, costing the Kingdom BD5,54050.00 with a saving of BD4.755 million. Economically, it is viable which will save money under these economic hardships and save the lives of patients and improve the quality of life and save over BD 4.755 million a year [36-39].
In conclusion, this review highlights the risk of osteoporosis related fractures that can be prevented by early screening and treating appropriately. This will not only reduce the economic impact due to osteoporosis but also decrease mortality and improve the quality of life. Secondly, studying all the citizens of Bahrain ≥50 years, who are ≤40000, will be a great option to assess the pattern of osteoporosis and fragility fractures. This will give the region, the right step as ethnic differences in the review countries do not differ from each other much.
CONSENT FOR PUBLICATION
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PRISMA guidelines and methodology were followed.
CONFLICT OF INTEREST
The authors declare no conflicts of interest, financial or otherwise.
|||Sadat-Ali M, AlMomen AW, AlOmar HK, AlAlwan SA, Gullenpet AH, AlAnii FM. The current issues on osteoporosis among male Saudi Arabians. J Men’s Health 2017.
|||Sadat-Ali M, Al-Habdan IM, Al-Turki HA, Azam MQ. An epidemiological analysis of the incidence of osteoporosis and osteoporosis-related fractures among the Saudi Arabian population. Ann Saudi Med 2012; 32(6): 637-41.
|||Sadat-Ali M, Mattar ME. Osteoporosis among Bahraini Citizens: The First Report. Int J Appl Basic Med Res 2020; 10(3): 164-6.
|||AlFaraidy M, AlHawas AA, Al-Othman AA, Al-Dakheel DA, Tayara BK. Mortality and Morbidity after femoral fragility fractures Int. J Med Res 2017; 45(3): 1175-80.|
|||Al-Saleh Y, Sulimani R, Sabico S, et al. 2015 Guidelines for Osteoporosis in Saudi Arabia: Recommendations from the Saudi Osteoporosis Society. Ann Saudi Med 2015; 35(1): 1-12.
|||Sadat-Ali M, Al-Omran A, Al-Bakr W, Azam MQ, Tantawy A, Al-Othman A. Established osteoporosis and gaps in the management: Review from a teaching hospital. Ann Med Health Sci Res 2014; 4(2): 198-201.
|||Sadat-Ali M, AlShammari SM, Uddin FZ, Alani FM, Dahduli OS. Are we closing the gaps in the management of osteoporosis following fragility fractures of the femur? J Int Med Res 2019; 47(5): 1843-7. Epub ahead of print
|||Bubshait D, Sadat-Ali M. Economic implications of osteoporosis-related femoral fractures in Saudi Arabian society. Calcif Tissue Int 2007; 81(6): 455-8.
|||Sadat-Ali M, Al-Dakheel DA, Azam MQ, et al. Reassessment of osteoporosis-related femoral fractures and economic burden in Saudi Arabia. Arch Osteoporos 2015; 10: 37.
|||Al-Shoumer KAS, Nair V. Prevalence of low bone mass in postmenopausal Kuwaiti women residents in the largest province of Kuwait. Arch Osteoporos 2012; 7: 147-53.
|||Fawsy T, Sreedharan J, Muttappallymyalil J, et al. Risk factors associated with low bone mineral density in Ajman UAE. Gulf Med J 2012; 1(S2): S25-9.|
|||D’Souza MS, Isac C, Venkatesaperumal R, Amirtharaj A, Balachandran S, et al. Examining the risk factors among omani women: Risk assessment and their implications. J Nov Physiother 2013; 3: 143.
|||Hyassat D, Alyan T, Jaddou H, Ajlouni KM. Prevalence and risk factors of osteoporosis among jordanian postmenopausal women attending the national center for diabetes, endocrinology and genetics in jordan. Biores Open Access 2017; 6(1): 85-93.
|||Bener A, Hammoudeh M, Zirie M. Prevalence and predictors of osteoporosis and the impact of life style factors on bone mineral density. Int J Rheum Dis 2007; 10(3): 227-33.|
|||Hamdi Kara I, Aydin S, Gemalmaz A, et al. Habitual tea drinking and bone mineral density in postmenopausal Turkish women: Investigation of prevalence of postmenopausal osteoporosis in Turkey (IPPOT Study). Int J Vitam Nutr Res 2007; 77(6): 389-97.
|||Gorial FI, Aubaese ND, Husaeen NH. Prevalence and associated factors of osteoporosis in post-menopausal Iraqi women: A cross-sectional two centers study. Int J Mod Biol Med 2013; 3(1): 41-9.|
|||Hemmati F, Sarokhani D, Sayehmiri K, Motadayen M. Prevalence of osteoporosis in postmenopausal women in iran: A systematic review and meta-analysis. The Iranian J Obstetrics Gynecology and Infertility 2018; 21(3): 90-102.|
|||al-Nuaim AR, Kremli M, al-Nuaim M, Sandkgi S. Incidence of proximal femur fracture in an urbanized community in Saudi Arabia. Calcif Tissue Int 1995; 56(6): 536-8.
|||What is Osteoporosis? 2020. Available from: https://www.iofbone health.org/|
|||Memon A, Pospula WM, Tantawy AY, Abdul-Ghafar S, Suresh A, Al-Rowaih A. Incidence of hip fracture in Kuwait. Int J Epidemiol 1998; 27(5): 860-5.
|||Kanis JA, Odén A, McCloskey EV, Johansson H, Wahl DA, Cooper C. A systematic review of hip fracture incidence and probability of fracture worldwide. Osteoporos Int 2012; 23(9): 2239-56.
|||Tuzun S, Eskiyurt N, Akarirmak U, et al. Incidence of hip fracture and prevalence of osteoporosis in Turkey: The FRACTURK study. Osteoporos Int 2012; 23(3): 949-55.
|||Maharlouei N, Khodayari M, Forouzan F, Rezaianzadeh A, Lankarani KB. The incidence rate of hip fracture in Shiraz, Iran during 2008-2010. Arch Osteoporos 2014; 9: 165.
|||Bleibler F, Rapp K, Jaensch A, Becker C, König H-H. Expected lifetime numbers and costs of fractures in postmenopausal women with and without osteoporosis in Germany: A discrete event simulation model. BMC Health Serv Res 2014; 14: 284.
|||MetLife Mature Market Institute. Market survey of long-term care costs The 2011 metlife market survey of nursing home, assisted living, adult day services, and home care costs 2011.|
|||National Osteoporosis Foundation. Fast Facts 2011. Available from: http://www. nof. org/node/40|
|||Viswanathan M, Reddy S, Berkman N, et al. Screening to prevent osteoporotic fractures: An evidence review for the us preventive services task force: Evidence synthesis no 162 Rockville, MD: Agency for healthcare research and quality; 2018 AHRQ publication 15-05226-EF-1 2018.|
|||Shepstone L, Lenaghan E, Cooper C, et al. Screening in the community to reduce fractures in older women (SCOOP): A randomised controlled trial. Lancet 2018; 391(10122): 741-7.
|||Viswanathan M, Reddy S, Berkman N, et al. Screening to prevent osteoporotic fractures: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA 2018; 319(24): 2532-51. [published June 26, 2018].
|||Zizic TM. Pharmacologic prevention of osteoporotic fractures. Am Fam Physician 2004; 70(7): 1293-300.
|||Sözen T, Özışık L, Başaran NC. An overview and management of osteoporosis. Eur J Rheumatol 2017; 4(1): 46-56.
|||Abrahamsen B, Skjødt MK, Vestergaard P. Hip fracture rates and time trends in use of anti-osteoporosis medications in Denmark for the period 2005 to 2015: Missed opportunities in fracture prevention. Bone 2019; 120: 476-81.
|||Mariconda M, Costa GG, Cerbasi S, et al. The determinants of mortality and morbidity during the year following fracture of the hip: A prospective study. Bone Joint J 2015; 97-B(3): 383-90.
|||Nazrun AS, Tzar MN, Mokhtar SA, Mohamed IN. A systematic review of the outcomes of osteoporotic fracture patients after hospital discharge: Morbidity, subsequent fractures, and mortality. Ther Clin Risk Manag 2014; 10: 937-48.
|||Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res 2007; 22(3): 465-75.
|||Kanis JA, Johnell O. Requirements for DXA for the management of osteoporosis in Europe. OsteoporosInt 2005; 6: 229-38.
|||Giversen IM. Time trends of age-adjusted incidence rates of first hip fractures: A register-based study among older people in Viborg County, Denmark, 1987–1997. OsteoporosInt 2006; 17: 552-64.|
|||Lönnroos E, Kautiainen H, Karppi P, et al. Increased incidence of hip fractures. A population based-study in Finland. Bone 2006; 39(3): 623-7.