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Swedish osteoporosis care

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Summary

Mini-abstract

The objective of this study was to review and describe the current state of Swedish osteoporosis care and to highlight ongoing challenges. This report encompasses quantitative health outcomes based on Swedish registry data as well as organizational and management aspects.

Executive summary

Swedish osteoporosis care is characterized by a significant burden of disease, difficulties in identifying high-risk patients, and fragmented pathways for patients in need of secondary fracture prevention. This report aimed to describe the current state, gaps, and challenges in Swedish osteoporosis care, using Swedish national databases, questionnaires, and interviews with healthcare representatives. A secondary aim was to develop quality and process measures to compare differences between counties and to use those measures to describe the interaction between quantitative health outcomes and aspects of care organization and management. In conjunction with fractures, a considerably smaller proportion of men are treated than women, and a smaller proportion of older women are treated compared to younger groups. Between 3 and 16 % of patients receive treatment after a fracture, and the treatment rate in this patient group can likely increase. In addition to an unsatisfactory treatment rate, a limited number of those treated continue treatment throughout the recommended treatment durations, leading to increased risk of fracture. With a substantial variation between counties, there is a clear difficulty to identify non-persistent patients and switch to an alternative treatment. Collaboration around the patient across specialties has been lacking, and systems for secondary prevention have been concentrated to a few counties. However, when this study was conducted, there was a general trend towards implementing regional care programs. This report suggests possible strategies for improving quality of care and, hopefully, it can provide a basis for future evaluations and regional improvement of osteoporosis care in Sweden and other countries.

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Notes

  1. This report defines major osteoporotic fracture in the same way as in Quality and Efficiency in Swedish Healthcare; ICD-10 S32.1-8, S52.5-6, S42.2-3, S72.0-4, S22.x, S82.1.

  2. Only patients with a first care occasion in inpatient care for any of the defined diagnosis codes are included.

  3. For example, in the report “Unequal conditions for health and healthcare” [Ojämna villkor för hälsa och vård: Jämlikhetsperspektiv på hälso- och sjukvården”], the National Board of Health and Welfare reports challenges in certain healthcare areas where national guidelines are in place [59].

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Acknowledgments

This study was sponsored by Merck Sharp & Dohme (Sweden).

Conflicts of interest

EJ, DE, FB, and OS have previously consulted for companies marketing products for osteoporosis.

Author information

Authors and Affiliations

  1. Quantify Research, Hantverkargatan 8, 112 21, Stockholm, Sweden

    Emma Jonsson, Daniel Eriksson, Fredrik Borgström & Oskar Ström

  2. Department of Orthopaedics, Skåne University Hospital, Malmö, Sweden

    Kristina Åkesson

  3. Department of Medical Sciences, Uppsala University, Uppsala, Sweden

    Östen Ljunggren

  4. Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden

    Stina Salomonsson

  5. Merck Sharp & Dohme (Sweden), Sollentuna, Sweden

    Stina Salomonsson

  6. LIME/MMC, Karolinska Institutet, Stockholm, Sweden

    Fredrik Borgström & Oskar Ström

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  1. Emma Jonsson
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Corresponding author

Correspondence to Oskar Ström.

Appendix

Appendix

Definitions

Study population

Data on all patients in Sweden were retrieved from the National Patient Register and the Prescribed Drug Register, which are linked to the Cause of Death Register. Table 10 shows details of data and study period, i.e., the time frame in which data about identified patients is collected.

Table 10 Data and study period
Full size table

Inclusion criteria include the following:

  • Age 50 and older

  • At least one filled prescription of osteoporosis medication or a registered fracture, between 1 January 2007 and 31 December 2011

Exclusion criteria are as follows:

Index dates

Two separate index dates were used in this report: (1) patients who filled their first prescription of osteoporosis medication and (2) patients with fracture.

  • Start of treatment: no registered filling of a prescription of osteoporosis medication in the pre-index period (24 months)

  • First fracture: no registered fracture in the pre-index period (5 years)

When “fracture-free” or “without prior fracture” is indicated in the report, this means no registered fracture during the 5 years prior to treatment start. When “first treatment” or “start of treatment” is indicated, this means no registered filling of a prescription of osteoporosis medication within 24 months.

Treatment persistence

In this report, treatment persistence is defined as the total time from start of treatment to discontinuation of treatment. This is measured as the time from the first filling of a prescription until the last filled prescription runs out. Patients can have gaps between filled dosages, but is defined as non-persistent if the gap exceeds 8 weeks, including the length of the filled dosage. The analyses take into account any potential accumulation of medication from overlapping prescriptions.

Fracture codes

Included fractures are those fractures least likely to have occurred as the result of a high-energy trauma. The fracture types and the related International Classification of Diseases 10th version (ICD-10) codes are listed in Table 11.

Table 11 Fracture codes
Full size table

ATC codes

In Sweden, alendronic acid is recommended as the first-line treatment for osteoporosis. Zoledronic acid, risedronic acid, and denosumab are recommended as second-line treatment options. Medications with lower priority according to Swedish guidelines are raloxifene, teriparatide, strontium ranelate, and ibandronate. Price, year of introduction, and subsidy limit are presented in Table 3 of the report. Table 12 below shows medications and ATC codes that were included in the report. In some counties, zoledronic acid is procured on requisition. As the Prescribed Drug Register does not collect data on such products, many patients treated with zoledronic acid have been excluded in analyses.

Table 12 ATC codes
Full size table

Osteoporosis codes

Table 13 below provides the ICD-10 codes for osteoporosis diagnoses.

Table 13 ICD-10 codes: osteoporosis
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Jonsson, E., Eriksson, D., Åkesson, K. et al. Swedish osteoporosis care. Arch Osteoporos 10, 24 (2015). https://doi.org/10.1007/s11657-015-0222-7

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