The health and economic burden of osteoporotic fractures in Singapore and the potential impact of increasing treatment rates through more pharmacological options



This study aims to estimate the health and economic burden of osteoporosis in Singapore from 2017 to 2035, and to quantify the impact of increasing the treatment rate of osteoporosis.


Population forecast data of women and men aged 50 and above in Singapore from 2017 to 2035 was used along with prevalence rates of osteoporosis to project the osteoporosis population over time. The population projections by sex and age group were used along with osteoporotic fracture incidence rates by fracture type (hip, vertebral, other), and average direct and indirect costs per case to forecast the number of fractures, the total direct health care costs, and the total indirect costs due to fractures in Singapore. Data on treatment rates and effects were used to model the health and economic impact of increasing treatment rate of osteoporosis, using different hypothetical levels.


Between 2017 and 2035, the incidence of osteoporotic fractures is projected to increase from 15,267 to 24,104 (a 57.9% increase) F 10,717 to 17,225 (a 60.7% increase) and M 4550 to 6878 (a 51.2% increase). The total economic burden (including direct costs and indirect costs to society) associated with these fractures is estimated at S$183.5 million in 2017 and is forecasted to grow to S$289.6 million by 2035. However, increasing the treatment rate for osteoporosis could avert up to 29,096 fractures over the forecast period (2017–2035), generating cumulative total cost savings of up to S$330.6 million.


Efforts to improve the detection, diagnosis, and treatment of osteoporosis are necessary to reduce the growing clinical, economic, and societal burden of fractures in Singapore.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2


  1. 1.

    International Osteoporosis Foundation (2013) Asia-Pacific Audit: Singapore

  2. 2.

    Svedbom A, Hernlund E, Ivergard M, Compston J, Cooper C, Stenmark J, McCloskey EV, Jonsson B, Kanis JA, IOF EURPo (2013) Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporos 8:137.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Yung CK, Fook-Chong S, Chandran M (2012) The prevalence of recognized contributors to secondary osteoporosis in South East Asian men and post-menopausal women. Are Z score diagnostic thresholds useful predictors of their presence? Arch Osteoporos 7:49–56.

    Article  PubMed  Google Scholar 

  4. 4.

    Cheung C-L, Ang SB, Chadha M, Chow ES-L, Chung Y-S, Hew FL, Jaisamrarn U, Ng H, Takeuchi Y, Wu C-H, Xia W, Yu J, Fujiwara S (2018) An updated hip fracture projection in Asia: the Asian Federation of Osteoporosis Societies study. Osteoporosis Sarcopenia 4(1):16–21.

    Article  PubMed  Google Scholar 

  5. 5.

    Cooper C, Campion G, Melton LJ 3rd (1992) Hip fractures in the elderly: a world-wide projection. Osteoporos Int 2(6):285–289

    CAS  Article  Google Scholar 

  6. 6.

    Gullberg B, Johnell O, Kanis JA (1997) World-wide projections for hip fracture. Osteoporos Int 7(5):407–413

    CAS  Article  Google Scholar 

  7. 7.

    Koh LK, Saw SM, Lee JJ, Leong KH, Lee J, National Working Committee on O (2001) Hip fracture incidence rates in Singapore 1991-1998. Osteoporos Int 12(4):311–318

    CAS  Article  Google Scholar 

  8. 8.

    International Osteoporosis Foundation (2009) The Asian audit epidemiology, costs and burden of osteoporosis in Asia 2009. Switzerland

  9. 9.

    Chau PH, Wong M, Lee A, Ling M, Woo J (2013) Trends in hip fracture incidence and mortality in Chinese population from Hong Kong 2001-09. Age Ageing 42(2):229–233.

    Article  Google Scholar 

  10. 10.

    Chen FP, Shyu YC, Fu TS, Sun CC, Chao AS, Tsai TL, Huang TS (2017) Secular trends in incidence and recurrence rates of hip fracture: a nationwide population-based study. Osteoporos Int 28(3):811–818.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Yong EL, Ganesan G, Kramer MS, Logan S, Lau TC, Cauley JA, Tan KB (2019) Hip fractures in Singapore: ethnic differences and temporal trends in the new millennium. Osteoporos Int 30:879–886.

    CAS  Article  PubMed  Google Scholar 

  12. 12.

    Tay E (2016) Hip fractures in the elderly: operative versus nonoperative management. Singapore Med J 57(4):178–181.

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Wong MK, Arjandas Ching LK, Lim SL, Lo NN (2002) Osteoporotic hip fractures in Singapore--costs and patient’s outcome. Ann Acad Med Singap 31(1):3–7

    CAS  PubMed  Google Scholar 

  14. 14.

    Mitra AK, Low CK, Chao AK, Tan SK (1994) Social aspects in patients following proximal femoral fractures. Ann Acad Med Singapore. Ann Acad Med Singapore 23(6):876–878

    CAS  PubMed  Google Scholar 

  15. 15.

    Lee AY, Chua BS, Howe TS (2007) One-year outcome of hip fracture patients admitted to a Singapore hospital: quality of life post-treatment. Singap Med J 48(11):996–999

    CAS  Google Scholar 

  16. 16.

    Kung AW, Fan T, Xu L, Xia WB, Park IH, Kim HS, Chan SP, Lee JK, Koh L, Soong YK, Soontrapa S, Songpatanasilp T, Turajane T, Yates M, Sen S (2013) Factors influencing diagnosis and treatment of osteoporosis after a fragility fracture among postmenopausal women in Asian countries: a retrospective study. BMC Womens Health 13:7.

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Gani L, Reddy SK, Alsuwaigh R, Khoo J, King TFJ (2017) High prevalence of missed opportunities for secondary fracture prevention in a regional general hospital setting in Singapore. Arch Osteoporos 12(1):60–64.

    Article  PubMed  Google Scholar 

  18. 18.

    Department of Statistics S (2017) Popul Trends 2017. Accessed February 9 2018

  19. 19.

    Lee J, Lee S, Jang S, Ryu OH (2013) Age-related changes in the prevalence of osteoporosis according to gender and skeletal site: the Korea National Health and Nutrition Examination Survey 2008-2010. Endocrinol Metab (Seoul) 28(3):180–191.

    Article  Google Scholar 

  20. 20.

    Chandran M, Tan MZ, Cheen M, Tan SB, Leong M, Lau TC (2013) Secondary prevention of osteoporotic fractures--an “OPTIMAL” model of care from Singapore. Osteoporos Int 24(11):2809–2817.

    CAS  Article  Google Scholar 

  21. 21.

    Tan LT, Wong SJ, Kwek EB (2017) Inpatient cost for hip fracture patients managed with an orthogeriatric care model in Singapore. Singapore Med J 58(3):139–144.

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Ng CS, Lau TC, Ko Y (2017) Cost of osteoporotic fractures in Singapore. Value Health Reg Issues 12:27–35.

    Article  PubMed  Google Scholar 

  23. 23.

    Watts JJ, Abimanyi-Ochom, J., Sanders, K.M. Osteoporosis costing all Australians - a new burden of disease analysis - 2012 to 2022

  24. 24.

    Marshall D, Johnell O, Wedel H (1996) Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 312(7041):1254–1259.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Wells GA, Cranney A, Peterson J, Boucher M, Shea B, Robinson V, Coyle D, Tugwell P (2008) Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev 1:CD001155.

    Article  Google Scholar 

  26. 26.

    Schilcher J, Michaelsson K, Aspenberg P (2011) Bisphosphonate use and atypical fractures of the femoral shaft. N Engl J Med 364(18):1728–1737.

    CAS  Article  PubMed  Google Scholar 

  27. 27.

    Wysowski DK (2009) Reports of esophageal cancer with oral bisphosphonate use. N Engl J Med 360(1):89–90.

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    Black DM, Delmas PD, Eastell R, Reid IR, Boonen S, Cauley JA, Cosman F, Lakatos P, Leung PC, Man Z, Mautalen C, Mesenbrink P, Hu H, Caminis J, Tong K, Rosario-Jansen T, Krasnow J, Hue TF, Sellmeyer D, Eriksen EF, Cummings SR, Trial HPF (2007) Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med 356(18):1809–1822.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  29. 29.

    Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL (2004) Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases. J Oral Maxillofac Surg 62(5):527–534

    Article  Google Scholar 

  30. 30.

    Jha S, Wang Z, Laucis N, Bhattacharyya T (2015) Trends in media reports, oral bisphosphonate prescriptions, and hip fractures 1996-2012: an ecological analysis. J Bone Miner Res 30(12):2179–2187.

    CAS  Article  Google Scholar 

  31. 31.

    Wang Z, Bhattacharyya T (2011) Trends in incidence of subtrochanteric fragility fractures and bisphosphonate use among the US elderly, 1996-2007. J Bone Miner Res 26(3):553–560.

    CAS  Article  PubMed  Google Scholar 

  32. 32.

    Wang Z, Ward MM, Chan L, Bhattacharyya T (2014) Adherence to oral bisphosphonates and the risk of subtrochanteric and femoral shaft fractures among female medicare beneficiaries. Osteoporos Int 25(8):2109–2116.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Whitaker M, Guo J, Kehoe T, Benson G (2012) Bisphosphonates for osteoporosis--where do we go from here? N Engl J Med 366(22):2048–2051.

    CAS  Article  PubMed  Google Scholar 

  34. 34.

    International Osteoporosis Foundation (2005) The adherence gap: why osteoporosis patients don’t continue with treatment

  35. 35.

    Rabenda V, Hiligsmann M, Reginster JY (2009) Poor adherence to oral bisphosphonate treatment and its consequences: a review of the evidence. Expert Opin Pharmacother 10(14):2303–2315.

    CAS  Article  PubMed  Google Scholar 

  36. 36.

    Freemantle N, Satram-Hoang S, Tang ET, Kaur P, Macarios D, Siddhanti S, Borenstein J, Kendler DL, Investigators D (2012) Final results of the DAPS (Denosumab Adherence Preference Satisfaction) study: a 24-month, randomized, crossover comparison with alendronate in postmenopausal women. Osteoporos Int 23(1):317–326.

    CAS  Article  PubMed  Google Scholar 

  37. 37.

    Cummings SR, San Martin J, McClung MR, Siris ES, Eastell R, Reid IR, Delmas P, Zoog HB, Austin M, Wang A, Kutilek S, Adami S, Zanchetta J, Libanati C, Siddhanti S, Christiansen C, Trial F (2009) Denosumab for prevention of fractures in postmenopausal women with osteoporosis. N Engl J Med 361(8):756–765.

    CAS  Article  Google Scholar 

  38. 38.

    Kanis JA, Oden A, Johnell O, Jonsson B, de Laet C, Dawson A (2001) The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporos Int 12(5):417–427.

    CAS  Article  PubMed  Google Scholar 

  39. 39.

    Fujiwara S, Kasagi F, Masunari N, Naito K, Suzuki G, Fukunaga M (2003) Fracture prediction from bone mineral density in Japanese men and women. J Bone Miner Res 18(8):1547–1553.

    Article  PubMed  Google Scholar 

  40. 40.

    Pongchaiyakul C, Nguyen ND, Jones G, Center JR, Eisman JA, Nguyen TV (2005) Asymptomatic vertebral deformity as a major risk factor for subsequent fractures and mortality: a long-term prospective study. J Bone Miner Res 20(8):1349–1355.

    Article  PubMed  Google Scholar 

  41. 41.

    Center JR, Nguyen TV, Schneider D, Sambrook PN, Eisman JA (1999) Mortality after all major types of osteoporotic fracture in men and women: an observational study. Lancet 353(9156):878–882.

    CAS  Article  Google Scholar 

  42. 42.

    Keen RW (2003) Burden of osteoporosis and fractures. Curr Osteoporos Rep 1(2):66–70

    Article  Google Scholar 

  43. 43.

    Hiligsmann M, Reginster JY (2011) Cost effectiveness of denosumab compared with oral bisphosphonates in the treatment of post-menopausal osteoporotic women in Belgium. Pharmacoeconomics 29(10):895–911.

    Article  PubMed  Google Scholar 

  44. 44.

    Hiligsmann M, Rabenda V, Gathon HJ, Ethgen O, Reginster JY (2010) Potential clinical and economic impact of nonadherence with osteoporosis medications. Calcif Tissue Int 86(3):202–210

    CAS  Article  Google Scholar 

Download references


This study was funded by Amgen Inc.

Author information



Corresponding author

Correspondence to Manju Chandran.

Ethics declarations

Conflict of interest

Manju Chandran, Tang Ching Lau, Isabelle Gagnon-Arpin, Alexandru Dobrescu, and Wenshan Li have no conflict of interest. Mallory Leung, Narendra Patil, and Zhongyun Zhao hold Amgen stock and are employees of Amgen.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


Technical appendix

Table 4 Population projections for adults 50 years old and over, Singapore, 2017–2035
Table 5 Base risk estimates by age and sex, Singapore, 2017
Table 6 Forecasted number of fractures by type, gender, age, and year

Example of how fracture rates were estimated for e.g. females aged 50–59 years

The base risks of fractures by gender and age group are calculated using the following formulae, given information on incidence rate, relative risk of fracture of osteoporotic patients vs. patients without osteoporosis, and the prevalence rate of osteoporosis.

$$ {\mathrm{Incidence}\ \mathrm{rate}}_{\mathrm{female},50-59,\mathrm{Hip}\ \mathrm{FX},\mathrm{basecase}}={\mathrm{Baserisk}}_{\mathrm{female},50-59,\mathrm{Hip}\ \mathrm{FX}}\times \left(\ {\mathrm{RR}}_{\mathrm{Osteo}}\times {\mathrm{Prev}\ \mathrm{rate}}_{\mathrm{Osteo}}+\left(\ 1-{\mathrm{Prev}\ \mathrm{rate}}_{\mathrm{Osteo}}\right)\right) $$
$$ {\mathrm{Incidence}\ \mathrm{rate}}_{\mathrm{female},50-59,\mathrm{Hip}\ \mathrm{FX},\mathrm{basecase}}=0.2530\% $$

i.e., the incidence rate of hip fracture for female patients is 253 cases per 100,000 persons. Given the population of females aged 50–59 is 456,978, the number of hip fracture cases for female aged 50–59 is 0.00253 × 456,978 = 1156.

Take an example of female patients in the age group of 50–59. The base risk of hip fracture is given by:

$$ {\mathrm{Baserisk}}_{\mathrm{Fractures}}={\mathrm{Incidence}\ \mathrm{rate}}_{\mathrm{Fractures}}/\left(\ {\mathrm{RR}}_{\mathrm{Osteo}}\times {\mathrm{Prev}\ \mathrm{rate}}_{\mathrm{Osteo}}+\left(\ 1-{\mathrm{Prev}\ \mathrm{rate}}_{\mathrm{Osteo}}\right)\right) $$
$$ {\mathrm{Baserisk}}_{\mathrm{female},50-59,\mathrm{Hip}\ \mathrm{FX}}=0.00253/\left(\ 1.9\times 15.2\%+\left(\ 1-15.2\%\right)\right) $$
$$ {\mathrm{Baserisk}}_{\mathrm{female},50-59,\mathrm{Hip}\ \mathrm{FX}}=0.22\% $$

In the treatment scenario, since we assume the increase in treatment is fully attributed to the use of denosumab, the relative risk of FX for the OP patients is the weighted average between RROsteoporosis and RRDenosumab:

$$ {\mathrm{RR}}_{\mathrm{new}}=\Delta \mathrm{TR}\times {\mathrm{RR}}_{\mathrm{Denosumab}}+\left(1-\Delta \mathrm{TR}\right)\times {\mathrm{RR}}_{\mathrm{Osteoporosis}} $$

where ΔTR = 10%, 20%, 30%, or 47% uptake of denosumab.

RRDenosumab is the relative risk of fracture of OP patients with intake of Denosumab, i.e., RRDenosumab = RROsteoporosis × (1-relative risk reduction of denosumab by fracture type).

In the counterfactual exercise of ΔTR = 10% uptake of denosumab,

$$ {\mathrm{RR}}_{\mathrm{new}}=10\%\times 1.9\ \mathrm{x}\ \left(1\hbox{--} 40\%\right)+\left(1\hbox{--} 10\%\right)\times 1.9 $$
$$ {\mathrm{RR}}_{\mathrm{new}}=1.824 $$

The RRnew are then plugged into the incidence rate equation to imply the new incidence rate of fractures in order to predict the incidence of fracture by various scenarios.

The new incidence of hip fracture with a 10% uptake of denosumab is:

$$ {\mathrm{Incidence}\ \mathrm{rate}}_{\mathrm{female},50-59,\mathrm{hip},10\%}=0.22\%\times \left(\ 1.824\times 15.2\%+\left(\ 1-15.2\%\right)\right) $$
$$ {\mathrm{Incidence}\ \mathrm{rate}}_{\mathrm{female},50-59,\mathrm{hip},\kern0.5em 10\%\mathrm{uptake}}=0.2504\% $$

Given 10% uptake of denosumab, the incidence rate for female hip fracture patients, 50–59 years of age, is 250 cases per 100,000 persons. With the assumption of 10% uptake of denosumab, the number of cases in 2017 is 0.002504 × 456,978 = 1144.

Therefore, the number of hip fracture cases averted for female aged 50–59 is 1156–1144 = 12.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Chandran, M., Lau, T.C., Gagnon-Arpin, I. et al. The health and economic burden of osteoporotic fractures in Singapore and the potential impact of increasing treatment rates through more pharmacological options. Arch Osteoporos 14, 114 (2019).

Download citation


  • Osteoporosis
  • Osteoporotic fractures
  • Economic burden
  • Asia
  • Singapore
  • Health burden