SPINE Volume 41, Number 4, pp 328–336 ß 2016 Wolters Kluwer Health, Inc. All rights reserved EPIDEMIOLOGY Prevalence and Incidence of Osteoporosis and Osteoporotic Vertebral Fracture in Korea Nationwide Epidemiological Study Focusing on Differences in Socioeconomic Status Sung Bae Park, MD, PhD,Ã Jayeun Kim, PhD,y Je Hoon Jeong, MD,z Jung-Kil Lee, MD, PhD,§ Dong Kyu Chin, MD, PhD,{ Chun Kee Chung, MD, PhD,jj Sang Hyung Lee, MD, PhD,Ã and Jin Yong Lee, MD, PhD# Results. In 2012, the standardized prevalence of OP in the Study Design. A cross-national study. NHI and MA groups was 3968 and 6927 per 100,000, Objective. To determine the prevalence and incidence of respectively (odds ratio, 3.83). The standardized incidence of osteoporosis (OP) and osteoporotic vertebral fracture (OVF) in OP in the MA group was significantly higher than in the NHI Korea and to investigate if socioeconomic status has an effect. group in 2011 and 2012 (odds ratios, 2.34 and 2.19, respect- Summary of Background Data. As life expectancy increases, ively). In addition, the standardized incidence of OVF in the MA OP and related fragility fractures are also increasing. This group in 2011 and 2012 was 408 and 389 per 100,000, presents a serious challenge, not only for health authorities but respectively, and the incidence in the MA group was signifi- also for individuals, their families, and society overall. Determin- cantly higher than in the NHI group (odds ratios, 4.13 and 4.12, ing the prevalence and incidence of OP and related fragility respectively; P < 0.001). fractures is the first step in developing strategies to reduce their Conclusion. We confirmed that the prevalence and incidence increasing disease burdens. Concurrently, we need to confirm of OP and OVF in the MA group were higher than those in the whether people with low socioeconomic status are more NHI group. It showed that low income might be a significant susceptible to these diseases. factor related to OP and OVF. Methods. Using the Health Insurance Review and Assessment Key words: fracture, incidence, osteoporosis, prevalence, Service (HIRA) database from 2008 to 2012, we estimated the socioeconomic status, vertebrae. annual prevalence and incidence of OP and OVF and investi- Level of Evidence: 3 gated the differences according to socioeconomic status by Spine 2016;41:328–336 National Health Insurance (NHI) beneficiaries and Medical Aid (MA) recipients. t has been estimated that more than 200 million people From the ÃDepartment of Neurosurgery, Seoul National University Boramae suffer from osteoporosis (OP) across the world1; 27.5 Medical Center, Seoul, Korea; yInstitute of Health and Environment, Seoul National University, Seoul, Korea; zDepartment of Neurosurgery, Soon- million people (22 million women and 5.5 million men) § I 2 3 chunhyang University Bucheon Hospital, Bucheon, Korea; Department of in Europe and at least 10 million in the United States have Neurosurgery, Chonnam National University Research Institute of Medical suffered from OP. OP should be considered a major public Sciences, Chonnam National University Hospital & Medical School, Gwangju, Korea; {Department of Neurosurgery, Yongdong Severance Spine health concern because its prevalence is continuously esca- Hospital, Yonsei University College of Medicine, Seoul, Korea; lating as a result of an increase in the elderly population, and jjDepartment of Neurosurgery, Seoul National University College of Medi- # it is closely associated with fragility fractures, which com- cine, Seoul, Korea; and Public Health Medical Service, Seoul National 1 University Boramae Medical Center, Seoul, Korea. monly occur in the spine, wrist, or hip. For example, in the Acknowledgment date: June 5, 2015. First revision date: August 7, 2015. European Union, it has been estimated that the number of Acceptance date: August 20, 2015. osteoporotic fractures was 3.79 million in 2000 and that 3.5 1,2 The manuscript submitted does not contain information about medical million new fragility fractures were sustained in 2010. device(s)/drug(s). As life expectancy increases, OP and related fragility The Korea Healthcare Technology R&D Project, Ministry for Health and fractures will also increase. This presents a serious chal- Welfare, Republic of Korea (HI10C2020) grant funds were received in support of this work. lenge, not only for health authorities but also for individ- Address correspondence and reprint requests to Jin Y. Lee, MD, PhD, Public uals, their families, and society overall. OP and related Health Medical Service, Seoul National University Boramae Medical fragility fractures have a serious impact on people’s health Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 156–707 Korea; E-mail: and quality of life because they can result in chronic pain, [email protected] morbidity (long-term disability), and mortality.4–7 Accord- DOI: 10.1097/BRS.0000000000001291 ing to the results from the Global Burden of Disease study, 328 www.spinejournal.com February 2016 Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. EPIDEMIOLOGY Osteoporosis and Osteoporotic Vertebral Fracture in Korea Park et al musculoskeletal disorders including OP and fragility All types of healthcare organizations and facilities in fractures ranked as the second largest cause of disability Korea must submit medical claim data to the Health Insur- estimated by the years lost due to disability worldwide.8 ance Review and Assessment Service (HIRA) to receive Furthermore, we should pay more attention to the possib- reimbursement after seeing a Korean patient. HIRA is a ility that socioeconomic status can affect the epidemiology Korean government agency responsible for conducting of OP and related fragility fractures or vice versa because reviews of medical claim data and evaluating the appropri- poverty could be related to osteoporotic fracture, infection, ateness of medical benefits submitted by healthcare organ- and obesity.9,10 If people with low socioeconomic status are izations. Therefore, HIRA accumulates all medical records more susceptible to these diseases, the economic impact on based on medical claim data submitted by medical facili- their families would be more serious than in other groups. ties.15 For example, HIRA gathered 1.3 billion of medical Even if the same medical bills are charged, the proportion of claims from 45.8 million Korean citizens in 2011. the medical costs to the total family income would be higher Finally, the HIRA database from 2008 to 2012 was used in low-income families. to determine the annual prevalence and incidence of OP Korea is one of the most rapidly aging countries; and OVF, and to investigate the differences according to the proportion of the elderly (aged 65) will increase to socioeconomic status. 24.4% (11.7 million) by 2030 and approach 38.8% (15.6 million) in 2050.11 The number of patients with Definition of Diagnosing Osteoporosis OP and related fractures in Korea will increase continu- In Korea, the diagnosis of OP relies on the quantitative ously, and the social and economic burden due to these assessment of bone mineral density (BMD) in the lumbar diseases in the future will also grow rapidly.12 The first step vertebrae or femoral neck. The World Health Organization to deal with this problem effectively and efficiently is working group proposed that osteoporosis should be diag- to determine the prevalence and incidence of OP and nosed in epidemiologic studies when BMD is 2.5 standard related fractures. To do so, we can confirm the size of deviations or more below the mean for healthy young adult problem (i.e., how many people have already had the women in the spine, hip, or wrist (corresponding to a T score diseases and how many people will develop the diseases). À2.5).16 Therefore, after clinicians measure the BMD of Among OP-related fragility fractures, osteoporotic patients, they register information about the patients who vertebral fracture (OVF) tends to occur before other major are diagnosed with osteoporosis, according to the World OP-related fragility fractures, such as hip fractures. There- Health Organization guideline, into the medical system. The fore, it can be used as a single indicator to represent other medical information about the patients with OP is sent and OP-related fragility fractures.13 saved to the HIRA database in Korea. For these reasons, we conducted this study to determine the prevalence and incidence of OP and OVF in Korea from Patient Selection Process 2008 to 2012, and investigated if socioeconomic status Using the HIRA database to access data from 2008 to 2012, affects the prevalence and incidence. we extracted the annual data of patients who had been treated for OP or OVF. In this study, a patient with OP refers MATERIALS AND METHODS to a person who had at least one of the diagnostic codes including M810, M818, M819, M800, M808, or M809, Data Source based on the International Classification of Diseases, 10th Every Korean citizen is covered by the obligated universal Revision (ICD-10). In addition, a patient with OVF refers to healthcare system from birth to death; either National one of the following two cases: one is the case where a Health Insurance (NHI) or Medical Aid (MA). As of person who was diagnosed with at least one of the following 2008, among the entire 51,842,366 (100.0%) members ICD-10 codes: M800, M808, or M809; and the other is the of the Korean population, 50,001,027 (96.4%) were NHI case where a person was diagnosed with at least one of the beneficiaries and 1,841,339 (3.6%) were MA recipients.14 following ICD-10 codes: M810, M818, or M819, and also NHI is operated by NHI premiums gathered from benefi- diagnosed with one of these ICD-10 codes: S220, S221, or ciaries and government subsides. MA is only an option for S32 at the same time (Table 1).