ME Audit Iran

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1 IRAN OVERVIEW to provide everyone with their required information in the field of osteoporosis. Among other activities, Osteoporosis, also known as the silent disease, is the Osteoporosis Research Center publishes a set of considered a health priority in Iran. The disease educational brochures and booklets and holds various national and international congresses and workshops, is believed to be responsible for a large number of 1,2,3 . fractures, which impose a heavy burden on society both for the general public and healthcare providers, Previous studies conducted in this field have revealed with the aim of informing the general population about that the prevalence of osteoporosis and osteopenia in different aspects of osteoporosis. These brochures at least one measured site in the Iranians aged 50 years are commonly distributed among patients referring to osteoporosis clinics. It should be added that the or older is 22.2% and 59.9% in women and 11.0% and 50.1% in men, respectively. Among subjects younger Iranian Ministry of Health and Medical Education is than 50 years, about 33.0% of women and 31.6% of aiming to approve the modified version of the ‘National 4,5 Osteoporosis Guideline’, developed in our centre, to be men have reduced bone mass . used for family physicians working in this field. Despite the high prevalence of osteoporosis and osteopenia in Iran, there is not enough information The National Osteoporosis Research Network was regarding the prevalence of osteoporosis-related established in the first days of the year 2011. The fractures and the burden of the disease. In view of the network, which has members of research centres from lack of data in this field, the Osteoporosis Research different medical universities, aims to provide a basis for Center - Endocrinology and Metabolism Research carrying out various multi-centre studies in the field of Institute affiliated with the Tehran University of osteoporosis in order to pave the way for tackling the silent disease. The network also aims to improve the Medical Sciences (a collaborative member of WHO and IOF) is conducting numerous national projects. monitoring, treatment and prevention of the disease in different parts of the country. These include: Developing Osteoporotic Hip Fracture Registry, The Burden of Osteoporosis in Iran, ® , Assessment Developing an Iranian version of FRAX of Geometry in Iranian Population and expanding the Iranian Multi-Center Osteoporosis Study’ (IMOS), Population projection for Iran until FIGURE 1 Number of hip fractures for 2010 and projections for 2020 and 2050 in people aged over 50 years in Iran previously performed in five main cities in the country, 2050 to two other provinces. Fortifying Milk with Vitamin D 70 or over total 50 or over Supplements is another main project conducted by the center with the aim of tackling vitamin D deficiency, a 140 000 000 70 and over major risk factor contributing to osteoporosis in Iran. 120 000 000 The Osteoporosis Research Center has also initiated a 50 and over programme to develop an electronic medical recording 100 000 000 and registry system for osteoporotic patients. In the total next phases of the programme, the software would be 80 000 000 distributed throughout the whole country in order to 60 000 000 develop a national registry system. 40 000 000 In the modern world, websites play an important role in 20 000 000 educating not only the general public but also healthcare providers. The Osteoporosis Research Center has http://emir.tums.ac.ir/osteo ) and launched both a Persian ( 2010 2020 2050 http://emir.tums.ac.ir/osteo-en an English website ( ), aiming US Census Bureau REF 1

2 8 . In a cross-sectional investigation assessing lumbar spine KEY FINDINGS risk factors for osteoporosis, ninety women aged 48.5 ± 8.3 years, 27.8% were found to be osteopenic at The present population in Iran is estimated to be 76 the lumbar spine and 35.6% at the femoral neck. The million, of this 14% (11 million) is 50 years of age or 6 (table 1 and fig 2) prevalence of osteoporosis was 13.3% . over and 3% (2.6 million) is 70 or over. By 2050, it is estimated that 34% (42 million) of the population will be 50 or over and 11% (14 million) will be 70 or over while Hip fracture the total population will increase to 127 million . (fig 1) In a nationwide prospective study assessing the burden of hip fracture in Iran, Iran accounted for 0.85% of the EPIDEMIOLOGY global burden of hip fracture and 12.4% of the burden 9 . In Iran, it is estimated that currently around 34% of of hip fracture in the Middle East the total population has osteopenia, and according to In 2010, the number of hip fractures in people aged the Endocrinology and Metabolism Research Center over 50 years is estimated to be 472.1 cases per 100 000 (EMRC), two million people are at risk of fracture, establishing osteoporosis as one of the chief health population (fig 3) . 6,7 . problems in the country Number of hip fractures for 2010 and projections for 2020 and 2050 in people aged over 50 years in Iran Number of hip fractures in 2010 and FIGURE 3 In a 2008 study by Hosseinapanah et al., 11% of 245 projections for 2020 and 2050 in people aged randomly selected postmenopausal women with a mean 7 over 50 years age of 57.7 ± 7 years were found to be osteoporotic in the femoral neck and 25.3% were osteoporotic in the 120 000 # of hip fractures 100 000 TABLE 1 Osteoporosis and osteopenia in 2010 and projection 80 000 YEAR OSTEOPOROSIS OSTEOPENIA 3 024 798 25 969 046 2010 60 000 40 303 730 3 592 708 2020 40 000 44 276 071 5 548 203 2050 20 000 FIGURE 2 Number of people (in millions) with osteopenia and osteoporosis in 2010, 2020 and Number of hip fractures for 2010 and projections for 2020 and 2050 in people aged over 50 years in Iran 6 2050 2050 2010 2020 osteopenia osteoporosis 50 A 2005 cohort study in Shiraz, Iran, included 1,833 osteoporosis hip fracture patients with a mean age of 74.3 years in women and 74.2 years in men. The age-adjusted osteopenia 40 incidence rates of hip fracture standardized to the 1985 US white population were 325.7/100 000 for men and 30 519.1/100 000 for women. The age-adjusted incidence rates of hip fracture standardized to the 1989 US white population were 384.6/100 000 for men and 20 10 . In a prospective survey 548.2/100 000 for women by Moayyeri et al. conducted in 9 provinces across the 10 country, the age-standardized annual incidence rates of hip fracture were estimated at 127.3/100 000 and 11 . 164.6/100 000 for males and females respectively 2010 2020 2050 2

3 In an Iranian study assessing falls leading to hip fracture, are about 52 DXA in Tehran, the capital of Iran, and about 74 other devices in the other 30 provinces in the Abolhassani et al found that the crude annual incidence of fall events and related hip fractures for those over the country (the number of devices in these provinces range age of 50 years were 237.1 and 93.6 per 100 000 person- from 1 to 8). DXA is available in nearly all big cities all 12 . years, respectively across the country. It should be noted that DXA is not available in five provinces. There is no waiting time for a DXA scan as it is performed at the same time the patient In Iran, 84.3 % of cervical and trochanteric femoral fractures are surgically treated. The average number of is referred to the imaging centre. hospital bed days for all hip fractures is 8.3 days. The cost of a DXA assessment is USD 48.50 and ultra sound costs the same. 13 Direct costs of hip fractures (USD) TABLE 2 REIMBURSEMENT POLICY TOTAL DIRECT COST YEAR (IN MILLION USD) The governmental insurances reimburse 70% of the 28 2010 cost of a DXA assessment. It should be noted that 51 2020 Khadamat Darmani, one of the main governmental 250 2050 insurances, only reimburses the cost if the prescription is written by an endocrinologist, rheumatologist or nephrologist. The governmental insurances pay the price of all Iranian-made osteoporotic medications, Comparative tables of hospital bed TABLE 3 except for PTH analogues. days and costs DIRECT TOTAL Private health care insurance reimburse 100% of HOSPITAL COSTS (IN COSTS (IN the DXA exam and all Iranian made osteoporotic PATHOLOGY BED, DAYS MILLION MILLION medications. PER YEAR USD) USD) Hip fractures CALCIUM AND VITAMIN D 28 300 000 n/a (surgical treatment Calcium, vitamin D supplements and fortified foods are available in Iran. However, only milk and some fruit - Heart dis 74 n/a 328 904 15,16 juices are products fortified with calcium and vitamin ease 17 D in Iran. These products are not available everywhere 743 2429 590 Other and few individuals use them. In collaboration with the Iranian Ministry of Health and Medical Education, EMRI is conducting a project aiming to point out the Ahmadi-Abhari et al. conducted a study in which the Global Burden of Disease method created by the WHO benefits of using fortified milk in different groups. Apart was applied. It was found that hip fractures yielded an from this project, the country holds several seminars overall 1.9 DALY (disability-adjusted life years) per 1000 and congresses to increase public awareness regarding 14 . The DALY osteoporosis and the importance of taking supplements of the population above 50 years of age and fortified milk to strengthen bones. Many per 1000 for both Iranian men and Iranian women was 9 programmes on related issues are also broadcast in the . lower than that of their counterparts worldwide national mass media (television, radio and newspapers). Vertebral fracture PREVENTION, EDUCATION, LEVEL OF AWARENESS No available information. DIAGNOSIS As a health priority in Iran osteoporosis related fractures form part of the country’s surveillance programme, undertaken by various governmental and non- In total, there are 126 DXA machines in Iran (0.017 per governmental agencies: 10 000 population). Considering the available data there 3

4 • The country has managed to develop an Iranian RECOMMENDATIONS osteoporosis network which aims to increase public awareness in different parts of the country and Considering the lack of information regarding the accurate burden of osteoporosis in Iran and the lack of improve patient care, and to conduct multi-centre any fracture registries in the countries, the majority of research in this field. In a study applying the the reports and studies conducted in this field seem to be Health Belief Model for Osteoporosis Prevention incomplete. However, certain national projects will be among middle school girl students, 76% of implemented, which will give us more accurate data on students admitted to ingestion of less than 670 mg of calcium daily before the study intervention. the mentioned fields in the coming years. After the intervention, 74% of the students REFERENCES increased their intake to between 650 and 1300 mg of calcium. Furthermore, 50% of the girls in the Larijani B, Bonjour J, Aghaei Meybodi HR, Mohajery Tehrani M (2007) 1. Osteoporosis in Iran, overview and management. Iranian J Publ Health; intervention arm had less than 20-30 minutes of Supplement Osteoporosis: 1-13 physical activity three times a week before, and this 2. Aghaei Meybodi HR, Heshmat R, Maasoumi Z, Soltani A, Hossein- 18 Nezhad A, Keshtkar A, et al. (2008) Iranian Osteoporosis Research . increased to 89% Network: Background, Mission and Its Role in Osteoporosis Management. Iranian J Publ Health; A supplementary issue on Osteoporosis and Bone • Holding various public education seminars, Turnover(1):1-6 particularly in October concurrent with World 3. Maalouf G, Gannage-Yared M, Ezzedine J, Larijani B, Badawi S, Rached osis. J A, et al. (2007) Middle East and North Africa consensus on osteopor Osteoporosis Day. Musculoskelet Neuronal Interact. 7(2):131-43 • Several pamphlets, booklets and posters on various Aghaei Meybodi HR, Khashayar P, Heshmat R, Rezaei Homami M, 4. Nabipour I, Rajabian R, Omrani GH, Bahrami A, Larijani B. The osteoporosis-related topics are developed and sent to prevalence of osteoporosis in an Iranian Population. [Unpublished Data] different parts of the country. 5. Salehi I, Khazaeli S, Najafizadeh SR, Ashraf H, Malekpour M (2009) High prevalence of low bone density in young Iranian healthy individuals. Clin • A national osteoporosis guideline has been developed. Rheumatol 28: 173-177 • A multicenter study on the prevalence of osteoporosis Aghaei Meybodi HR, Khashayar P, Heshmat R, Rezaei Homami M, 6. Nabipour I, Rajabian R, Omrani GH, Bahrami A, Larijani B. The and vitamin D deficiency is being conducted in prevalence of osteoporosis in an Iranian Population [Unpublished Data] several major Iranian cities. Keshtkar A, Larijani B, Satleghi M, Majidian M, Heshmat R (2010) The 7. incidence of osteoporotic hip fracture in Iran, a review. Osteoporos Int 21 • Several workshops and seminars are being held to (Suppl. 1) keep health professionals working in the related Hosseinpanah F, Rambod M, Hossein-nejad A, Larijani B, Azizi F. (2008) 8. Association between vitamin D and bone mineral density in Iranian fields updated. postmenopausal women. J Bone Miner Metab 26: 86-92 9. Ahmadi-Abhari S, Moayyeri A, Abolhassani F. (2007) Burden of hip fracture in Iran. Calcif Tissue Int 80: 147-153 A National Guideline for Osteoporosis Prevention, 10. Soveid M, Serati AR, Masoompoor M (2005) Incidence of hip fracture in Shiraz, Iran. Osteoporos Int 16:1412-1416 Diagnosis and Management has already been 11. Moayyeri A, Soltani b, Larijani B, Naghavi M, Alaeddini F, Abolhassani developed and is to be revised and translated in F (2006) Epidemiology of hip fracture in Iran: results from the Iranian multicenter study on accidental injuries. Osteoporos Int 17: 1252-1257 English for regional use. Guidelines have been issued Abolhassani F, Moayyeri A, Naghavi M, Soltani A, Larijani B, Shalmani HT 12. for nurses, physiotherapists and nutritionists working (2006) Incidence and characterisitics of falls leading to hip fracture in Iranian population. Bone 39: 408-413 in this field. Aghaei Meybodi HR, Khashayar P, Heshmat R, Rezaei Homami M, 13. Nabipour I, Rajabian R, Omrani GH, Bahrami A, Larijani B. The prevalence of osteoporosis in an Iranian Population [Unpublished Data] The Iranian Osteoporosis Society (IOS) is actively Johnell O, Kanis JA (2004) An estimate of the worldwide prevalence, 14. collaborating to increase public awareness in the field mortality and disability associated with hip fracture. Osteoporos Int 15: 897-902 of osteoporosis. In this regard, it provides both general 15. Larijani B, Fakhrzadeh H, Mohaghegh M, Pourebrahim R, Akhlaghi MR public and healthcare providers with related information (2003) Burden of coronary heart disease on the Iranian oil industry. Eastern Mediterranean Health Journal 9(5-6) through its site (emir.tums.ac.ir/ios). It also helps in 16. Hadaegh F, Harati H, Ghanbarian A, Azizi F (2009) Prevalence of coronary the development of material on various osteoporosis- heart disease among Tehran adults : Tehran Lipid and Glucose Study. Eastern Mediterranean Health Journal 15(1): 157- 166 related topics and sends it to different parts of the Madanchi N, Pajouhi M, Mohajeri Tehrani MR, Heshmat R, Tabatabaei 17. Melazi O, Larijani B. The efficacy of care provided for diabetic foot patients country. While multi-centric projects are being carried in Shariati and Imam Khomeini Hospital [Unpublished Data] out, a recent study has shown that Iranians have a low 18. Hazavehei SM, Taghdisi MH, Saidi M (2007) Application of the health belief model for osteoporosis prevention among middle school girl students, knowledge regarding the importance of calcium and Garmsar, Iran. Education for Health 20(1): 1-11 vitamin D consumption in improving bone health. Their 19. Azemati, B, Heshmat, R, Keshtkar, AA, Bagheri, M, Sheykholeslam, R, Nadim, A (2010) Comparison of knowledge, attitude and practice of urban knowledge regarding sources of foods rich in calcium, on and rural households towards nutritional factors related to osteoporosis and 19 the other hand, was relatively higher . osteopenia. Iranian Journal of Epidemiology 5(4): 14-20 4

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