By 2025, it is estimated that 4.5 million fragility fractures will occur in the European Union (EU) each year, and that 34 million people will be living with osteoporosis, a chronic disease which weakens bones and leaves people at risk of a fragility fracture.1

Few diseases affect so many of us as we grow older: approximately 1 in 2 women and 1 in 5 men in Europe over 50 years of age will experience a fragility fracture in their lifetime1 – often leading to a loss of mobility and independence.2

This represents a huge economic burden. Fragility fractures in 2010 were estimated to cost €37.4 billion to EU healthcare systems, which accounted for around 3% of healthcare costs, significantly higher than for many other leading chronic diseases.1 3

Yet osteoporosis and fragility fractures have for too long been ignored in health policy and European research agendas.4 5 Even policies, strategies and programmes that focus on healthy ageing and women’s health may ignore the impact of osteoporosis and fragility. This has left millions of people – mostly women – without access to the care and support they need to live full, independent lives.

By prioritising osteoporosis and fragility fractures, gender differences in health and wellbeing can be reduced. In addition, the quality of life of older people can be enhanced and the financial sustainability of our already stretched healthcare systems can be strengthened.

As the authors, contributors and supporters of this policy toolkit, we cannot accept a future where preventable fragility fractures are allowed to cause such needless suffering and cost. The time has come for urgent action on osteoporosis and fragility fractures, uniting patient, carer and clinical leadership with wider societal and political advocacy actors in order to strengthen the call for change.

We endorse the policy aspirations of the International Osteoporosis Foundation and the Fragility Fracture Network’s global call to action6 and seek to play our part in building wider societal and political awareness for progress and change. We have developed specific calls to action for European institutions, national leadership and regional and local systems.

Call to action for European institutions

The European Union should recognise the scale of societal and structural interests at stake, and foster strategic cooperation between countries.

European institutions, including the European Commission (in cooperation with member states) and the European Parliament, should:

Call to action for national leadership

Historical failures in the care of osteoporosis and the prevention of fragility fractures are profound and will not be resolved without political, whole‑system leadership.

We call on policymakers to ensure public policy is fit for purpose in light of future demands. Specifically, we call on governments, parliaments, payers and national public health institutes to, at a minimum:

  • Integrate osteoporosis, fragility fractures and falls prevention into high-level national strategies and plans for health and healthcare, including those which aim to address chronic diseases and women’s health.
  • Acknowledge the huge significance of fragility fractures by ensuring they are integrated into wider societal plans, including those for population health, healthy ageing, long-term care including informal care, and workforce productivity.
  • Develop a national consensus on preventing fragility fractures through more systematic identification of people with osteoporosis. This should include consideration of screening specific groups. Any national decision on screening must be based on national epidemiological and economic data, including the feasibility and cost-effectiveness of integrating osteoporosis screening alongside other screening programmes, such as those for breast cancer.
  • Adopt and encourage the implementation of clinical guidelines for osteoporosis and fragility fracture prevention and care. These guidelines should be available in the national language and, at a minimum, include nationally approved risk assessment tools, as well as timely referral and access to osteoporosis diagnosis.
  • Ensure that reimbursement structures reflect national scientific consensus on detection, care and prevention of osteoporosis and fragility fractures. Reimbursement decisions should reflect the true costs of fragility fractures to the wider healthcare system and society. At a minimum, there should be reimbursement for nationally recommended diagnostic tools (such as dual-energy X-ray absorptiometry (DXA) scanning and the Fracture Risk Assessment Tool (FRAX) and treatments.
  • Develop nationwide registries and audits to enable local-level monitoring and surveillance of patient health outcomes. This should include collecting and monitoring data on the diagnosis of osteoporosis and for the prevention and care of fragility fractures, spanning hip and vertebral fractures at a minimum. Policymakers should also consider how these data could be used to incentivise improvements in the quality of care.
  • Actively support efforts to improve public awareness of osteoporosis, fragility fractures and falls prevention. This includes ensuring people have a clear understanding of their personal risk factors and the preventive options available to them.

Call to action for regional and local systems

Improvements to people’s lives will ultimately be driven by improved access to appropriate prevention and care at a local level.

We call on health system leaders, including payers and the medical community, to invest in sustainable, multidisciplinary care models for osteoporosis, fragility fractures and falls prevention, which span hospital, primary and community care settings. This will require:

  • Primary care professionals to take a leadership role in the detection, management and care of osteoporosis and fragility fractures. Specific roles and responsibilities in primary care should be developed with professional bodies and payers. Delegation to other roles (e.g. pharmacists, specialist nurses and physiotherapists) should be considered alongside requirements for professional education and training for all involved.
  • Every locality to develop and adopt an osteoporosis and fragility fracture care pathway. This should include the development of local criteria to establish to whom the pathway should be applied.
  • Ensuring the availability of person-centred multidisciplinary models of care with demonstrated impact on reducing the risk of repeat fractures and death. At the very least, every general hospital should offer orthogeriatric services and a coordinated follow-up service (e.g. fracture liaison service) so that every fracture patient has the option to be treated or referred there for care and immediate follow-up post-fracture. This care should be delivered in a way that addresses people’s needs and respects their preferences.
  • Ensuring that a comprehensive falls assessment is available for every geriatric patient. This should be available in clinical settings as well as community settings (such as specialist housing and people’s own homes) and offer the opportunity for self-assessment. It should bring together multidisciplinary input and risk factor management for falls alongside detection and treatment of osteoporosis.
Date of preparation: October 2020.
References +
  1. Hernlund E, Svedbom A, Ivergard M, et al. 2013. Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Archives of osteoporosis 8: 136
  2. Ross PD. 1997. Clinical consequences of vertebral fractures. The American journal of medicine 103(2a): 30S-42S; discussion 42S-43S
  3. Wilkins E, Wilson L, Wickramasinghe K, et al. 2017. European cardiovascular disease statistics 2017. Brussels: European Heart Network
  4. European League Against Rheumatism (EULAR). 2017. RheumaMap. A Research Roadmap to transform the lives of people with Rheumatic and Musculoskeletal Diseases. Brussels: EULAR
  5. Briggs AM, Persaud JG, Deverell ML, et al. 2019. Integrated prevention and management of non-communicable diseases, including musculoskeletal health: a systematic policy analysis among OECD countries. BMJ Global Health 4(5): e001806
  6. Dreinhöfer KE, Mitchell PJ, Bégué T, et al. 2018. A global call to action to improve the care of people with fragility fractures. Injury 49(8): 1393-97
  7. European Innovation Partnership on Active and Healthy Ageing. Welcome to the EIP on AHA portal. Available from: [Accessed 06/10/20]
  8. Chrodis Plus. Chrodis+: Implementing good practices for chronic diseases. Available from: [Accessed 03/12/19]
  9. Joint Action European Union. 2019. ADVANTAGE JA -A comprehensive approach to promote a disability-free Advanced age in Europe: the ADVANTAGE initiative. Available from: [Accessed 01/09/20]
  10. European Commission. European Social Fund. Available from: [Accessed 07/10/20]
  11. OECD/EU. 2018. Health at a glance: Europe 2018: State of health in the EU cycle. Paris: Publishing O
  12. European Commission. Steering Group on Health Promotion, Disease Prevention and Management of Non-Communicable Diseases. Available from: [Accessed 07/10/20]
  13. European Commission. Expert Panel on effective ways of investing in health: Overview. Available from: [Accessed 07/10/20]
  14. European Agency for Safety and Health at Work. OSH strategies. Available from: [Accessed 07/10/20]
  15. European Commission. Horizon Europe – the next research and innovation framework programme. Available from: [Accessed 07/10/20]