Osteoporosis and fragility fracture prevention in Belgium

Belgium has not prioritised osteoporosis and fragility fractures in national policies. While local champions in some areas have implemented fragility fracture care pathways, national programmes to improve care have not been developed and services vary considerably.

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Osteoporosis and fragility fracture prevention in Belgium

Burden and impact of osteoporosis and fragility fractures

Osteoporosis affects many older people in Belgium, and fragility fractures impose a considerable cost. According to the most recent estimates, 600,000 people in Belgium had osteoporosis in 2010.1

Building a system that works: policies for scrutiny, accountability and investment

Building a system that works: policies for scrutiny, accountability and investment

National guidance for managing osteoporosis has been developed,2 3 but there are no policies to ensure clinical practice follows this guidance.4 Reimbursement data have sometimes been analysed to assess the use of specific services, such as dual-energy X-ray absorptiometry (DXA) scans,5 but there are no national audits or databases to monitor and evaluate care for osteoporosis or fragility fractures.4

Changes to reimbursement policy in recent years have improved access to some first-line treatments for osteoporosis. Reimbursement of all osteoporosis medications was previously restricted to people who met specific eligibility criteria, such as those diagnosed with osteoporosis or who had a previous fracture.2 3 This resulted in severely limited access to these medications.6 But recent revisions to reimbursement policy mean there are no longer specific criteria for reimbursement of some first-line treatments, although the criteria have become more stringent for second-line treatments.4

Co-payments are required for prescription medications in Belgium,7 but out-of-pocket expenses for osteoporosis medication are generally thought to be low.4 Vulnerable groups are entitled to additional financial support,7 aiding access to necessary treatments.

In 2011, Belgium had the highest proportion of DXA machines per capita among 27 European countries6 – they are widely available and waiting times are short.4 But DXA scans are only reimbursed for certain groups, such as women over 65 years of age who have a family history of osteoporosis, people who have already had a fragility fracture, or people with another condition known to cause osteoporosis.3 This means many people lack access to investigation before a first fracture occurs.

Catching it early: detection and management in primary care

Catching it early: detection and management in primary care

Guidance recommends assessment of fracture risk,3 but diagnosis of osteoporosis is often not prioritised. Primary care organisations in some parts of Belgium are engaged with falls and fracture prevention and have developed relevant guidelines.8 9

Clinical recommendations support the use of risk assessment algorithms such as the Fracture Risk Assessment Tool (FRAX) before conducting further investigations or prescribing treatment.3 However, Belgium seems to lack programmes that encourage early detection of osteoporosis, and general practitioners (GPs) may not be confident in diagnosing and treating it.4 Fracture risk is under-investigated – a 2013 survey found that around a third of GPs were aware of FRAX but fewer than 20% reported using it in daily practice.10

In the absence of national programmes to promote early diagnosis of osteoporosis, there is little incentive for primary care professionals to initiate investigation.

Getting people back on track: facilitating multidisciplinary post-fracture care

Getting people back on track: facilitating multidisciplinary post-fracture care

There is great variation in care; it is really a lottery. It depends on the individual hospital or the individual GP.
MICHAËL LAURENT, BELGIAN BONE CLUB

Geriatric care is integrated into treatment of older people in hospitals, but the management of fragility fractures can vary. The national geriatric programme includes the implementation of ‘internal liaison teams’.11 In some hospitals, these specialist teams are available to assess all people aged 75 years and over who have been admitted to any department, identifying those who require specialist geriatric care.11 In other hospitals, multidisciplinary teams are engaged in the identification and treatment of osteoporosis and fragility fractures.4 While there are no national programmes or standards for fragility fracture care, in a few hospitals these teams aid the identification of older people who should be assessed for osteoporosis and who require orthogeriatric management.4

Some hospitals have dedicated orthogeriatric units, such as Imelda Hospital in Bonheiden,4 or osteoporotic fracture care pathways, such as the pharmacist-led pathway in AZ Sint-Jan hospital12 These programmes tend not to be formally monitored or evaluated, and financial support is extremely limited, so care can vary considerably between hospitals.4

Implementation of hospital-based fracture liaison services (FLS) in Belgium is increasing, but with little policy support.4 There is also notable variation in care. For example, the use of DXA scans varies hugely, with some districts conducting nearly 10 times as many scans as others each year.5 Clinicians from a range of specialties have implemented FLS in some hospitals to identify, investigate and initiate treatment for people with osteoporosis, but limited funding is a considerable challenge.4 It is not clear how many of these services perform against international best-practice standards as only four FLS in the country have been evaluated through Capture the Fracture. Of these, one has been awarded a silver rating, two have been awarded bronze and one is in progress.13

Supporting quality of life as part of healthy and active ageing: prevention of falls and fractures in later life

Supporting quality of life as part of healthy and active ageing: prevention of falls and fractures in later life

The number of falls in care homes is one of the indicators used by the national government to assess healthcare system performance, but data are only available for Flanders,14 because Brussels and Wallonia do not collect data on falls. To support and promote falls prevention, the Flemish government collaborates with the Flanders Fall and Fracture Prevention Expertise Centre (Expertisecentrum Val- en fractuurpreventie Vlaanderen).15 The Centre provides information on effective strategies to prevent falls in both care homes and the community.16 It runs annual awareness campaigns, produces educational materials and offers training courses for healthcare providers and informal carers.17

Engaging patients and public: awareness, activation and self-management

Engaging patients and public: awareness, activation and self-management

Public engagement with osteoporosis and fragility fracture prevention seems to be limited,4 with few activities to increase awareness. Information is available from GP organisations, which have developed guidelines and online resources to support falls and fracture prevention.8 9 There used to be a national osteoporosis patient organisation but it no longer seems to be active.4 The Belgian Bone Club works to improve osteoporosis prevention and management, but its activities target healthcare professionals and researchers while public-facing activities remain limited.18 While many countries across Europe and around the world participate in World Osteoporosis Day, there are no official events planned in Belgium.19

Self-management among people who have osteoporosis is suboptimal. Data from 2003–2008 – the most recent figures available – showed that people frequently stopped taking osteoporosis medication within the first three months after it was prescribed.3

This information is based on research conducted for the 2020 publication Osteoporosis and fragility fractures: a policy toolkit.
Date of preparation: October 2020.
Hub-PRO-0820-00003
References +
  1. Svedbom A, Hernlund E, Ivergard M, et al. 2013. Osteoporosis in the European Union: a compendium of country-specific reports. Archives of osteoporosis 8: 137
  2. Body JJ, Bergmann P, Boonen S, et al. 2010. Evidence-based guidelines for the pharmacological treatment of postmenopausal osteoporosis: a consensus document by the Belgian Bone Club. Osteoporosis international 21(10): 1657-80
  3. Belgian Health Care Knowledge Centre. 2011. Prévention médicamenteuse des fractures ostéoporotiques. Brussels: KCE
  4. Laurent M. 2019. Interview with Taylor Morris at The Health Policy Partnership [telephone]. 03/10/19
  5. Meeus P, Dalcq V, Geystelen AV. 2019. Medical practice variations: bone densitometry (50 years and older). Brussels: Directorate for Research Development and Quality promotion: appropriate care unit
  6. Kanis JA, Borgstrom F, Compston J, et al. 2013. SCOPE: a scorecard for osteoporosis in Europe. Archives of osteoporosis 8: 144
  7. Vogler S, Haasis MA, Dedet G, et al. 2018. Medicines reimbursement policies in Europe. Copenhagen: World Health Organisation
  8. Société Scientifique de Médecine Générale. 2008. Recommandations de bonne pratique: Prévention des chutes chez les personnes âgées. Brussels: SSMG
  9. Domus Medica. 2015. Praktijkinstrumenten val- en fractuurpreventie. Antwern: Domus Medica
  10. Bruyere O, Nicolet D, Compere S, et al. 2013. Perception, knowledge, and use by general practitioners of Belgium of a new WHO tool (FRAX) to assess the 10-year probability of fracture. Rheumatology international 33(4): 979-83
  11. Baeyens J. 2010. Belgian care programme for older patients. The journal of nutrition, health & aging 14(6): 474-75
  12. Saey S, Piette Y, Verstraete B, et al. 2018. Building for better bones: evaluation of a clinical pathway in the secondary prevention of osteoporotic fractures. Eur J Hosp Pharm 25(4): 210-13
  13. International Osteoporosis Foundation. 2019. Capture the Fracture. Map of best practice. Available from: www.capturethefracture.org/map-of-best-practice-page [Accessed 01/09/20]
  14. For a Healthy Belgium. Care for the elderly. [Updated 25/04/19]. Available from: www.healthybelgium.be/en/health-system-performance-assessment/specific-domains [Accessed 01/09/20]
  15. Expertiscenetrum Val- en fractuurpreventie Vlaanderen. Week van de Valpreventie. Available from: www.valpreventie.be/week-van-de-valpreventie-algemene-informatie [Accessed 07/10/20]
  16. Expertiscenetrum Valpreventie Vlaanderen. Het Expertisecentrum. Available from: www.valpreventie.be [Accessed 01/09/20]
  17. Expertiscenetrum Val- en fractuurpreventie Vlaanderen. Aanbod. Available from: www.valpreventie.be/aanbod [Accessed 01/09/20]
  18. Belgian Bone Club. The Belgian Bone Club. Available from: www.bbcbonehealth.org [Accessed 01/09/20]
  19. International Osteoporosis Foundation. World Osteoporosis Day. Available from: www.worldosteoporosisday.org [Accessed 01/09/20]