Osteoporosis and fragility fracture prevention in Bulgaria

While osteoporosis was a policy priority in Bulgaria until 2010, more recent efforts to raise its profile at the national level have not been successful. Accordingly, programmes to improve prevention and treatment of osteoporosis, fragility fractures and falls have not been developed in the last decade. A shortage of national data makes it difficult to assess the scale of the problem, and the lack of reimbursement is a significant barrier to appropriate care.

 

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Osteoporosis and fragility fracture prevention in Bulgaria

Burden and impact of osteoporosis and fragility fractures

The burden of osteoporosis in Bulgaria is significant, although the amount spent on osteoporosis care is among the lowest in Europe.1 2 Based on European estimates, it is thought that approximately 21% of women and 6% of men aged 50 and over are estimated to be living with osteoporosis in Bulgaria.1 2 This contributed to approximately 38,000 fragility fractures in 2010, a figure that is expected to increase to 40,000 by 2025.1 In 2010, the health system spent around €42 million on osteoporosis, equating to €6 per capita – lower than every other country in the European Union except Romania.1 2

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

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

Osteoporosis and fragility fractures are not currently prioritised at the policy level and there is no national registry to collect relevant data. The National Osteoporosis Programme 2006–2010 was implemented to reduce the burden of osteoporosis and improve care,3 but was terminated after the initial period of five years. Since then, there have been no further national efforts to address osteoporosis or fragility fractures, despite repeated calls for new programmes.4 5 The current National Health Strategy action plan mentions the need to implement a new osteoporosis programme between 2016 and 2020,6 and some proposals have been developed, but these were not adopted by the Ministry of Health.5 In line with this seeming lack of national interest, there is no national registry to collect any data related to osteoporosis or fragility fractures.5

Reimbursement policy in Bulgaria may restrict access to osteoporosis diagnosis and treatment. Healthcare is provided through the public National Health Insurance Fund but out-of-pocket spending is relatively high, particularly for pharmaceuticals.7 In 2014, 79% of pharmaceutical costs were paid out of pocket, leading to some concern over access to medications in Bulgaria.7 Indeed, in 2010 it was estimated that 98% of men and 95% of women with osteoporosis were not being treated,1 a problem reportedly related to the low level of reimbursement.4 Osteoporosis medication is partially reimbursed for postmenopausal women but dual-energy X-ray absorptiometry (DXA) scans are  not covered by the National Health Insurance Fund, restricting access for many people.5 8 9

Catching it early: detection and management in primary care

Catching it early: detection and management in primary care

Assessment of fracture risk is recommended in clinical guidelines, but may not be routinely implemented. Clinical guidelines published by the Bulgarian Society for Endocrinology recommend that fracture risk is assessed in all women aged 50 and over using medical history and the Fracture Risk Assessment Tool (FRAX®), followed by a DXA scan if necessary.10 However, FRAX® is often not used in practice, reportedly due to the lack of a reliable country-specific model and the fact that it is not linked to reimbursement of treatment.5 Given the lack of available data in the country, it is not clear how often osteoporosis is detected before a first fracture occurs.

General practitioners (GPs) are usually responsible for the ongoing management of people with osteoporosis, but they often face significant barriers to providing best-practice care. To initiate treatment, women at risk of osteoporosis should be referred by their GP to a specialist for an initial appointment, where they receive a prescription for osteoporosis medication if they are diagnosed with the disease.5 After this appointment, the GP generally takes responsibility for further monitoring and the continued management of the patient.5 However, it may be challenging for GPs to refer all eligible women to a specialist for osteoporosis as they are limited to a certain number of specialist referrals per month and other conditions are often prioritised.5 In addition, the lack of reimbursement for DXA scans makes it difficult for clinicians to diagnose osteoporosis or monitor any changes in bone density and make informed decisions about stopping, continuing or changing medications in the medium to long term.5

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

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

Clinical practice and reimbursement policy may inhibit access to osteoporosis treatment for people who have sustained a fragility fracture. Fragility fractures in Bulgaria are primarily treated by orthopaedic surgeons with little input from other specialists. While orthopaedic surgeons usually do not prescribe osteoporosis treatment, a person who has experienced a fragility fracture will frequently be referred to a rheumatologist or endocrinologist by the orthopaedic surgeon or the GP.5 However, according to an expert interviewed for this country profile, fragility fractures are not part of the eligibility criteria for reimbursement of osteoporosis medication in Bulgaria, which is a significant barrier to appropriate post-fracture care and prevention of subsequent fractures.5

Prescribing osteoporosis medication after a hip fracture is a good common-sense measure. However, this strategy has not been adopted in Bulgaria. MIHAIL BOYANOV, UNIVERSITY HOSPITAL ALEXANDROVSKA, MEDICAL UNIVERSITY SOFIA

Post-fracture follow-up care does not appear to be well-established in Bulgaria. There do not seem to be any fracture liaison services (FLS) or similar programmes.5 11 There have reportedly been some efforts to implement such services, but limited cooperation between specialists and a lack of national funding has restricted roll-out.5

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

There is some national interest in healthy ageing, but little attention seems to have been paid to falls prevention in Bulgaria. The Ministry of Labour and Social Policy has published a national ageing strategy, which focuses on supporting older people to remain socially and economically active and includes some references to health.12 The National Health Strategy 2020 also discusses the importance of supporting healthy ageing and increasing life expectancy through improving lifestyle factors.13 However, neither of these documents discusses preventing falls or fractures, and there does not currently seem to be any significant governmental interest in such initiatives.5

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

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

There has been some public education activity at a local level, but national organisations are primarily oriented towards professionals rather than the public. Some local campaigns have been implemented in recent years, often focused on providing free or reduced-price DXA scans.9 14-16 These campaigns have been linked to World Osteoporosis Day and International Women’s Day.9 14-16 In 2019, a city-wide World Osteoporosis Day awareness campaign was implemented in Burgas, which included risk assessments and a range of educational materials.17 Civil society organisations, including the Bulgarian Rheumatology Society,18 the Bulgarian Endocrinology Society19 and the Bulgarian Society for Clinical Densitometry,20 are engaged in improving osteoporosis care but focus primarily on professionals.

Most people who are prescribed osteoporosis medication continue taking it for at least the first year. While the type of medication and the frequency with which it is taken affect adherence,21 a study looking at one particular drug found that the proportion of people still on medication after two years was 58.9%.22

 

This information is based on research conducted in 2020.
Date of preparation: February 2021    HB-PRO-1220-00013
References +
  1. Svedbom A, Hernlund E, Ivergard M, et al. 2013. Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporos 8: 137
  2. 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). Arch Osteoporos 8: 136
  3. Ministry of Health. The National Osteoporosis Program 2006-2010 will limit the risk of disease and cases of disability. [Updated 29/06/06]. Available from: www.mh.government.bg/bg/novini/aktualno/natsionalnata-programa-za-borba-s-osteoporozata-20 [Accessed 27/04/21]
  4. National Assembly of the Republic of Bulgaria. A national program for limiting osteoporosis in Bulgaria for a new five-year period is needed, said Dr Nigar Jafer, Chairman of the Health Care Committee. [Updated 10/04/14]. Available from: www.parliament.bg/bg/news/ID/3088 [Accessed 27/04/21]
  5. Boyanov M. 2020. Interview with Taylor Morris at The Health Policy Partnership [telephone]. 28/05/20
  6. Ministry of Health of the Republic of Bulgaria. 2016. Action plan for the completion of the National Health Strategy 2020. Sofia: Ministry of Health
  7. Dimova A, Rohova M, Atanasova E, et al. 2017. Drug policy in Bulgaria. Value Health Reg Issues 13: 50-54
  8. Dexa Medical. Center for osteoporosis and osteometry – Varna. Available from: www.dexamedical.com [Accessed 27/04/21]
  9. Bulgarian National Radio. Campaign for prevention of osteoporosis in Varna. [Updated 10/03/20]. Available from: www.bnr.bg/varna/post/101238437/kampania-za-prevencia-na-osteoporozata-vav-varna [Accessed 27/04/21]
  10. Bulgarian Society of Endocrinology. 2019. Recommendations for good practice in osteoporosis. Sofia: Bulgarian Society for Endocrinology
  11. Capture the Fracture. Map of Best Practice. Available from: www.capturethefracture.org/map-of-best-practice [Accessed 27/04/21]
  12. Ministry of Labour and Social Policy. National strategy for an active life of adults in Bulgaria (2019-2030). Sofia: Ministry of Labour and Social Policy
  13. Ministry of Health. 2016. National Health Strategy 2020. Sofia, Bulgaria: Ministry of Health
  14. Peycheva G. They measure bone density in an osteoporosis campaign. [Updated 07/10/19]. Available from: www.dariknews.bg/regioni/stara-zagora [Accessed 27/04/21]
  15. Darik News. They measure bone density in an osteoporosis campaign. [Updated 09/10/17]. Available from: www.dariknews.bg/regioni/ruse [Accessed 27/04/21]
  16. Vratsa D. Prophylactic free bone density tests in Montana. [Updated 30/11/18]. Available from: www.dariknews.bg/regioni/vraca [Accessed 27/04/21]
  17. World Osteoporosis Day. World Osteoporosis Day in Burgas, Bulgaria. [Archived web content]
  18. Georgiev T, Stoilov R. 2019. Bulgarian rheumatology: science and practice in a cost-constrained environment. Rheumatol Int 39(3): 417-29
  19. Bulgarian Society of Endocrinology. Good practices. Available from: www.endo-bg.com/dobri-praktiki [Accessed 27/04/21]
  20. International Osteoporosis Foundation. Bulgarian Society for Clinical Densitometry. Available from: www.osteofound.org/member_societies [Accessed 27/04/21]
  21. Petranova T, Boyanov M, Shinkov A, et al. 2017. Medication-taking behaviour in Bulgarian women with postmenopausal osteoporosis treated with denosumab or monthly oral bisphosphonates. Arch Osteoporos 13(1): 1
  22. Kuzmanova SI, Solakov PC, Geneva-Popova MG. 2011. Adherence to bisphosphonate therapy in postmenopausal osteoporotic women. Folia Med (Plovdiv) 53(3): 25-31