Osteoporosis and fragility fracture prevention in Croatia

Osteoporosis and fragility fractures are not currently prioritised in Croatian health policy, despite hip fractures being identified as a leading cause of death in the country. The national health system provides good access to diagnostics and treatment, but there are no dedicated services to ensure the necessary care is provided to people living with osteoporosis – particularly those who have already sustained a fragility fracture. In the absence of a national database, policymakers cannot assess the scale of the problem or identify key areas for improvement. Policy action is needed to improve disease surveillance and support the delivery of multidisciplinary post-fracture services.

 

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Osteoporosis and fragility fracture prevention in Croatia

Burden and impact of osteoporosis and fragility fractures

The burden of osteoporosis in Croatia is not known, but hip fractures are a leading cause of death. Due to a lack of available data, the number of people living with osteoporosis in Croatia is unknown,1 although the burden is likely to be considerable given that the country has an old and ageing population.2 However, hip fractures have been identified as one of the top ten causes of death, leading to 831 deaths in 2018.3

Hip fractures impose a major burden on the entire system. The burden is not only financial, but also includes the disability and mortality that can result.’ VELIMIR ALTABAS, SESTRE MILOSRDNICE UNIVERSITY CLINICAL HOSPITAL

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 do not seem to be prioritised at policy level and key data are not collected. Strategy documents published by the Ministry of Health in Croatia do not discuss osteoporosis, and experts interviewed for this profile agreed that interest in the condition has diminished considerably in the last decade.1 4 While there are national disease-specific registries for other conditions,3 there is no registry for osteoporosis or fragility fractures,5 making it difficult to estimate the scale of the problem or identify key areas for improvement. There are some data on fractures collected by the Croatian Institute for Public Health, but it is not clear which of these are fragility fractures linked to osteoporosis and no information is collected on management of these fractures.3

There is a lack of quality data to show us where we are now and where we are going. VELIMIR ALTABAS, SESTRE MILOSRDNICE UNIVERSITY CLINICAL HOSPITAL

Reimbursement policy supports access to osteoporosis diagnosis and treatment. People in Croatia are required to participate in the national health insurance scheme, run by the Croatian Health Insurance Fund (Hrvatski zavod za zdravstveno osiguranje).6 This generally provides good access to healthcare and medicines with low out-of-pocket costs,6 7 including for dual-energy X-ray absorptiometry (DXA) scans and osteoporosis treatments. While a small co-payment may be required for DXA, this does not seem to be viewed as a significant barrier to access.1 4 Commonly used medications to treat osteoporosis are included in the Basic Medications list and reimbursed at 100%.7 8

Catching it early: detection and management in primary care

Catching it early: detection and management in primary care

A broad range of at-risk groups are eligible for DXA scans to identify osteoporosis, but there is a lack of data on how effectively this is supporting early diagnosis. A national Fracture Risk Assessment Tool (FRAX®) model for Croatia has been developed, but it is not commonly used in practice.9 Instead, DXA is considered to be the gold standard for diagnosing osteoporosis, and its use is recommended in national guidelines.1 4 10 These guidelines outline a wide range of groups who are eligible for DXA scans, including women over 65, men over 70 and adults with a fragility fracture. Primary care providers or specialists can make referrals for DXA, and while the guidelines do not specify who should be responsible for this,10 it appears that most referrals are made in primary care.1

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

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

The complex needs of older people with fragility fractures may not be met in Croatia where in-hospital fracture care tends to focus on surgery alone, without the input of a multidisciplinary team. National osteoporosis guidelines are focused on the diagnosis and medical treatment of osteoporosis,10 while there do not appear to be any guidelines or targets for in-hospital fragility fracture care. For example, there is no target to undertake hip fracture surgery within 48 hours of admission, as there is in other European countries.11 12 Fragility fractures of the hip are usually treated by an orthopaedic surgeon without the involvement of other specialists, such as geriatricians,1 who may be able to better support patients’ wider health needs.

Just because somebody suffers a hip fracture, that doesn’t mean they will receive osteoporosis treatment at all. There is a huge gap in treatment. VELIMIR ALTABAS, SESTRE MILOSRDNICE UNIVERSITY CLINICAL HOSPITAL

Following a fragility fracture, prevention of subsequent fractures represents a considerable gap in care. After repairing a hip fracture, orthopaedic surgeons in Croatia generally do not refer patients for osteoporosis investigation or treatment, reportedly because this is not considered part of their role.1 However, many people who have sustained a hip fracture are referred to a physical rehabilitation centre after hospital discharge.1 Here, they may receive appropriate diagnosis and treatment services from specialists in physical medicine and rehabilitation according to published guidelines, which include investigation and treatment for osteoporosis.13 Aside from the care provided in rehabilitation centres, there are currently no dedicated post-fracture follow-up services in place, such as fracture liaison services (FLS).4 14 An FLS was introduced in a hospital in Zagreb in 2014,15 but the service was ultimately not successful due to lack of engagement and referral from orthopaedic surgeons managing the fractures.4

A real step forward would be the implementation of a fracture liaison service. If it were successful, it would be really valuable for people with fragility fractures. SIMEON GRAZIO, SESTRE MILOSRDNICE UNIVERSITY CLINICAL HOSPITAL

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 limited policy focus on healthy ageing in Croatia and, where there is, it rarely links to preventing falls and fragility fractures. Healthy ageing does not seem to be a national priority, although the topic has gained some attention in 2020 as part of Croatia’s presidency of the Council of the European Union.16 At a local level, some city governments, including Poreč-Parenzo17 and Rijeka,18 have developed their own healthy ageing strategies, although they do not focus on osteoporosis or falls and fracture prevention. There may be local falls prevention interventions available in some areas, but they do not seem to be widely taken up by the public or promoted at policy level.4

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

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

National civil society organisations were previously very active in raising awareness of osteoporosis, but these activities have reduced considerably in the last decade. More than ten years ago, it seems that there was a national drive to improve public awareness and understanding of osteoporosis and fragility fracture risk.1 4 During the international Bone and Joint Decade (2000–2010), national organisations in Croatia were engaged in a range of effective public awareness campaigns,19 but interest in these activities has since declined considerably. For example, the Croatian League Against Rheumatism – a large national patient and professional organisation whose main activities were public education and supporting people with musculoskeletal conditions – was highly engaged,19 but no longer appears to be active in the area of osteoporosis. Similarly, the Croatian Osteoporosis Society previously engaged in preventive and public education activities,20 but has not been active recently.4

Treatment data are limited, but it appears that people in Croatia continue taking osteoporosis medication once it has been prescribed. National data on treatment are not available, but a small study from 2008 found that 86% of people on weekly osteoporosis medication took it regularly for a year.21 It is difficult to draw further conclusions about treatment adherence without large-scale studies or a comprehensive national database.

 

This information is based on research conducted in 2020.
Date of preparation: October 2020.
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References +
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