Osteoporosis and fragility fracture prevention in Finland

Finland’s national guidelines support identification and management of osteoporosis and fragility fractures, with many people being diagnosed before a first fracture. Though few national strategies have been implemented to prevent osteoporosis, falls prevention is a policy priority which has lent support to a range of falls and fracture prevention programmes.

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Osteoporosis and fragility fracture prevention in Finland

Burden and impact of osteoporosis and fragility fractures

The burden of osteoporosis in Finland is comparable to other countries in Europe. When last assessed in 2010, it was estimated that 304,453 people aged 50 years or over in Finland had osteoporosis.1

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

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

Healthcare policies in Finland aim to improve health services and support independence in older age, but do not specifically address osteoporosis or fragility fractures. National legislation, such as the Health Care Act3 and the Act on Supporting the Functional Capacity of the Older Population and on Health Care Services of Older Persons,4 specify how health and social care should be operated and monitored in order to promote population health and ensure older people have access to all necessary services. However, specific diseases are generally not addressed in national policies and there seems to be a lack of strategies that discuss osteoporosis or fragility fractures.

Data on hip fracture treatment are collected in a national healthcare database, but there do not appear to be any programmes dedicated to monitoring and evaluating fracture care. National data on inpatient care are collected in the Care Register for Health Care and can be used for research and monitoring purposes.5 Hospitals, health centres and other institutions enter the details on each patient’s condition and the treatment received,5 so data on treatment of hip fractures and associated medication usage can be accessed.5 However, there are no questions that are specific to osteoporosis or fracture management,5 nor does there appear to be a dedicated fracture database or national audit.

While all people in Finland are covered by the social health insurance system, limited reimbursement means some people cannot access osteoporosis care. As part of the national healthcare system, medications and services are partially reimbursed, but co-payments must be made by the individual or through private health insurance.6  For the most disadvantaged people, co-payments are a barrier to care; a survey of Finnish Osteoporosis Association (Suomen Luustoliitto) members found that 6.5% of people with osteoporosis felt they could not afford, or usually could not afford, their osteoporosis treatment.7 8 Social assistance may be available to anyone in this position to help them pay their medical expenses.9

Catching it early: detection and management in primary care

Catching it early: detection and management in primary care

Clinical guidance in Finland promotes diagnosis and treatment of osteoporosis in primary care and this often happens before a first fracture. Primary care professionals are often responsible for investigating osteoporosis and initiating treatment.10 This is supported by extensive clinical guidance, which discusses risk factors for osteoporosis and the various treatment options available.10 While around a third of people are diagnosed with osteoporosis after they have already had a fracture, a survey of osteoporosis patients found that 20% were diagnosed when they were seeing their primary care doctor about another illness and another 16% were diagnosed when they specifically asked their doctor about it.7 8 This suggests that many primary care providers are aware of key risk factors and assess patients for osteoporosis in line with clinical guidance.

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

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

Management of a fracture depends on the area where a person lives and how the national guidelines have been put into practice. PAULIINA TAMMINEN, FINNISH OSTEOPOROSIS ASSOCIATION

Multidisciplinary in-hospital management of fragility fractures is recommended in clinical guidance, but there are no national programmes to promote best-practice care. Detailed clinical guidance in Finland describes best practice in hip fracture care with a focus on multidisciplinary management and rehabilitation.2 To meet these recommendations, some hospitals have implemented hip fracture programmes in which dedicated care pathways are used to ensure patients are seen by multiple specialists, including geriatricians.11 In one hospital where a multidisciplinary hip fracture programme was implemented, the rate of deaths within 30 days of a fracture was lower among people who received a comprehensive geriatric assessment.11 However, implementation of such programmes does not seem to be incentivised or monitored nationally, and care pathways differ between hospitals.7

Effective nurse-led post-fracture services which include diagnosis and treatment for osteoporosis are in place in some areas, but there remain gaps in access.7 In many organisations, including primary care practices, health centres and hospitals, designated osteoporosis nurses review fractures and identify patients who should be followed-up and treated.7 These nurse-led models of care are recommended in national guidance,10 but have not yet been universally adopted.7 This may be due, in part, to varying health and social care priorities at a local level.7

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

Falls prevention is recognised as a national health priority in Finland as falls-related deaths continue to increase. Among Finland’s rapidly ageing population, falls are a serious concern, with around 1,200 people dying from accidental falls in 2017.12 In response, the prevention of falls has been identified as a national public health priority13 and interventions are being implemented at the local and national level.14 As part of this, a falls prevention network which encourages collaboration across municipalities and provinces is currently being developed with funding from the Ministry of Social Affairs and Health.15 In addition, falls prevention is an integral component of national osteoporosis and hip fracture prevention guidance.2 10 Despite these initiatives, national statistics have not yet shown a decline in falls-related deaths.12

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

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

Civil society is active in educating the public about osteoporosis and the risk of fragility fractures. The Finnish Osteoporosis Association offers a range of free training courses which support professionals to promote awareness and self-management among people with osteoporosis, including educating the public on how to prevent falls.7 16 In addition, it provides peer support, rehabilitation and educational materials for people with osteoporosis.7 Similarly, the Finnish Osteoporosis Society offers a range of educational resources for people with osteoporosis, such as public lectures, a booklet on self-management17 and an annual two-day course on osteoporosis.

In the past 30 years, I have seen great improvement in the recognition of osteoporosis and fractures in the population.
TIMO JÄMSÄ, UNIVERSITY OF OULU

Good awareness of osteoporosis and key risk factors helps to support early diagnosis in Finland. Public awareness of osteoporosis seems to have improved over time,18 leading people to ask their doctor about osteoporosis screening before experiencing a first fracture.7 A recent survey of people with osteoporosis found that 20% were diagnosed this way.7 8 Specifically, 15% knew about the risks and were worried about their bone health, 3% noticed they were getting shorter and 2% were advised by somebody with osteoporosis to get screened.7 8

 

This information is based on research conducted for the 2020 publication Osteoporosis and fragility fractures: a policy toolkit.
Date of preparation: October 2020.
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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. Duodecim. 2017. Lonkkamurtuma. Helsinki: Duodecim
  3. Health Care Act. 2010. Finland: 30/12/10
  4. Act on supporting the functional capacity of the older population and on social and health care services for older persons. 2012. Finland: 28/12/12
  5. Finnish institute for health and welfare. Care register for health care. [Updated 26/02/16]. Available from: www.thl.fi/en/web/thlfi-en [Accessed 01/09/20]
  6. Kela. Reimbursements for medicine expenses. [Updated 01/01/19]. Available from: www.kela.fi/web/en/medicine-expenses [Accessed 01/09/20]
  7. Holm A, Tamminen P. 2019. Interview with Taylor Morris at The Health Policy Partnership [telephone]. 30/09/19
  8. Holm A. 2019. Osteoporoosin hyvä hoito: Luustoliiton kyselyn tuloksia 2019. Helsinki: Luustoliitto
  9. Kela. Types of expenses for which you can get basic social assistance. [Updated 28/11/16]. Available from: www.kela.fi/web/en/social-assistance [Accessed 01/09/20]
  10. Duodecim. 2018. Osteoporoosi. Helsinki: Duodecim
  11. Pajulammi HM, Pihlajamäki HK, Luukkaala TH, et al. 2017. The Effect of an In-Hospital Comprehensive Geriatric Assessment on Short-Term Mortality During Orthogeriatric Hip Fracture Program-Which Patients Benefit the Most? Geriatr Orthop Surg Rehabil 8(4): 183-91
  12. Official Statistics of Finland. 2018. Causes of death. Helsinki: OSF
  13. Ministry of Social Affairs and Health. 2014. Target programme for the prevention of home and leisure accident injuries 2014-2020. Helsinki: Ministry of Social Affairs and Health
  14. Finnish institute for health and welfare. Injury prevention: older people. [Updated 20/08/18]. Available from: www.thl.fi/en/web/injury-prevention/accidental-injuries/older-people [Accessed 01/09/20]
  15. UKK instituutti. Iäkkäiden kaatumisten ehkäisy. [Updated 29/08/19]. Available from: www.ukkinstituutti.fi/kaatumisseula [Accessed 01/09/20]
  16. Luustoliitto. Koulutukset ammattilaisille. Available from: www.luustoliitto.fi/ammattilaisille/koulutukset [Accessed 01/09/20]
  17. Suomen Osteoporoosiyhdistys. Luustoterveyttä murkusta mummoon. Helsinki: Suomen Osteoporoosiyhdistys
  18. Jämsä T. 2019. Interview with Taylor Morris at The Health Policy Partnership [telephone]. 21/08/19