Osteoporosis and fragility fracture prevention in France

France is beginning to prioritise osteoporosis and the prevention of fragility fractures and falls in health policy. However, awareness and understanding of osteoporosis among healthcare professionals and patients is often poor, leading to delays in diagnosis and significant gaps in treatment.

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Osteoporosis and fragility fracture prevention in France

Burden and impact of osteoporosis and fragility fractures

Osteoporosis and fragility fractures are common in France, imposing considerable costs. Over a million sick days were taken following a fragility fracture in 2017, having a negative impact on workforce productivity.1 In France, as in other European countries, life expectancy is increasing and so is the burden of osteoporosis.2 The number of people hospitalised for a fracture related to osteoporosis increased by approximately 10% between 2011 and 2013.2

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

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

Osteoporosis management and prevention of subsequent fractures are beginning to feature in national strategies. In 2017, the French Anti-Rheumatism Association (L’Association Française de Lutte Anti-Rhumatismale; AFLAR) and the National Alliance Against Osteoporosis (l’Alliance nationale contre l’ostéoporose) published a White Paper calling for urgent action on the part of health authorities.2 In 2018, the Ministry of Solidarity and Health published a new strategy, ‘My Health 2022’ (Ma Santé 2022), to improve access to care and support collaborative working between health professionals.3 Improving long-term care for people with osteoporosis is named as a priority objective in this strategy.4 While the strategy does not specify how osteoporosis care should be improved, guidance is currently under development, and may include support for implementing new fracture liaison services (FLS).5

Healthy ageing and falls prevention are also integrated into national prevention policy. The National Health Strategy for 2018–2022 aims to improve healthcare nationwide through preventive health measures and improving care quality. The strategy refers to nutrition, exercise and falls prevention as key priorities in  tackling chronic diseases, as well as the importance of disseminating messages on ageing well and identifying fragility risk in older people.6

France collects data on osteoporosis via the comprehensive National Health Data System (Système National des Données de Santé), which is available on request to people conducting research of public interest.7 For example, trends in use of osteoporosis medication can be assessed to investigate the impact of new programmes.5 Many individual hospitals also collect data on fragility fractures;8 however, there are no open-access databases or national audits on osteoporosis.8

Reimbursement policies for bone mineral density (BMD) testing are in place, but their complex nature may be contributing to underutilisation.5 Since 2006, French national health insurance covers BMD testing for people who have sustained a fragility fracture, regardless of age or gender, as well as for people with certain risk factors.9 10 However, some general practitioners (GPs) are still unclear about which people are covered under the reimbursement policies, leading to reduced rates of BMD testing in France.2 11

The health system supports good access to osteoporosis treatments in France.8 10 Many treatments are reimbursed for all patients following a fracture and for those at risk of fracture.8 10

Catching it early: detection and management in primary care

Catching it early: detection and management in primary care

Many primary care professionals lack the knowledge to effectively identify people with osteoporosis.12 13 Studies have revealed that GPs in France may underestimate the associated risks2 and may not initially consider a diagnosis of osteoporosis.13 A 2017 survey found that 66% of GPs felt they needed to be better informed about osteoporosis.2 It has also been noted that complexities in national guidance may act as a barrier to appropriate management of osteoporosis in primary care.5 In addition, GPs may be uncertain about interpreting results of diagnostic tests.14

This has contributed to a decrease in the number of people being assessed for osteoporosis. In 2011, France had good provision of dual-energy X-ray absorptiometry machines in comparison with many other European countries11 as well as a country-specific Fracture Risk Assessment Tool (FRAX).11 15 However, the number of BMD assessments has not increased with the rising population at risk of osteoporosis.2 9 In fact, there has been a decrease in BMD assessments each year of approximately 6%.2

Gaps in knowledge among GPs have also contributed to alarmingly low treatment rates for women with osteoporosis in France.1 12 13 16 Research shows that only 15% of women over 50 years of age receive treatment after an initial fragility fracture,1 and some GPs prescribe only vitamin D and calcium as treatments for osteoporosis.8 Reasons are varied and may include poor awareness of evidence-based clinical guidelines, difficulties in understanding the benefit–risk ratio of various treatments, and time restrictions during consultations.8

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

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

One of the problems in our health system is the lack of collaboration between general practitioners, specialists and pharmacists. DIDIER POIVRET, REGIONAL HOSPITAL METZ-THIONVILLE

Lack of standardised care pathways and multidisciplinary working in France leave many people at risk of repeat hospitalisation following a fragility fracture.8 17 National osteoporosis guidelines recommend a comprehensive approach to fracture and falls prevention, with individualised assessment of risk factors and the provision of appropriate multidisciplinary care.10 However, limited multidisciplinary collaboration in fracture care has been noted as a considerable challenge to implementation of FLS in France.5 An estimated 15–30 FLS are in operation in France,1 8 and only 10–25% of hospitals report having a fracture referral system.1 However, there are some examples of effective FLS, including the service at Lille University Hospital. It is estimated that the introduction of FLS for all people aged over 50 years could prevent 2,665 fragility fractures in France every year.1

Efforts to improve the post-discharge care pathway for people with a fragility fracture are underway, but are yet to show positive outcomes. A hospital discharge programme that launched in 2010, Programmes d’accompagnement du retour à domicile après hospitalisation (PRADO), aims to provide better follow-up for patients in the community.18 As part of this service, a national health insurance advisor liaises with the multidisciplinary team to coordinate discharge from hospital.18 While PRADO has been effective for some conditions, patients with fragility fractures have not benefited as much; this may be at least partly due to limited coordination between hospital staff and the national health insurance advisors.8

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 programmes have been initiated at local and regional levels in France, with some evidence of impact. For example, the multidisciplinary Montpellier falls prevention clinic has been shown to reduce the number of falls and fear of falling, alongside improving mobility among older patients.19 Further research is needed to asses the impact of these initiatives on a larger scale.

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

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

People in France have difficulties in understanding the risk of osteoporosis and the disability associated with fragility fractures. Many people still believe that having a fracture when they fall is normal. THIERRY THOMAS, UNIVERSITY HOSPITAL ST ETIENNE

Low awareness of osteoporosis and misunderstandings in the population contribute to low levels of treatment. People with osteoporosis lack understanding of their condition, are often wary of treatments and are concerned about side effects due to negative publicity on social media and in the press.8 14 20 21 Combined with the fact that, as noted above, some GPs may not adequately prioritise the management of osteoporosis,20 this has resulted in a large proportion of people not taking the medication they need to prevent fractures.20 22

While public awareness campaigns exist in France, their impact is unclear. AFLAR runs a number of public awareness campaigns on osteoporosis, including the launch in 2014 of a ‘Bone Thief’ mobile application aimed at the general public and physicians,23 and a 2018 national awareness campaign for World Osteoporosis Day.24 Public understanding of osteoporosis remains low, however, and there is a need for further evidence-based public awareness programmes which highlight the benefits of osteoporosis prevention and treatment.5 14 20

 

This information is based on research conducted for the 2020 publication Osteoporosis and fragility fractures: a policy toolkit.
References +
  1. International Osteoporosis Foundation. 2018. Broken bones, broken lives: A roadmap to solve the fragility fracture crisis in France. Nyon: IOF
  2. Association Française de Lutte Antirhumatismale (AFLAR), Alliance Nationale Contre L’Osteoporose. 2017. ‘Livre Blanc – États Généraux De L’ostéoporose – Pour un plan de santé publique contre les fractures liées à l’ostéoporose’. Paris: AFLAR
  3. Ministere des Solidarites et de la Sante. Ma santé 2022 : un engagement collectif. Available from: https://solidarites-sante.gouv.fr/systeme-de-sante-et-medico-social/masante2022/ [Accessed 01/09/20]
  4. Ministère des Solidarités et de la Santé. 2018. MA SANTÉ 2022: Dossier de presse. Paris: Ministère des Solidarités et de la Santé
  5. Poivret D. 2019. Interview with Taylor Morris at The Health Policy Partnership [telephone]. 01/11/19
  6. République Francaise Ministère des solidarités et de la santé. 2017. Stratégie nationale de santé 2018-2022. Paris: Ministere des Solidarites et de la Sante
  7. National Fund for Employee Workers’ Health Insurance (CNAMTS). Système National des Données de Santé (SNDS). Available from: https://www.snds.gouv.fr/SNDS/Accueil [Accessed 01/09/20]
  8. Thomas T. 2019. Interview with Taylor Morris and Emily Kell at The Health Policy Partnership [telephone]. 20/09/19
  9. Canoui-Poitrine F, Jaglal S, Chapurlat R, et al. 2010. Has reimbursement of bone mineral density testing and anti-osteoporotic treatments improved management of osteoporosis in France? Bone 47(4): 790-4
  10. Briot K, Roux C, Thomas T, et al. 2018. 2018 update of French recommendations on the management of postmenopausal osteoporosis. Joint Bone Spine 85(5): 519-30
  11. Kanis JA, Borgstrom F, Compston J, et al. 2013. SCOPE: a scorecard for osteoporosis in Europe. Archives of osteoporosis 8: 144
  12. Flais J, Coiffier G, Le Noach J, et al. 2017. Low prevalence of osteoporosis treatment in patients with recurrent major osteoporotic fracture. Archives of osteoporosis 12(1): 24
  13. Erny F, Auvinet A, Chu Miow Lin D, et al. 2015. Management of osteoporosis in women after forearm fracture: Data from a French health insurance database. Joint Bone Spine 82(1): 52-55
  14. Merle B, Haesebaert J, Bedouet A, et al. 2019. Osteoporosis prevention: Where are the barriers to improvement in French general practitioners? A qualitative study. PLOS ONE 14(7): e0219681
  15. Kanis JA, Cooper C, Rizzoli R, et al. 2019. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporosis International 30(1): 3-44
  16. Viprey M, Caillet P, Canat G, et al. 2015. Low Osteoporosis Treatment Initiation Rate in Women after Distal Forearm or Proximal Humerus Fracture: A Healthcare Database Nested Cohort Study. PLoS One 10(12): e0143842
  17. Teixeira A, Trinquart L, Raphael M, et al. 2009. Outcomes in older patients after surgical treatment for hip fracture: a new approach to characterise the link between readmissions and the surgical stay. Age and Ageing 38(5): 584-89
  18. International Osteoporosis Foundation. 2019. France’s first national service to provide post-hospitalisation follow up care for fragility fracture patients. Available from: https://www.capturethefracture.org/france%E2%80%99s-first-national-service-provide-post-hospitalization-follow-care-fragility-fracture-patients [Accessed 01/09/20]
  19. Blain H, Dabas F, Mekhinini S, et al. 2019. Effectiveness of a programme delivered in a falls clinic in preventing serious injuries in high-risk older adults: A pre- and post-intervention study. Maturitas 122: 80-86
  20. Alami S, Hervouet L, Poiraudeau S, et al. 2016. Barriers to Effective Postmenopausal Osteoporosis Treatment: A Qualitative Study of Patients’ and Practitioners’ Views. PLoS One 11(6): e0158365
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  22. Belhassen M, Confavreux CB, Cortet B, et al. 2017. Anti-osteoporotic treatments in France: initiation, persistence and switches over 6 years of follow-up. Osteoporosis International 28(3): 853-62
  23. AFLAR. 2019. Labellisation “Le Voleur d’Os” – Medappcare Application “Le Voleur d’OS”. Available from: http://www.aflar.org/le-voleur-d-os [Accessed 01/09/20]
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