Osteoporosis and fragility fracture prevention in Ireland

Falls and fragility fractures have gained national policy attention in recent years, although osteoporosis is not generally viewed as a policy priority in Ireland. Collaborative efforts between clinicians and national organisations have resulted in the introduction of new programmes, such as a national hip fracture database, which are having a meaningful impact on the management of fragility fractures.

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Osteoporosis   and fragility fracture prevention in Ireland

Burden and impact of osteoporosis and fragility fractures

Osteoporosis and fragility fractures impose a considerable burden on the health system in Ireland, which will increase significantly as the population ages.

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

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

Prevention of falls and fragility fractures is beginning to gain attention at the national level in Ireland. Published in 2008, the Strategy to Prevent Falls and Fractures in Ireland’s Ageing Population discusses the burden and risk factors of falls and fractures, including an overview of osteoporosis and recommendations for reducing this burden.3 While there do not appear to be more recent policies or strategies for fracture prevention, this strategy led to the development of a national programme on falls and bone health, which is ongoing.4 However, osteoporosis does not seem to be positioned as a priority condition in national policy,5 and funding for programmes that aim to improve the management of osteoporosis appears to be limited.5 6

The Irish Hip Fracture Database (IHFD) is a well-established audit of hip fracture management and outcomes in Ireland. It was introduced in 2012 to improve the quality of hip fracture care in hospitals, as assessed against international standards.7 All 16 acute hospitals in the country participate in the audit and upload data on patients aged 60 years and older who are admitted for a hip fracture.8 In 2018, data coverage reached 99% and 10 hospitals achieved a complete data coverage at 100%.9 Care of people with hip fractures is assessed against six standards and reported annually by site, to allow hospitals to identify key areas for improvement.8 Data on other fragility fractures are not yet collected, although a fracture liaison service (FLS) database is reported to be in development.5 6

Reimbursement policy in Ireland supports access to osteoporosis treatment, although access to dual-energy X-ray absorptiometry (DXA) scans may vary. Doctors may prescribe any approved osteoporosis treatment they believe to be most appropriate,5 and much of the cost of osteoporosis medications is reimbursed through the national Drugs Payment Scheme.10 This supports good access to treatment.11 However, reimbursement of DXA scans may vary between insurance companies, and there may be limited availability of this service in public hospitals.11

Catching it early: detection and management in primary care

Catching it early: detection and management in primary care

Clinical guidance supports the use of DXA scans to assess fragility fracture risk before the first fracture occurs.2 The Irish Osteoporosis Society (IOS) has published guidance highlighting the value of identifying fracture risk and specifies a range of indications for DXA scanning.2 While this guidance is shared with every general practitioner (GP) in Ireland, it may not always be put into practice.5 As a result, osteoporosis may go undiagnosed even after multiple fractures have occurred.5

After a person has had a fragility fracture and been diagnosed, to prevent further fractures, it is essential that all causes of bone loss are investigated and addressed and the most appropriate medication prescribed for that person. Prevention of fractures should also be a priority, starting in utero and continuing throughout life. MOIRA O’BRIEN, IRISH OSTEOPOROSIS SOCIETY

A Fracture Risk Assessment Tool (FRAX) for Ireland is available but it remains unclear whether it is widely used. While a country-specific FRAX tool has been developed and calibrated using national hip fracture data and Irish mortality rates,12 clinical guidance does not specify how this should be used to inform decision-making2 and it is not recommended by the IOS due to its limitations.5 Clinical guidance states that osteoporosis should be diagnosed using a DXA scan in combination with detailed clinical information and blood tests, and use of an online self-assessment is also promoted by the IOS.2 Guidance also details each of the available medications.2

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

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

Orthogeriatric services are relatively new to Ireland, but geriatric or orthogeriatric care of older people with hip fractures is increasing rapidly. In 2014, there was only one orthogeriatrician appointed in Ireland,7 and in 2016, seven of the sixteen acute hospitals had at least some orthogeriatric involvement in hip fracture management.13 Since then, orthogeriatrics services have been introduced in more hospitals,8 and more than two-thirds of people with hip fractures were seen by a geriatrician while in hospital in 2018.9

The IHFD has supported annual improvements in hip fracture management and outcomes, although gaps remain. Key metrics that improved between 2017 and 2018 include the proportion of people who were seen by a geriatrician in hospital, and those who received a bone health assessment or a specialist falls assessment.9 The proportion of people who were admitted to an orthopaedic ward or theatre from the emergency department within the target time of 4 hours increased between 2017 and 2018, but remains low at 17%.9 An expert interviewed for this country profile suggested that achievement of this target may be hindered by wider health system issues such as hospital overcrowding.6 In addition, there is notable variation between hospitals in terms of service provision and achievement of best practice standards.9

A pay-for-performance incentive scheme has recently been introduced and is further contributing to improvements in hip fracture outcomes. The hip fracture Best Practice Tariff (BPT), Ireland’s only incentive payment scheme for hospitals, was introduced in 2018.6 9 Through this scheme, eligible hospitals receive an incentive payment of €1,000 for every patient whose management meets eight standards of care per patient.9 To qualify for this scheme, hospitals must submit at least 90% of eligible data and must have in place an audit coordinator, a clinical lead and a hip fracture governance committee.9 In the first year, €278,000 was paid to hospitals through the scheme, covering 7% of hip fractures in the country meeting all eight BPT measures.9 Data from the IHFD show that some measures of hip fracture management have improved considerably since the introduction of the BPT.9

The Best Practice Tariff is already having a huge impact on hip fracture outcomes. It is particularly helpful for reaching the criteria that are more difficult to achieve.CONOR HURSON, IRISH HIP FRACTURE DATABASE

Some Irish hospitals have established FLS, but data are limited. When last assessed in 2016, seven out of the sixteen acute hospitals had a fracture liaison nurse.13 As a national FLS database has not yet been implemented, it is not clear how many FLS are currently in place or what impact these services are having on fracture outcomes. Only six services in Ireland are registered with Capture the Fracture; two have received a silver rating, three have received bronze and one is currently under review.14

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

National strategies support the development of falls prevention services. With a rapidly ageing population, the incidence of falls in some areas is rising quickly and there is a clear need to implement comprehensive falls prevention programmes.15 As mentioned above, a national strategy on falls and fracture prevention was published in 2008,3 which gave rise to the AFFINITY National Falls and Bone Health Project in 2013.4 This national project aims to foster integration of key services and develop a comprehensive falls and fracture prevention strategy, including guidance for community falls services and a falls and bone health information service for the public.16 It also highlights the importance of integrating prevention and rehabilitation services to reduce both falls and their impact on the health and wellbeing of older people.4

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

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

Awareness of osteoporosis in Ireland appears to be low,5 despite sustained efforts of the Irish Osteoporosis Society. IOS is a highly active patient organisation seeking to raise awareness of osteoporosis among clinicians and the public. To improve public awareness, the IOS publishes extensive information about prevention and management of osteoporosis on its website17 18 and runs a national helpline.5 19 It also aims to engage with GPs to educate them about osteoporosis and current guidance.5

Use of osteoporosis medication is suboptimal in Ireland. A study conducted in 2012 reported that one year after being prescribed osteoporosis medication, 64% of women and 60% of men were still taking it; these numbers dropped to 45% of women and 29% of men after three years.20 Improved engagement in primary care may be needed as 30% of people on osteoporosis medication (bisphosphonates) do not have their treatment reviewed by a GP for 5 years,21 despite recommendations to monitor bone health via repeat DXA scans up to every two years.2 5

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 +
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  2. Irish Osteoporosis Society. 2012. Osteoporosis guidelines 2 for health professionals. Dublin: Irish College of General Practitioners
  3. Health Service Executive. 2008. Strategy to prevent falls and fractures in Ireland’s ageing population. Dublin: Health Service Executive
  4. Health Service Executive. About AFFINITY national falls and bone health project 2018-2023. Available from: www.hse.ie/eng/services/list/4/olderpeople/falls-prevention-and-bone-health [Accessed 01/09/20]
  5. O’Brien M. 2019. Interview with Taylor Morris at The Health Policy Partnership [telephone]. 25/11/19
  6. Hurson C. 2019. Interview with Taylor Morris at the Health Policy Partnership [telephone]. 15/11/19
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  9. National Office of Clinical Audit. 2019. Irish Hip Fracture Database national report 2018. Dublin: NOCA
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  14. Capture the Fracture. Map of Best Practice. Available from: www.capturethefracture.org/map-of-best-practice [Accessed 01/09/20]
  15. Fan CW, Duggan J, Rodger D, et al. 2017. Increased number of community-living older adults attending an emergency department with falls and fractures: North Dublin experience. Irish journal of medical science 186(3): 693-97
  16. Health Service Executive. 2019. Update on AFFINITY national falls and bone health project – May 2019. Dublin: HSE
  17. Irish Osteoporosis Society. Diet and Osteoporosis. Available from: www.irishosteoporosis.ie/treatments/diet-osteoporosis[Accessed 01/09/20]
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