Osteoporosis and fragility fracture prevention in Italy

The Italian government has recognised the importance of integrated osteoporosis, fragility fracture and falls prevention as a policy priority, and the government is active in promoting best-practice management of osteoporosis at a national level. Yet large variations in access to early diagnosis and treatment occur at the regional level, leaving many people without access to optimal osteoporosis or fragility fracture care and prevention services.

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Osteoporosis and fragility fracture prevention in Italy

Burden and impact of osteoporosis and fragility fractures

A significant number of people in Italy are affected by osteoporosis and fragility fractures, putting financial stress on the Italian healthcare system.1

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

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

Osteoporosis is a priority for the Ministry of Health in Italy. In 2018, the National Intervention Strategy for Osteoporosis was finalised by the Ministry in collaboration with scientific societies. This strategy aims to define an overall systematic approach to the prevention, diagnosis and treatment of osteoporosis and ensure greater continuity of care and multidisciplinary collaboration.2

Fragility fractures are integrated into prevention plans. The National Prevention Plan (NPP) led by the Ministry of Health defines objectives at the national level, following which regional prevention plans are created.3 The latest NPP for 2014–2018 identified ‘hospitalisation due to fragility fractures for patients over 75 years old’ as a key performance indicator to measure physical activity, and set a 15% reduction target by the end of 2018, although it is unclear whether this target has been reached.1 4

The framework for a national registry for fragility fractures has been established, but adaptation and implementation in the country’s regions is uneven. The need for more comprehensive epidemiological data on fragility fractures in Italy prompted the Ministry of Health to develop the Italian Registry for Fragility Fractures (Registro Italiano delle Fratture da Fragilità) in 2015.5 The registry aims to collect data on the socioeconomic impact of fragility fractures, assess the effectiveness of health policy interventions and allocate resources more appropriately.5 However, while frameworks for data collection have been created at a national level, until 2018 many regions still needed to implement databases to allow for appropriate tracking of data against indicators.1

Restrictions in the reimbursement of diagnostic tests in Italy can result in unequal access to care.6 Dual-energy X-ray absorptiometry (DXA) scans are reimbursed by the Italian public health system, but there are some restrictions on eligibility for full reimbursement. For example, women aged 65 years and over without additional risk factors are excluded, meaning osteoporosis may still be largely undiagnosed among postmenopausal women.6

Osteoporosis medications are reimbursed in Italy for certain groups. This includes people with a history of one or more fragility fractures, postmenopausal women, and men over 50 years of age with certain risk factors (for example, depending on bone mineral density score).7

Catching it early: detection and management in primary care

Catching it early: detection and management in primary care

Variation in access to diagnostic tools has led to delays in diagnosis. As measured in 2010, despite the high availability of DXA machines, the average waiting time to receive a DXA bone scan in Italy is approximately 83 days.8 9 Many DXA units are situated in research centres or private hospitals and are only available in some parts of the country, which means that people face a ‘diagnostic lottery’ depending on where they live.9

A range of tools to assess fracture risk are available in Italy. A country-specific Fracture Risk Assessment Tool (FRAX) is widely used for evaluating the risk of a fragility fracture.7 In addition, a FRAX-derived algorithm called FRAHS was recently developed for use among general practitioners for risk assessment.7 10 Other tools developed in Italy, such as Derived Fracture Risk Assessment (DeFRA), have not yet been validated on a large scale.7

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

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

The importance of multidisciplinary care following a fragility fracture is highlighted in a range of guidance documents. Various scientific societies, including the Italian Society of Orthopaedics and Traumatology (Societá Italiana de Ortopedia e Traumatologia; SIOT), the Italian Society of Osteoporosis, Mineral Metabolism and Skeletal Diseases (Societá Italiana dell’Osteoporosi del Metabolismo Minerale e delle Malattie dello Scheletro; SIOMMMS) and the Italian Society of Rheumatology (Societá Italiana di Reumatologia; SIR), have developed recommendations on integrated and multidisciplinary models for the management of osteoporosis and fragility fractures.7 10 These have been implemented in some areas, as demonstrated by the multidisciplinary hip fracture unit in Careggi University Hospital.11 12

Access to multidisciplinary care models for people with fractures is variable, however. In some regions, plans exist for multidisciplinary care for fragility fractures, known as PDTA (Percorso Diagnostico-Terapeutici Assistenziali, or Diagnostic Therapeutic Assistant Pathway).13 14 While these support access to models of care based on the fracture liaison service model,15 they may not be available in all parts of the country. In fact, fewer than 3% of Italian hospitals have established referral systems for fracture patients.1

As a consequence of these regional disparities,16 many Italian patients do not receive optimal care following a fragility fracture.1 15 17 A study conducted in 2017, which analysed data from four Italian hospitals, reported that more than 75% of elderly patients did not receive any medication for osteoporosis on discharge from hospital after a hip fracture.1 18 Failure to provide appropriate treatment in hospital can lead to an increased risk of subsequent fractures and premature death.17

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 osteoporosis and fragility fracture guidelines discuss the importance of making lifestyle and behavioural changes to prevent falls. These highlight physical activity and vitamin D intake as key measures to reduce the risk of fractures among older people.10 19 In addition, the Ministry of Health provides guidance for falls prevention and management of people in hospitals and nursing homes.20 Emphasis is placed on the provision of risk assessment tools, healthcare professional training and physical activity interventions.20

Despite national guidance, the level of support that older people receive following a fragility fracture is quite variable. Home-based rehabilitation is not available in all regions and is provided at the discretion of local health authorities.16 In addition, the Italian health system does not provide any specific reimbursement for home assistance for older patients with significant disabilities and multiple conditions.16

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

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

Discontinuation of osteoporosis treatment leaves many people at risk of further fractures.21 A 2013 study undertaken in the Campania region found that 70% of Italian patients had discontinued their osteoporosis medication after six months and only 14% were on medication one year after initiation.22 Common reasons include side effects and lack of motivation.23

Improving knowledge of osteoporosis among patients and the public may play a crucial role in supporting people to keep taking medication.24 While public information about osteoporosis is available online through the Ministry of Health25 and national societies, there is an urgent need for national awareness campaigns that address the links between fragility fractures and osteoporosis, and highlight the safety and long-term effectiveness of medication in preventing future fractures.24

 

This information is based on research conducted for the 2020 publication Osteoporosis and fragility fractures: a policy toolkit.
References +
  1. International Osteoporosis Foundation. 2019. Broken Bones, Broken Lives: A roadmap to solve the fragility fracture crisis in Italy. Nyon: IOF
  2. Ministero della Salute. 2018. Una strategia di intervento per l’osteoporosi. Available from: http://www.salute.gov.it/portale/news/p3_2_1_1_1.jsp?lingua=italiano&menu=notizie&p=dalministero&id=3365 [Accessed 01/09/20]
  3. Morciano L, Caredda E. 2018. The Governance of Prevention in Italy. Biomedicine and Prevention 3(173): 223-25
  4. Ministero della Salute. 2015. Ridurre il carico prevenibile ed evitabile di morbosità, mortalità e disabilità delle malattie non trasmissibili. Available from: http://www.salute.gov.it/portale/temi/p2_6.jsp?lingua=italiano&id=4241&area=prevenzione&menu=obiettivi [Accessed 01/09/20]
  5. Tarantino U, Feola M, Rao C, et al. 2011. Epidemiologia delle fratture da fragilità nel Lazio: approccio globale e nostra esperienza. Archivio di Ortopedia e Reumatologia 122(3): 10-12
  6. Brandi ML, Guglielmi G, Masala S, et al. 2012. When the government actively faces the burden of osteoporosis: the Italian experience. Archives of osteoporosis 7: 21-4
  7. Tarantino U, Iolascon G, Cianferotti L, et al. 2017. Clinical guidelines for the prevention and treatment of osteoporosis: summary statements and recommendations from the Italian Society for Orthopaedics and Traumatology. Journal of Orthopaedics and Traumatology 18(1): 3-36
  8. 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
  9. Kanis JA, Borgstrom F, Compston J, et al. 2013. SCOPE: a scorecard for osteoporosis in Europe. Archives of osteoporosis 8: 144
  10. Nuti R, Brandi ML, Checchia G, et al. 2019. Guidelines for the management of osteoporosis and fragility fractures. Internal and Emergency Medicine 14(1): 85-102
  11. Rostagno C, Cartei A, Buzzi R, et al. 2013. Multidisciplinary approach to hip fracture in the elderly: florence experience. Emerg Med 3: 148-52
  12. Rostagno C, Cartei A, Civinini R, et al. 2018. Hip fracture unit: beyond orthogeriatrics. Internal and Emergency Medicine 13(5): 637-39
  13. REGIONE FRIULI VENEZIA GIULIA: Direzione centrale salute integrazione socio sanitaria politiche sociali e famiglia. 2016. Percoso Assistenziale del Paziente con Osteoporosi: Indicazioni di Appropriatezza per il Riferimento Allo Specialista Reumatologo. Available from: http://www.malatireumaticifvg.org/malattie/docs/Percorso%20Assistenziale_%20Osteoporosi%20-%20Artrosi.pdf [Accessed 01/09/20]
  14. REGIONE LOMBARDIA: Azienda Socio-Sanitaria Territoriale di Pavia. 2016. Percorso Diagnostico Terapeutico Assistenziale Ospedale – Territorio per Pazienti con Fratture da Fragilita e con Osteoporosi. Available from: http://www.asst-pavia.it/sites/default/files/documenti/PIC%20Cont%20assist%20osp_terr%20pz%20fratture%20e%20osteoporosi%20rev%200%202016_0.pdf [Accessed 01/09/20]
  15. Il Papavero Rosso Web. 2018. Fratture da fragilità: linee guida dedicate, percorso diagnostico terapeutico assistenziale standard e tempestività di intervento. Available from: https://www.ilpapaverorossoweb.it/article/fratture-da-fragilit%C3%A0-linee-guida-dedicate-percorso-diagnostico-terapeutico-assistenziale [Accessed 01/09/20]
  16. Pioli G, Pellicciotti F, Davoli ML, et al. 2010. Hip fracture management and outcomes in Italy. European Geriatric Medicine 1(2): 104-07
  17. Degli Esposti L, Sinigaglia L, Rossini M, et al. 2012. Adherence to therapeutic and diagnostic recommendations in patients with femur fracture and at risk of re-fracture or death: results of an analysis of administrative databases. Reumatismo 64(1): 18-26
  18. Gonnelli S, Caffarelli C, Iolascon G, et al. 2017. Prescription of anti-osteoporosis medications after hospitalization for hip fracture: a multicentre Italian survey. Aging clinical and experimental research 29(5): 1031-37
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