Osteoporosis and fragility fracture prevention in Portugal

National health policy in Portugal provides good access to osteoporosis diagnosis and treatment, but does not prioritise key services to support early detection or delivery of post-fracture care. While some data are collected on osteoporosis, comprehensive data on fragility fractures are lacking. In the absence of a national strategy, the implementation of these services depends on local decision-makers and individual clinicians, resulting in varied care and treatment gaps across the country.

Click below to read a case study on a multidisciplinary osteoporosis outpatient clinic in Portugal:

Read More

Find out more about osteoporosis and fragility fractures in Portugal in this Portuguese-language infographic:

Download Infographic

Osteoporosis and fragility fracture prevention in Portugal

Burden and impact of osteoporosis and fragility fractures

The burden of osteoporosis and fragility fractures in Portugal is heavy and expected to grow. In 2010, approximately 22% of women and 7% of men aged 50 and over were living with osteoporosis, contributing to approximately 52,000 fragility fractures each year.1 As the population ages, annual fragility fractures are expected to reach 69,000 by 2025.1 At the same time, the economic cost of fragility fractures is projected to increase from €577 million in 2010 to €717 million in 2025.1 Furthermore, hip fractures have been estimated to result in 12% excess deaths in the first year compared to people of the same gender and age in the general population.2

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 appear to be prioritised at national level in Portugal. The National Health Service (Serviço Nacional de Saúde; SNS) has established 12 priority health programmes, covering both clinical and public health topics,3 but there is no dedicated programme for osteoporosis or fragility fractures, which may be treated differently in different regions or hospitals.4 Similarly, prevention of falls does not seem to be prioritised and is only briefly mentioned in the national strategy for active and healthy ageing.5

Policymakers in Portugal do not have osteoporosis and fragility fractures on their agenda. ANDRÉA MARQUES, COIMBRA UNIVERSITY HOSPITAL

Some data about osteoporosis are collected at national level although comprehensive data on fragility fractures are currently lacking. Data on osteoporosis are collected through the Reuma.pt registry which is used to monitor disease progression and the impact of treatment.6 7 The Central Administration of the Health System (Administração Central do Sistema de Saúde) also collects a range of hospital performance data to support improvements in care access and quality, and in hospitals’ economic performance.8 In 2013, the proportion of hip fracture surgeries conducted within 48 hours of admission was added to the indicator framework,9 meaning that this information is collected monthly from each hospital and made publicly available.8 10 The Portuguese Society of Rheumatology (Sociedade Portuguesa de Reumatologia; SPR) is reportedly in the process of developing a national fracture database.4

Reimbursement policy in Portugal provides good access to osteoporosis diagnosis and treatment. There appears to be good access to bone density measurement,with a sufficient number of dual-energy X-ray absorptiometry (DXA) machines and a short waiting time to access this service.11 The service is fully reimbursed by the SNS, as are the majority (69–100%) of the costs of medication for osteoporosis.4 11

Catching it early: detection and management in primary care

Catching it early: detection and management in primary care

Early detection and management of osteoporosis seem to be suboptimal in Portugal. Based on currently available data, it appears to be difficult to assess how often osteoporosis is detected before a first fracture.4 However, experts interviewed for this country profile reported that early detection of osteoporosis is often suboptimal, due in part to its asymptomatic characteristics.12 In addition, while the detection and management of some diseases such as diabetes is reimbursed in primary care based on the use of quality indicators, this does not seem to be the case for the detection of osteoporosis.13 The extent to which general practitioners (GPs) prioritise fracture risk assessment therefore varies considerably,4 12 although many are reported to be interested in collaborating with specialists.12 Occasionally, osteoporosis is detected by other specialists, for example when a woman sees a gynaecologist around the time of menopause.12

The Fracture Risk Assessment Tool (FRAX) is key to informing management of osteoporosis and fracture risk in Portugal. A country-specific FRAX model has been developed and found to be useful in predicting fracture risk without measuring bone mineral density.14 National clinical guidelines on osteoporosis recommend using this tool to assess fracture risk in all men and women aged over 50, while DXA should only be used in certain circumstances – for example when FRAX estimates a fracture risk that is very close to the cost-effectiveness threshold for treatment.15 16 In practice, FRAX is reportedly used primarily by GPs and rheumatologists.12

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

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

There have been some efforts to improve fragility fracture management, but they vary by hospital. There are no national clinical guidelines or standards for the acute management of fragility fractures,4 although a clinical pathway for hip fractures has been proposed by the Portuguese Society for Orthopaedics and Traumatology (Sociedade Portuguesa de Ortopedia e Traumatologia).17 Most fragility fractures seem to be managed primarily by an orthopaedic surgeon rather than a multidisciplinary team.12 However, the first orthopaedics unit in Portugal was introduced in October 201518 and some additional services have been established since then.19 20 In the absence of incentives or policies at the national level, civil society organisations and local champions appear to be key to driving improvements in care.4

Because we don’t have a national strategy, hospitals organise their osteoporosis services differently and many hospitals still have none. ANDRÉA MARQUES, COIMBRA UNIVERSITY HOSPITAL

There is a significant treatment gap, even among people who have already experienced a fragility fracture. In 2010, the proportion of people at risk of fracture who were not being treated for osteoporosis was 24% for men and 37% for women.1 Although national recommendations state that osteoporosis medication should be prescribed for all people over 50 who have had at least one hip or vertebral fragility fracture,15 treatment rates remain low. Data from EpiReumaPt, a national cross-sectional study carried out during 2011–13, found that only around 14% of women aged over 65 who have had a fragility fracture have ever received osteoporosis treatment.21

People who need treatment often do not get it, but there is also a small proportion of people on treatment who don’t need it. HELENA CANHÃO, NOVA MEDICAL SCHOOL

There has been considerable interest in establishing fracture liaison services (FLS) in recent years. FLS are not yet the norm in Portugal; they are implemented to varying degrees in different hospitals, such as Coimbra and Guarda, but most hospitals have not yet established such a service.4 These services aim to ensure that people with fragility fractures are referred to rheumatology units where they are assessed for osteoporosis, initiated on medication where appropriate and followed up as needed.12 In hospitals without an FLS, a very small proportion of people with fragility fractures are treated for osteoporosis.4 However, the Portuguese Society of Rheumatology is reported to be discussing the wider roll-out of FLS through working groups it has convened on topics including osteoporosis and partnering with GPs.12

We need better communication between specialists and primary care. Strong liaison services linking departments would be highly beneficial in improving post-fracture care. HELENA CANHÃO, NOVA MEDICAL SCHOOL

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 are a serious problem for older people, but prevention of falls in the community does not appear to be a national priority. Falls are the main cause of accidental death in people aged over 65 in Portugal.22 To address this problem, the SNS has published a digital book for older people about preventing falls, particularly at home.22 However, there do not appear to be other major initiatives, and falls prevention is only briefly addressed in national strategy.5 In a hospital setting, however, the Ministry of Health’s National Plan for Patient Safety 2015–2020 includes falls prevention as a strategic objective.23

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

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

Public awareness of osteoporosis seems to be limited in Portugal. Experts interviewed for this profile reported that the public is not generally aware of osteoporosis, and tends not to recognise the link between osteoporosis and fractures.4 12 Some national societies have engaged in efforts to improve public awareness. For example, the National Association Against Osteoporosis (Associação Nacional Contra a Osteoporose; APOROS) is a patient association that provides extensive public information online and reportedly runs World Osteoporosis Day campaigns each year.12 24 However, its website does not list any new public awareness activities since 2015.25 SPR is also active in raising awareness, but focuses on professionals rather than the public.26

This information is based on research conducted in 2020.
Date of preparation: February 2021    HB-PRO-1220-00010
References +
  1. Svedbom A, Hernlund E, Ivergard M, et al. 2013. Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporos 8: 137
  2. Marques A, Lourenço Ó, da Silva JA. 2015. The burden of osteoporotic hip fractures in Portugal: costs, health related quality of life and mortality. Osteoporos Int 26(11): 2623-30
  3. Serviço Nacional de Saúde. Programas de Saúde Prioritários. [Updated 27/11/18]. Available from: www.sns.gov.pt/institucional/programas-de-saude-prioritarios [Accessed 27/04/21]
  4. Marques A. 2020. Interview with Taylor Morris at The Health Policy Partnership [telephone]. 01/06/20
  5. Grupo de trabalho interministerial. 2017. Estratégia nacional para o envelhecimento ativo e saudável 2017-2025. Lisbon: Servico nacional de saúde
  6. Santos MJ, Canhão H, Mourão AF, et al. 2017. Reuma.pt contribution to the knowledge of immune-mediated systemic rheumatic diseases. Acta Reumatol Port 42(3): 232-39
  7. Canhão H, Faustino A, Fonseca JE. 2014. Registo Nacional de Doentes Reumáticos, Reuma.Pt. Lisbon: Observatório Nacional das Doenças Reumáticas
  8. Administração Central do Sistema de Saúde. Benchmarking hospitals: goals. Available from: www.benchmarking-acss.min-saude.pt/BH_Enquadramento/Objetivos [Accessed 27/04/21]
  9. Borja-Santos R. Nenhum hospital operou todos os doentes com fractura na anca nas primeiras 48 horas. [Updated 11/10/13]. Available from: www.publico.pt/2013/10/11/sociedade/noticia [Accessed 27/04/21]
  10. Administração Central do Sistema de Saúde. Assistance performance. [Updated 20/11/19]. Available from: www.benchmarking-acss.min-saude.pt/BH_DesempAssistencialDashboard [Accessed 27/04/21]
  11. Hernlund E, Svedbom A, Ivergard M, et al. 2013. Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos 8: 136
  12. Canhão H. 2020. Interview with Taylor Morris at The Health Policy Partnership [telephone]. 27/05/20
  13. Canhão H. 2020. Personal communication by email: 27/07/20
  14. Marques A, Mota A, Canhão H, et al. 2013. A FRAX model for the estimation of osteoporotic fracture probability in Portugal. Acta Reumatol Port 38(2): 104-12
  15. Rodrigues AM, Canhão H, Marques A, et al. 2018. Portuguese recommendations for the prevention, diagnosis and management of primary osteoporosis – 2018 update. Acta Reumatol Port 43(1): 10-31
  16. Marques A, Rodrigues AM, Romeu JC, et al. 2016. Multidisciplinary Portuguese recommendations on DXA request and indication to treat in the prevention of fragility fractures. Acta Reumatol Port 41(4): 305-21
  17. Felicissimo P, Branco J. 2017. Precurso clínico e programa de alta nos doentes com fratura da extremidade proximal do fémur. Portuguese Journal of Orthopaedics and Traumatology 25(4): 303-10
  18. JustNews. Ortogeriatria do CHVNG/E reduziu internamentos, mortalidade e complicações pós-cirurgia. [Updated 20/09/19]. Available from: www.justnews.pt/noticias [Accessed 27/04/21]
  19. JustNews. Unidade de Ortogeriatria do Beatriz Ângelo otimiza resposta a idosos com fratura do fémur. [Updated 17/02/20]. Available from: www.justnews.pt/noticias [Accessed 27/04/21]
  20. Sociedade Portuguesa de Medicina Interna. Fratura proximal do fémur: ortogeriatria do HSFX com avaliação geriátrica global. [Updated 11/09/17]. Available from: www.spmi.pt/fratura-proximal-do-femur-ortogeriatria-do-hsfx-avaliacao-geriatrica-global [Accessed 27/04/21]
  21. Rodrigues AM, Eusébio M, Santos MJ, et al. 2018. The burden and undertreatment of fragility fractures among senior women. Arch Osteoporos 13(1): 22
  22. Servico nacional de saúde. Tropeções, quedas e trambolhões. [Updated 19/12/17]. Available from: www.sns.gov.pt/noticias [Accessed 27/04/21]
  23. Servico nacional de saúde. Quedas. Available from: www.dgs.pt/qualidade-e-seguranca/seguranca-dos-doentes [Accessed 27/04/21]
  24. Associaçã Nacional contra a Osteoporose. Quem somos. Available from: www.aporos.pt/quem-somos.html [Accessed 27/04/21]
  25. Associação Nacional contra a Osteoporose. Acções. Available from: www.aporos.pt/accoes.html [Accessed 27/04/21]
  26. Sociedade Portuguesa de Reumatologia. Programa de ação. Available from: www.spreumatologia.pt/programa-de-acao [Accessed 27/04/21]