Osteoporosis and fragility fracture prevention in Romania

While Romania has published national guidance for managing osteoporosis and treatment is fully reimbursed, there do not appear to be programmes in place to support delivery of best-practice prevention or treatment of osteoporosis and fragility fractures.

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Osteoporosis and fragility fracture prevention in Romania

Burden and impact of osteoporosis and fragility fractures

Osteoporosis and fragility fractures impose a considerable burden on the health system in Romania.1

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 have received some attention in Romania, but are not currently prioritised in policy. The National Health Insurance House (Casa Naţională de Asigurări de Sănătate) operates 15 specific health programmes,2 including the endocrine disease programme, which provides treatment for osteoporosis free of charge for people who have been diagnosed.3 In 2010, the national government also published guidance for the diagnosis and treatment of postmenopausal osteoporosis.4 However, osteoporosis is not included as a priority disease in the national health strategy for 2014–2020, which identifies a range of priority areas for prevention and treatment of chronic illnesses.5 An expert interviewed for this country profile reported that prioritisation and funding of osteoporosis programmes has declined over the past decade, leading to a reduction in treatment.6

As an endocrinologist, I can see that osteoporosis has not been a priority for policymakers over the past 10 years. As a result, support for the osteoporosis programme has declined, leading to a reduction in the number of treatments that are reimbursed and in the number of people who receive treatment.DIANA PAUN, NATIONAL INSTITUTE OF ENDOCRINOLOGY CI PARHON

National healthcare data, including data on osteoporosis and fragility fractures, are routinely collected in Romania, but they are not always used to support service improvement. Information systems for healthcare data are managed by national bodies,7 such as the National Health Insurance House.8 The national hospital discharge register is also used to collect data on all hospital admissions, including for hip fractures, but there is no dedicated registry for osteoporosis or fragility fractures.6 There are some recognised limitations with existing healthcare databases in Romania, such as incomplete and duplicate data, and information is made available to the public only upon request.7 Furthermore, the data are infrequently analysed or used to inform healthcare service delivery.7

Reimbursement policy in Romania supports access to osteoporosis treatment, although there may be some barriers to diagnosis.4 7 The national endocrine disease programme provides reimbursement for dual-energy X-ray absorptiometry (DXA) scanning to investigate osteoporosis, and for free treatment for people diagnosed with osteoporosis.6 7 Over 5,000 people with osteoporosis are treated through this programme each year.3 6 However, DXA scanning may be restricted due to the small number of DXA machines in the country,9 and treatment is usually only provided for people who have been diagnosed with osteoporosis through DXA scan or for those who have already had a fragility fracture.5 This means some people at high risk may not receive appropriate treatment before a fracture occurs if they do not have access to a DXA scan.9 10

Catching it early: detection and management in primary care

Catching it early: detection and management in primary care

Primary care providers are often involved in identification of fracture risk, but there may be gaps in service delivery. National guidance states that people at risk of osteoporosis should usually be identified in primary care,4 and awareness of osteoporosis risk seems to be high among primary care providers.6 This can be supported by the use of a country-specific fracture risk assessment (FRAX) tool,10 which is used by both primary care providers and specialists.6 However, diagnosis of osteoporosis and prescription of treatment are usually carried out in a hospital setting by a specialist who is responsible for the person’s ongoing osteoporosis management.6 Indeed, provision of services through primary care is an ongoing challenge in Romania as healthcare is disproportionately delivered in specialist or inpatient settings, with primary care reportedly being underutilised.7

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

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

Clinical guidance for post-fracture care is available, but there appears to be limited support for dedicated multidisciplinary services. Clinical guidance has been developed for diagnosis and treatment of postmenopausal osteoporosis4 and for the treatment of hip fractures.11 Post-fracture guidance, published by the Romanian Society of Orthopaedics and Traumotology (Societatea Romana de Ortopedie si Traumatologie; SOROT), is primarily focused on surgical treatment, although multidisciplinary working and early post-surgery mobilisation are discussed.11 However, there are few details about which specialists should be involved in multidisciplinary teams or how services should be organised.11 While it does not appear in clinical guidance, conducting surgery within 48 hours of admission has been noted as being occasionally referenced as a target.12 For example, in a performance audit of 10 Romanian hospitals, two hospitals reported that 100% of older patients with a hip fracture received surgical intervention within 48 hours of admission.13 More than 5% of people with hip fractures die in hospital in Romania14 but data on other outcomes do not appear to be available.

Post-fracture follow-up and care appear to be underdeveloped in Romania. Following a fragility fracture, people are not always prescribed medication.15 When last assessed in 2010, only 6% of men and 17% of women who were eligible for treatment were taking it,1 representing one of the largest treatment gaps of any country in the European Union.15 This may be due, in part, to the fact that surgical treatment of fractures is separate from investigation for osteoporosis, which is usually initiated in primary care and then carried out by a specialist such as an endocrinologist.6 Furthermore, there do not appear to be formal programmes in place for post-fracture follow-up care and Romania does not have any fracture liaison services registered with Capture the Fracture.16

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 significant cause of disability, but national strategies do not appear to address falls among older people. In Romania, falls are the second leading cause of disability, after lower back pain.17 Despite this, the national strategy for active ageing, published by the Ministry of Labour and Social Protection, does not discuss falls prevention as a priority area.18 While the Association for Prevention of Osteoporosis in Romania (ASPOR) highlights falls prevention as an important component of fracture prevention,19 there do not appear to be strategies or programmes in place to prevent falls in the older population.

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

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

Some public awareness campaigns have been implemented by civil society,21 resulting in reportedly high levels of awareness.7 ASPOR is active in promoting awareness of osteoporosis among both clinicians and the public.21 For example, it publishes an educational magazine for members, organises public campaigns and operates symposia and training courses.21 SROBMS is a professional society that also engages in public awareness activities, as well as running annual symposia and offering professional training courses.22 However, there do not appear to be national data available on public awareness or use of osteoporosis medication.

Some public awareness campaigns have been implemented by civil society,20 resulting in reportedly high levels of awareness.6 ASPOR is active in promoting awareness of osteoporosis among both clinicians and the public.20 For example, it publishes an educational magazine for members, organises public campaigns and operates symposia and training courses.20 SROBMS is a professional society that also engages in public awareness activities, as well as running annual symposia and offering professional training courses.21 However, there do not appear to be national data available on public awareness or use of osteoporosis medication.

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. Casa Naţională de Asigurări de Sănătate. Lista Programelor Naționale de Sănătate. [Updated 31/05/14]. Available from: www.cnas.ro/page-1/category/lista-programelor-nationale-de-sanatate.html [Accessed 01/09/20]
  3. Casa Naţională de Asigurări de Sănătate. Programul naţional de boli endocrine. Available from: www.cnas.ro/page/programul-national-de-boli-endocrine.html [Accessed 01/09/20]
  4. Ghid de practică medicală pentru specialitatea endocrinologie: ghid pentru diagnosticul si tratamentul osteoporozei de postmenopauza. 2010. Romania: 18/10/10
  5. Strategia Nationala din 18 noiembrie 2014: de sănătate 2014-2020. 2014. Romania: 18/11/19
  6. Păun D. 2019. Interview with Taylor Morris at the Health Policy Partnership [Telephone]. 11/12/19
  7. Vladescu C, Scintee SG, Olsavszky V, et al. 2016. Romania: health system review. Brussels: European Observatory on Health Systems and Policies
  8. Casa Naţională de Asigurări de Sănătate. Protecţia datelor cu caracter personal. Available from: www.cnas.ro/page/protectia-datelor-cu-caracter-personal-3.html [Accessed 01/09/20]
  9. Kanis J, Hernlund E, Svedbom A, et al. 2013. The osteoporosis treatment gap in Romania. Acta Endocrinologica (Buc) 9(4): 509-14
  10. Grigorie D, Sucaliuc A, Johansson H, et al. 2013. FRAX-based intervention and assessment thresholds for osteoporosis in Romania. Archives of osteoporosis 8: 164
  11. Lupescu O, Roman MD, Deleanu B, et al. 2018. Guidance and Guideline-recommendations for the treatment of femoral neck fractures Romanian Society of Orthopaedics and Traumatology- SOROT 2018. Romanian Journal of Orthopaedic Surgery and Traumatology 1(2): 101
  12. Georgescu NM. Fracture osteoporotice. Available from: www.providentamedical.ro/fracturile-osteoporotice/fracturile-osteoporotice [Accessed 01/09/20]
  13. Oxford Policy Management. 2017. Performance auditing of selected public hospitals with arrears. Bucharest: Ministerul Sanatatii
  14. Dobre R, Niculescu D, Popescu G, et al. 2019. In-hospital mortality rate after osteoporotic hip fracture in Bucharest. Romanian Journal of Orthopaedic Surgery and Traumatology 2(1): 48-51
  15. 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). Archives of osteoporosis 8: 136
  16. Capture the Fracture. Map of best practice. Available from: www.capturethefracture.org/map-of-best-practice [Accessed 01/09/20]
  17. Institute for Health Metrics and Evaluation. Romania. Available from: www.healthdata.org/romania [Accessed 01/09/20]
  18. Ministerul Muncii și Protecției Sociale. 2015. Strategia naţională pentru promovarea îmbătrânirii active şi protecţia persoanelor vârstnice 2015–2020. Bucharest: Ministerul Muncii și Protecției Sociale
  19. Association for the Prevention of Osteoporosis in Romania. Osteoporoza. Available from: www.aspor.ro/index.php [Accessed 01/09/20]
  20. Association for the Prevention of Osteoporosis in Romania. Association for the Prevention of Osteoporosis in Romania – ASPOR. Available from: www.aspor.ro/index.php [Accessed 01/09/20]
  21. Societatea Romana de Osteoporoza si Boli Musculoscheletice. Despre noi. Available from: www.srobms.ro/despre-noi.html [Accessed 01/09/20]