Osteoporosis and fragility fracture prevention in Spain

While osteoporosis has received some policy attention in Spain, a lack of strategic recommendations, investment and detailed national guidance has led to barriers in access to care and significant variation in clinical practice. However, civil society and clinicians across the country are active in improving fragility fracture prevention through implementing a national hip fracture audit and promoting multidisciplinary post-fracture care, which is well established in Spain.

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Osteoporosis and fragility fracture prevention in Spain

Burden and impact of osteoporosis and fragility fractures

The burden of osteoporosis and fragility fractures in Spain is high and rising. The number of people living with osteoporosis and experiencing fragility fractures is comparable to other EU countries, and is expected to rise rapidly.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 addressed in some national health strategies in Spain, but specific plans for reducing fragility fracture risk are lacking. Both the strategy for health promotion and prevention2 and the strategy on rheumatic and musculoskeletal diseases3 address the need to reduce the risk of osteoporosis. However, these documents provide few specific recommendations to support fragility fracture prevention.

The Spanish National Hip Fracture Registry (Registro Nacional de Fractura de Cadera; RNFC) has been established, but national investment is needed to secure its future. Initiated in 2016 by a network of clinicians across Spain, the RNFC collects data on people aged 75 years who present to hospital with a hip fracture and follows them up for 30 days after they are discharged.4 The data collected align with the Fragility Fracture Network Minimum Common Dataset and can be used for national and international assessment of hospital performance in hip fracture care.5 The registry is currently funded through industry donations and research grants, but national funding has been identified by experts as a priority to ensure its sustainability.5

Changes to reimbursement policy in the past decade have introduced a barrier to people taking osteoporosis treatment. In 2012, cost sharing for prescription medications was revised as part of wider austerity measures.6 This introduced a co-payment for older people, who were previously exempt from paying for prescriptions, and raised the existing co-payment for the working population.6 This change in policy has been associated with a decline in use of osteoporosis medication.6

Catching it early: detection and management in primary care

Catching it early: detection and management in primary care

Clinical guidance is limited, leading to nationwide variations in diagnosis and management of osteoporosis in primary care. While national guidelines discuss the use of both clinical risk factors and bone mineral density testing to diagnose osteoporosis,7 there is no consensus on which risk assessment tool or criteria should be used to initiate treatment.8 As a result, risk factors are often not recognised and people are rarely referred for further investigation.9 In addition, osteoporosis medication is frequently either over- or under-prescribed in primary care,8 and experts have called for development of policies to support appropriate management.10

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

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

While orthogeriatric services are common in Spain, delivery of internationally recognised best-practice standards for in-hospital hip fracture care varies considerably.4 Results from the first year of the RNFC showed that most patients (94%) were seen by key specialists such as orthogeriatricians in addition to the orthopaedic surgeon.4 5 However, fewer than half had surgery within 48 hours of admission.11 Initiation of osteoporosis medication in hospital was higher than in many other countries at around 40%,4 but varied between hospitals, ranging from 0% to 94%.5 Similar variation was noted in the proportion of patients who were mobile the day after surgery, which ranged from 0% in some hospitals to 97% in others.5

Implementation of fracture liaison services (FLS) is well established in Spain. The Spanish Society for Bone Research (Sociedad Española de Investigación Ósea y del Metabolismo Mineral; SEIOMM) is active in promoting the establishment of FLS across the country, and the number of FLS in Spain is among the highest in the world.1 This includes 48 services that have been evaluated through the Capture the Fracture programme, 13 of which have received a gold rating, while a further 17 are currently being evaluated.12

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 major problem for older people in Spain, both in the community13 and in care homes.14 Falls in care homes are relatively common – sometimes leading to fractures – and are most often prevented by restraining movement; however, restraint is associated with a greater occurrence of injuries from falls.14 In the whole population, the number of deaths resulting from falls has significantly increased in older men and women, leading experts to call for comprehensive falls prevention programmes.13 15

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

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

Civil society organisations in Spain are active in raising awareness about osteoporosis and fragility fracture prevention. Various organisations such as the Spanish Association for Osteoporosis and Arthritis (Asociación Española con la Osteoporosis y la Artrosis; AECOSAR),16 Hispanic Foundation for Osteoporosis and Metabolic Bone Disease (Fundación Hispana de Osteoporosis y Enfermedades Metabólicas Oseas; FHOEMO)17 and SEIOMM18 produce educational materials and run public awareness campaigns. In 2018, they collaborated to launch a campaign that aimed to raise public awareness of the consequences of osteoporosis and activate the medical community to engage with fracture prevention. The campaign, called Your Bones. Tomorrow and Always (Tus Huesos. Mañana y siempre), was built around a short film telling the story of a woman with osteoporosis.19

While osteoporosis medication use was previously high in Spain, self-management with osteoporosis treatment has significantly declined. In 2010, the use of osteoporosis medication was among the highest in the world, with around 28% of women over 50 years of age taking it. By 2015, however, based on data from the Valencia region, use had declined by about half; this has been attributed both to safety warnings about the potential for atypical fracture and the revised co-payment policy mentioned above.6

 

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. International Osteoporosis Foundation. 2018. Broken bones, broken lives: A roadmap to solve the fragility fracture crisis in Spain. Nyon: IOF
  2. Ministerio de Sanidad Servicios Sociales e Igualdad. 2014. Estrategia de promocion de la salud y prevencion en el SNS. Madrid: Ministerio de Sanidad Servicios Sociales e Igualdad
  3. Ministerio de Sanidad Servicios Sociales e Igualdad. 2013. Estrategia en enfermedades reumaticas y musculosqueleticas del Sistema Nactional de Salud. Madrid: Ministerio de Sanidad SErvicios Sociales e Igualdad
  4. Ojeda-Thies C, Sáez-López P, Currie CT, et al. 2019. Spanish National Hip Fracture Registry (RNFC): analysis of its first annual report and international comparison with other established registries. Osteoporosis International 30(6): 1243-54
  5. Registro Nacional de Fracturas de Cadera. 2018. Registro nacional de fracturas de cadera por fragilidad: Informe anual 2017. Madrid: RNFC
  6. Hurtado-Navarro I, Garcia-Sempere A, Rodriguez-Bernal C, et al. 2019. Impact of Drug Safety Warnings and Cost-Sharing Policies on Osteoporosis Drug Utilization in Spain: A Major Reduction But With the Persistence of Over and Underuse. Data From the ESOSVAL Cohort From 2009 to 2015. Frontiers in pharmacology 10: 768
  7. Grupo de trabajo de la Guía de Práctica Clínica sobre Osteoporosis y Prevención de Fracturas por Fragilidad. 2010. Guía de práctica clínica sobre osteoporosis y prevención de fracturas por fragilidad. Madrid: Agència d´Informació AiQeSAdC
  8. Martinez-Laguna D. 2018. Osteoporosis y Atención Primaria. Como valorar el riesgo de fractura. Utilización de las escalas de riesgo. Revista de osteoporosis y metabolismo mineral 10(1): Supplement: 5-8
  9. Abella CC. 2011. La osteoporosis en Atención Primaria. Revista de Osteoporosis y Metabolismo Mineral 3(2): 73-74
  10. Sanfélix-Gimeno G, Hurtado I, Sanfélix-Genovés J, et al. 2015. Overuse and underuse of antiosteoporotic treatments according to highly influential osteoporosis guidelines: a population-based cross-sectional study in Spain. PloS one 10(8): e0135475
  11. Ministerio de Sanidad Servicios Sociales e Igualdad. 2018. Actividad y calidad de los servicios sanitarios: Informe anual del sistema nacional de salud 2017. Madrid: Ministerio de Sanidad Consumo y Bienestar Social
  12. International Osteoporosis Foundation. 2019. Capture the Fracture. Map of best practice. Available from: www.capturethefracture.org/map-of-best-practice-page [Accessed 01/09/20]
  13. Rodríguez-Molinero A, Narvaiza L, Gálvez-Barrón C, et al. 2015. Caídas en la población anciana española: incidencia, consecuencias y factores de riesgo. Revista espanola de geriatria y gerontologia 50(6): 274-80
  14. Aranda-Gallardo M, Morales-Asencio JM, Enriquez de Luna-Rodriguez M, et al. 2018. Characteristics, consequences and prevention of falls in institutionalised older adults in the province of Malaga (Spain): a prospective, cohort, multicentre study. BMJ Open 8(2): e020039
  15. Padrón-Monedero A, Damián J, Pilar Martin M, et al. 2017. Mortality trends for accidental falls in older people in Spain, 2000-2015. BMC Geriatrics 17(1): 276
  16. Asocacion espanola con la osteoporosis y la artrosis. Objetivos estrategicos. Available from: www.aecosar.es/objetivos-estrategicos [Accessed 01/09/20]
  17. Fundacion Hispana de Osteoporosis y Enfermedades Metabolicas Oseas. Quienes Somos. Available from: www.fhoemo.com/quienes-somos [Accessed 01/09/20]
  18. Sociedad Espanola de Investigacion Osea y del Metablilosmo Mineral. Quienes somos. Available from: www.seiomm.org/quienes-somos [Accessed 01/09/20]
  19. Fundacion Hispana de Osteoporosis y Enfermedades Metabolicas Oseas. 2018. Tus Huesos Manana y Siempre. Madrid: FHOEMO