Osteoporosis and fragility fracture prevention in the Netherlands

Osteoporosis and fragility fractures are not prioritised in national health policies in the Netherlands and there is considerable variation in delivery of key services across the country. Recent developments such as the National Hip Fracture Audit and the establishment of fracture liaison services are supporting improvements in care, but have primarily been driven by professional organisations.

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Osteoporosis and fragility fracture prevention in the Netherlands

Burden and impact of osteoporosis and fragility fractures

The burden of osteoporosis in the Netherlands is considerable and incurs high costs.

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

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

While the Dutch government has a strong focus on prevention of disease, it does not appear to prioritise osteoporosis and fragility fractures. There is currently considerable policy focus on disease prevention,2 with the ambition of supporting health throughout life and ensuring that older people can maintain good health for as long as possible. However, the National Prevention Agreement focuses on lifestyle factors, while specific conditions such as osteoporosis are not addressed.2 An expert commentator has suggested that diseases such as diabetes, which have a more visible impact on health, are usually prioritised over osteoporosis, which does not cause symptoms until a fracture occurs.3

A national hip fracture registry has recently been established with the aim of improving hip fracture management. The Dutch Hip Fracture Audit began collecting data in 2016 and produced its first report in 2017.4 The audit, run by the Dutch Institute for Clinical Auditing, arose from multidisciplinary collaboration between a number of professional societies.4 While improvements in care have yet to be reported, the audit has been used to identify gaps in care across the Netherlands and is currently supporting three pilot projects to improve and standardise hip fracture monitoring and care.5

The health insurance system in the Netherlands supports universal access to key services for osteoporosis and fragility fracture prevention. The Health Insurance Act ensures that all people in the Netherlands are covered by a basic health insurance policy.6 The government specifies which services must be included in the basic package, which covers most essential medical care, hospital services and medications.6 As a result, people in the Netherlands seem to have good and equitable access to medications and services for fragility fracture prevention and treatment.3

Catching it early: detection and management in primary care

Catching it early: detection and management in primary care

While guidelines for preventing fragility fractures in primary care have been developed, detection of osteoporosis is often not a priority.3 National guidance for fracture prevention in primary care focuses on preventing subsequent fractures among people who have already experienced a fracture. The guidelines specify that general practitioners should proactively investigate osteoporosis in people who have already sustained a fragility fracture.7

Coupled with low levels of patient engagement with post-fracture services,8 this has contributed to considerable underdiagnosis of osteoporosis.9 In 2010, when the number of people with osteoporosis in the Netherlands was last recorded, only 148,200 had been officially diagnosed.9 This represents just 4.3% of women and 0.5% of men over 50 years of age, up to five times lower than the proportion of the population estimated to be living with the illness.1 9

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

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

Best-practice guidelines promote multidisciplinary care of people with hip fractures, although hospital performance varies.4 The Dutch Guideline to Multidisciplinary Treatment of Frail Elderly During Surgical Procedures was developed in 2016 to promote multidisciplinary care and support standardised practice across the country.10 The guideline calls for the involvement of orthogeriatrics and other services such as falls prevention, primary care and social services. Data from the Dutch Hip Fracture Audit show that, in 2018, 70% of hip fracture patients over 70 received orthogeriatric care that started before surgery, but with wide variation in performance between hospitals.5 However, the impact of the guideline on patient outcomes has not yet been reported.

Having a network of professionals involved in fracture liaison services has really helped to improve these services and increase their use.MICKAËL HILIGSMANN, MAASTRICHT UNIVERSITY

Fracture liaison services (FLS) are well established in the Netherlands, but identification of osteoporosis following a fracture is still suboptimal.9 Most hospitals have established an FLS to conduct post-fracture diagnosis of osteoporosis and initiate treatment.9 This seems to have been driven by a network of professionals working to increase the number of FLS.3 However, there is considerable variation in the services provided by FLS across the country, with experts calling for standardised guidance.11 In addition, low patient engagement with FLS is often a key barrier to identification and treatment of osteoporosis; on average, just under half (49%) of those eligible engage with an FLS.8

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

Effective falls prevention programmes are widely established, although access may vary across the country. The Dutch population is ageing rapidly, leading to a drastic increase in deaths from falls in recent years.12 To address this problem, a number of falls prevention programmes have been developed and are now officially recommended by the government.13 These programmes, designed for adults aged 55 and over, involve educational components and activities to improve mobility and balance or to increase awareness of risk associated with falls.13 A study showed that the Nijmegan Falls Prevention Programme Falling Past Time is a particularly effective programme which led to a 46% reduction in falls.14 Across the country, access to falls prevention programmes may vary, as they generally must be financed by individual municipalities or through insurance policies.15

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

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

Public awareness activities are primarily implemented by patient associations in the Netherlands. The Osteoporosis Association (Osteoporose Vereniging) is a volunteer-operated patient organisation which aims to support people with osteoporosis and promote prevention through its Strong Bones platform.16 This initiative focuses on improving bone health through exercise and good nutrition.17 For people who have already been diagnosed with osteoporosis, extensive information and various resources are available on the Osteoporosis Association website.18

The percentage of people consistently taking osteoporosis medication is low and there are few strategies in place to promote self-management. As per a study conducted in 2011, fewer than half of people who have been prescribed osteoporosis medication continue to take it for one year.19 Post-fracture follow-up is usually limited, with responsibility for ongoing management falling on primary care, where the management of osteoporosis is generally not prioritised.3 As a result, people with osteoporosis may not be adequately supported to keep taking their medication.3

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. Ministry of Health Welfare and Sport. 2019. The national prevention agreement: A healthier Netherlands. The Hague: Ministry of Health Welfare and Sport
  3. Hiligsmann M. 2019. Interview with Taylor Morris and Jody Tate at The Health Policy Partnership [telephone]. 12/08/19
  4. Voeten SC, Arends AJ, Wouters MWJM, et al. 2019. The Dutch Hip Fracture Audit: evaluation of the quality of multidisciplinary hip fracture care in the Netherlands. Archives of osteoporosis 14(1): 28
  5. Dutch Institute for Clinical Auditing. 2019. Annual report 2018: DHFA. Leiden: DICA
  6. Ministry of Health Welfare and Sport. 2018. Healthcare in the Netherlands. The Hague: Ministry of Health Welfare and Sport
  7. Nederlands Hulsartsen Genootschap. 2012. NHG-Standaard Fractuurpreventie. Utrecht: Nederlands Hulsartsen Genootschap
  8. van den Berg P, Schweitzer DH, van Haard PM, et al. 2015. Meeting international standards of secondary fracture prevention: a survey on Fracture Liaison Services in the Netherlands. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA 26(9): 2257-63
  9. Dunnewind T, Dvortsin EP, Smeets HM, et al. 2017. Economic Consequences and Potentially Preventable Costs Related to Osteoporosis in the Netherlands. Value in Health 20(6): 762-68
  10. Federatie Medisch Specialisten. 2016. Proximale femurfractuur – organisatie van zorg bij de behandeling van kwetsbare ouderen rondom chirurgische ingrepen. Utrecht: Federatie Medisch Specialisten
  11. Huntjens KM, van Geel TA, Blonk MC, et al. 2011. Implementation of osteoporosis guidelines: a survey of five large fracture liaison services in the Netherlands. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA 22(7): 2129-35
  12. Schuetze CF. 2018. Afraid of falling? For older adults, the Dutch have a cure [online]. The New York Times. Available from: www.nytimes.com/netherlands-falling-elderly [Accessed 01/09/20]
  13. National Institute for Public Health and the Environment. Interventieoverzicht Valpreventie. Available from: www.interventies.loketgezondleven.nl [Accessed 01/09/20]
  14. Weerdesteyn V, Rijken H, Geurts ACH, et al. 2006. A Five-Week Exercise Program Can Reduce Falls and Improve Obstacle Avoidance in the Elderly. Gerontology 52(3): 131-41
  15. Veiligheid NL. Voorbeelden om aan de slag te gaan met Valpreventie. Available from: www.veiligheid.nl/valpreventie/financieringsmogelijkheden-valpreventie-initiatieven [Accessed 01/09/20]
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  17. Sterke botten. Platform sterke botten. Available from: www.sterkebotten.nu [Accessed 01/09/20]
  18. Osteoporose Vereniging. Home page. Available from: www.osteoporosevereniging.nl [Accessed 07/10/20]
  19. Netelenbos JC, Geusens PP, Ypma G, et al. 2011. Adherence and profile of non-persistence in patients treated for osteoporosis—a large-scale, long-term retrospective study in The Netherlands. Osteoporosis International 22(5): 1537-46