Building a system that works: policies for scrutiny, accountability and investment
Integrated prevention, comprehensive registries and sufficient reimbursement are the cornerstones of an appropriate policy response to the challenge of osteoporosis and fragility fractures.
Integrating fragility fracture prevention into European and national policies and strategies
Osteoporosis and fragility fractures are highly relevant to broader policies on chronic diseases, healthy ageing, women’s health, and informal carers related to inequalities in social care. Many European countries recognise the importance of reducing frailty and maintaining mobility as part of healthy ageing and prevention,3 but osteoporosis does not usually appear in national prevention strategies. In policies for chronic disease, other conditions such as diabetes4 and heart disease5 receive far more attention.6 A recent analysis showed that musculoskeletal health, which includes osteoporosis and fragility fractures, was only included in half of non-communicable disease strategies for Organisation for Economic Co-operation and Development (OECD) countries.6
Recognition in policy would enable the development of vital services for osteoporosis and fragility fractures. National strategies often support implementation of programmes such as awareness campaigns,2 and could also support greater investment in elements including registries, diagnostic tools and preventive strategies.
Yet despite concerted efforts to put the issue on the political agenda,7 8 neither osteoporosis nor fragility fractures are viewed as urgent, even though they impose a significant burden.2 9 10 France, Italy and the UK are among the few countries that recognise osteoporosis as a policy priority.11-14
Women’s health may often be undervalued – few countries specifically address women’s needs in national health policy.15-17 In those that do, osteoporosis is often absent from health policies despite its significant impact on women’s health.15-18
Some European countries (Greece, Italy, Norway, Spain and the UK)19 20 are moving towards the formation of multi-stakeholder alliances – including policymakers, professional societies, the private sector and non-governmental organisations – to build national consensus on falls and fracture prevention. Such alliance-building is being spearheaded by organisations including the Fragility Fracture Network and the International Osteoporosis Foundation.21 22 This focus on consensus-building is crucial in developing and communicating a unified call for national policy change.
Establishing comprehensive registries and audits
Effective services depend on the availability of high-quality data. But data collected on osteoporosis and fragility fractures tend not to be comprehensive, comparable or consistent across Europe. Some northern European countries have well-established fracture registries, but there are relatively few registries in southern and eastern Europe.23 Even countries that do have registries rarely collect data on the number of all types of fragility fractures. In 2013, only 12 EU countries had comprehensive national fracture registries,2 the majority focusing on hip fractures. Other types of fracture, such as in the spine or forearm, are underreported across most of Europe.1 24
Regular clinical audits can help improve practice.24 National hip fracture audits, for example, have been shown to improve care standards in several countries, such as the UK and Spain.23 25-27 Introducing audits for other types of fractures could have a similar effect.
The way data on fractures are collected and analysed varies widely. This limits policymakers’ ability to compare performance between countries. National reports vary in both the quality and amount of data they capture, owing to differences in inclusion criteria or definitions used.23 24 To address this, recent initiatives have developed standard indicators to establish common international data sets. These include the FFN Minimum Common Dataset, adopted by several European countries including Spain.23
Setting up reimbursement structures
Reimbursement is the payment healthcare providers receive for delivering care and services to patients. Adequate reimbursement structures must be available to support access to high-quality care for osteoporosis and fragility fractures. Cost-effective strategies should fit the national context and must be sufficiently resourced to ensure that optimal fragility fracture care can be implemented at scale.28 But because there are so few osteoporosis-focused policies, osteoporosis detection and management in addition to fracture prevention services remain limited and underfunded.9 Decisions around reimbursement should consider the wider costs of failing to prevent fractures.
Diagnosis of osteoporosis is not always appropriately reimbursed.29 30 For example, reimbursement for dual-energy X-ray absorptiometry (DXA) scanning, a key step in diagnosis,2 is insufficient in many EU countries.1 Most EU member states provide at least partial reimbursement for DXA scanning, but only 10 countries are considered to offer good access to it: Denmark, Finland, Greece, Latvia, Luxembourg, the Netherlands, Portugal, Slovenia, Spain and Sweden.2 This is partly because, in many cases, reimbursement is limited to specific circumstances. For instance, it may be provided only for patients aged 65 years and over (Austria), only for women (Hungary), or only if the result is positive for osteoporosis (Bulgaria).2
And it’s not just diagnosis: reimbursement for osteoporosis medication is also often restricted, likely contributing to the shockingly low treatment rates across Europe.1 31 Medication accounts for a minimal proportion of osteoporosis care costs – less than 5% in many EU countries.32 Yet, in 2013, only eight member states (Austria, Germany, Ireland, Italy, the Netherlands, Slovenia, Sweden and the UK) provided full, unconditional reimbursement of at least one osteoporosis medication.2 In other countries, limited reimbursement can make treatment unaffordable or inaccessible.2 For example, Italy and Poland have imposed age restrictions,2 the Netherlands provides reimbursement only for women,1 and Spain and Finland require co-payments,33 34 which may present a barrier to medication use among disadvantaged groups.
- 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
- Kanis JA, Borgstrom F, Compston J, et al. 2013. SCOPE: a scorecard for osteoporosis in Europe. Arch Osteoporos 8: 144
- World Health Organization Regional Office for Europe. 2012. Strategy and action plan for healthy ageing in Europe, 2012–2020. Malta: WHO
- Richardson E, Zaletel J, Note E. 2016. National diabetes plans in Europe: What lessons are there for the prevention and control of chronic diseases in Europe? Ljublijana: National Institute of Public Health
- Eurostat. 2018. Cardiovascular diseases statistics. Brussels: European Commission
- Briggs AM, Persaud JG, Deverell ML, et al. 2019. Integrated prevention and management of non-communicable diseases, including musculoskeletal health: a systematic policy analysis among OECD countries. BMJ Global Health 4(5): e001806
- Dreinhöfer KE, Mitchell PJ, Bégué T, et al. 2018. A global call to action to improve the care of people with fragility fractures. Injury 49(8): 1393-97
- International Osteoporosis Foundation. 2018. Broken bones, broken lives: A roadmap to solve the fragility fracture crisis in Europe. Nyon: IOF
- Eisman JA, Bogoch ER, Dell R, et al. 2012. Making the first fracture the last fracture: ASBMR task force report on secondary fracture prevention. J Bone Miner Res 27(10): 2039-46
- Curtis EM, Moon RJ, Harvey NC, et al. 2017. The impact of fragility fracture and approaches to osteoporosis risk assessment worldwide. International journal of orthopaedic and trauma nursing 26: 7-17
- 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 25/09/19]
- Ministero della Salute. 2016. Patologie al Femminile. Available from: http://www.salute.gov.it/portale/donna/menuContenutoDonna.jsp?lingua=italiano&area=Salute%20donna&menu=patologie [Accessed 25/09/19]
- Ministere des Solidarites et de la Sante. Ma santé 2022: un engagement collectif. Available from: https://solidarites-sante.gouv.fr/systeme-de-sante-et-medico-social/masante2022/ [Accessed 04/11/19]
- Ali N, Qadery S, Narle G. 2019. Musculoskeletal Health: 5 year strategic framework for prevention across the lifecourse. London: PHE publications
- Public Health England. 2019. Healthy beginnings: applying All Our Health. London: PHE
- Plantenga J, Remery C. 2015. The policy on gender equality in the Netherlands; In-depth analysis for the FEMM committee. Brussels: European Parliament
- Government of Ireland. 2019. Women’s Health Taskforce. Available from: https://www.gov.ie/en/campaigns/-womens-health/ [Accessed 18/11/19]
- WHO Regional Office for Europe. 2016. Strategy on women’s health and well-being in the WHO European Region. Copenhagen: WHO Regional Office for Europe
- Mitchell P. 2019. Personal communication by email: 09/10/2019
- Fragility Fracture Network Greece. 2019. Available from: https://ffngr.wordpress.com [Accessed 10/10/19]
- International Osteoporosis Foundation. Home page. Available from:
https://www.iofbonehealth.org [Accessed 06/10/20]
Fragility Fracture Network. Home page. Available from: https://www.fragilityfracturenetwork.org/ [Accessed 06/10/20]
- 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. Osteoporos Int 30(6): 1243-54
- Johansen A, Golding D, Brent L, et al. 2017. Using national hip fracture registries and audit databases to develop an international perspective. Injury 48(10): 2174-79
- Patel NK, Sarraf KM, Joseph S, et al. 2013. Implementing the National Hip Fracture Database: An audit of care. Injury 44(12): 1934-39
- Ferguson KB, Halai M, Winter A, et al. 2016. National audits of hip fractures: Are yearly audits required? Injury 47(2): 439-43
- Neuburger J, Currie C, Wakeman R, et al. 2015. The impact of a national clinician-led audit initiative on care and mortality after hip fracture in England: an external evaluation using time trends in non-audit data. Med Care 53(8): 686-91
- Hiligsmann M, Kanis JA, Compston J, et al. 2013. Health technology assessment in osteoporosis. Calcif Tissue Int 93(1): 1-14
- Kurth A. 2019. Interview with Kirsten Budig at The Health Policy Partnership [Telephone]. 18/09/19.
- Harvey NC, McCloskey EV, Mitchell PJ, et al. 2017. Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures. Osteoporos Int 28(5): 1507-29
- McCloskey EV, J. Rathi SH, Blagden M, et al. 2019. Osteoporosis (op) diagnosis and treatment of women aged ≥70 years in primary care: results from a large european cross-sectional study. Breda: Amgen
- Svedbom A, Hernlund E, Ivergard M, et al. 2013. Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporos 8: 137
- 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. Front Pharmacol 10: 768
- Holm A, Tamminen P. 2019. Interview with Taylor Morris at The Health Policy Partnership [Telephone]. 30/09/19.