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.

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

Europe’s health systems must be prepared to respond to the growing burden of fragility fractures.1 This will require improvements in how health and social services take care of people both before and after a fracture. The improvements needed in fragility fracture care will require buy-in from stakeholders at all levels and a supportive policy environment that recognises osteoporosis as a priority.2

Three cross-cutting elements are required to ensure clinical care is optimised across the whole patient journey:

  • Integrating fragility fracture prevention into European and national policies and strategies. Strategic leadership in policy development must ensure long-term investment and accountability. Achievable targets based on a clear vision of current and future demand on the healthcare system will be essential.
  • Establishing comprehensive registries and audits. High-quality data on osteoporosis and fragility fractures must be available for effective scrutiny, performance management and planning.
  • Setting up reimbursement structures. Reimbursement must be sufficient to ensure access to best-practice care at all levels of service delivery.

Clinical guidelines are not enough to effect change – only governments can ensure appropriate funding structures and incentives are in place. We must make sure each stage in the patient journey is appropriately resourced and financed.

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.

Date of preparation: October 2020.
References +
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