CAPTURE THE FRACTURE®
PARTNERSHIPGUIDANCE FOR POLICY SHAPING

CAPTURE THE FRACTURE®
PARTNERSHIP
Guidance for Policy Shaping
Published November 2020
Authors: Cyrus Cooper (IOF President); Nick Fuggle, Kassim Javaid, Rafael
Pinedo-Villanueva
On behalf of the IOF Board and Executive Committee (Jean-Yves
Reginster, Chair of Committee of National Societies; Bess Dawson
Hughes, General Secretary; René Rizzoli, Treasurer; John Kanis, Honorary
President; Philippe Halbout, CEO).
Acknowledgement: IOF, Amgen and UCB are most grateful to The Health
Policy Partnership for permitting us to base this document on their
Osteoporosis and Fragility Fractures Policy Toolkit, also commissioned by
Amgen.

About IOF
The International Osteoporosis Foundation (IOF) is the world’s largest
nongovernmental organization dedicated to prevention, diagnosis andtreatment of osteoporosis and related musculoskeletal diseases. IOF
Members, including committees of scientific researchers as well as 260
patient, medical and research societies in more than 100 locations, work
together to make fracture prevention and healthy mobility a worldwide
health care priority. @iofbonehealth www.osteoporosis.foundation

About Capture the Fracture®
Capture the Fracture® (CTF) is a multi-stakeholder initiative led by theInternational Osteoporosis Foundation. The initiative hopes to drivechanges at local and international levels, so that secondary fracture
prevention becomes a global reality. Its aim is to set global best practices
for Fracture Liaison Services (FLS), while serving as a benchmark tool
to which clinics and hospitals can adhere and aspire to, while receiving
international recognition on the CTF Global Map of Best Practice. The CTF
program has a diverse set of tools that provides essential resourcesand documentation to drive quality improvement in FLS and offers
mentorship programs that support development and sustainability of
FLS at the local level. #CaptureTheFracture www.capturethefracture.org

partnership

An IOF initiative, supported by Amgen and UCB in collaboration with the University of Oxford.

3

4

CONTENTS

8 Preface
10

Executive Summary

11

About Post-Fracture Care Coordination Programs

12

About the Capture the Fracture® Partnership

14 Call to Action
18

National

20

Regional and Local

22 Making the Case
32

24

What are Osteoporosis and Fragility Fractures?

28

The Cost of Inaction:
The Economic Case for Change

The Building Blocksof an Effective Policy Response
34

A System That Works

38

Catch it Early:
Detection and Management of Subsequent Fractures

44

Treat it Well:
Facilitating Multi-Disciplinary Post-Fracture Care50

Healthy Active Ageing:
Preventing Falls and Fractures in Later Life
Through Good Health Earlier in Life

56

Enhance Engagement:
Awareness, Activation and Self-Management

62
References
66
Glossary

PREFACE

8

This document extolls the vital importance of preventing fractures, andparticularly future fractures in individuals who have already broken abone. There are clear public health and financial benefits to confronting
the issue of secondary fracture prevention.
“Osteoporosis is a major public health concern causing more than
8.9 million debilitating and lifechanging fragility fractures every year
across the globe with serious societal and economic consequences.
The ageing of society is driving an enormous increase in fragility fracture
incidence and imposing a massive burden on patients, their families,
health systems and societies around the world.
A fragility fracture is caused by osteoporosis and is a lifechanging event
which can have an impact on the individual’s quality of life and ability tolive independently. Every three seconds, someone in the world breaks
a bone because of osteoporosis. Once a woman has her first fragility
fracture due to osteoporosis, she is five times more likely to fracture
again within a year – and her risk remains elevated over time.
In spite of the screening and the availability of effective treatments fewer
than 1 in 5 women are diagnosed and over 90% of patients with a fragility
fracture are not treated. Osteoporosis-related fractures are responsible
for more hospitalizations than heart attacks, strokes, and breast cancer.”This toolkit will:

1 Address
The policy needs of such secondary fracture
prevention by outlining the generic components
of global, regional and national calls to action.

2 Explain
The need for Post-Fracture Care (PFC)
Coordination Programs.

3 Provide
A step-by-step policy guide to design andevaluate PFC Coordination Programs in hospitals
and health systems throughout the world.
9

CAPTURE THE FRACTURE ®
PARTNERSHIPGUIDANCE FOR POLICY SHAPING
Executive Summary
The Headline

Fragility fractures are the broken bones which cripple millions of adults
and can be prevented with proven and effective therapies.

The Problem

Fragility fractures affect millions of individuals globally. It is estimatedthat 13.5 million fractures per year will occur by 2025 with a costof $400 billion to global healthcare systems. It is a problem which
has been overlooked by policy makers for too long and is set to rise
exponentially with the expanding elderly population.
However, a solution exists.

The Solution

Capture the Fracture® Partnership - Guidance for Policy Shaping
provides a step-wise approach to building policy which is not only
based on decades of dedicated, rigorous research but has also been
repeatedly shown to improve patient outcomes, save money andsave lives. It is targeted at the highest risk group; those who have alreadyfractured, and so is termed Post-Fracture Care. This guidance document
outlines four simple building blocks of an effective policy response:

CATCH FRACTURES EARLY

Ensure that those who have fractured are identified for treatment

TREAT FRACTURES WELL

Employ world-class models of Post-Fracture Care to treat those identified

LIFETIME PREVENTION

Encourage healthy ageing through straightforward public health measures

ENHANCE ENGAGEMENT

Empower the public to understand the problem and become part of the solution

The Bottom Line

Fragility fractures, like other chronic diseases, are not going away.
However, unlike other chronic diseases, there is a solution which is tried,tested and ready to use. It will reduce fractures by up to 50%, it will
deliver financial savings, it will save lives.
10

ABOUT POST-FRACTURE
CARE COORDINATIONPROGRAMS
Post-Fracture Care (PFC) Coordination Programs, such as Fracture Liaison
Services (FLS), are coordinated systems of care that identify, treat andmonitor patients presenting with a fragility fracture.
PFC Coordination Programs have demonstrated their potential clinicaland cost effectiveness and have been recommended worldwide to
reduce fracture risk after a first fracture.
PFC Coordination Programs are designed to:

Close the care gap
Currently only 20% of fragility fracture patients are offered screening
or treatment for osteoporosis. This represents a substantial missed
opportunity to reduce fractures and is known as ‘The Care Gap’.

Enhance communication
Between health care providers by providing a care pathway for thetreatment of fragility fracture patients.

80%
FRACTURE

PATIENTS

OFFERED

TREATMENT

AND/OROSTEOPOROSISARE NEVER
SCREENINGFOR

PFC Coordination Programs Structure
PFC Coordination Programs, most commonly known as FLS, are made up
of a committed team of stakeholders, employing a dedicated co-ordinatorto act as the link between the patient and the orthopaedic team, theosteoporosis and falls prevention services, and the primary care physician.
An FLS ensures that all patients presenting with fragility fractures to the
locality or institution receive fracture risk assessment and treatment
where appropriate. The service is comprised of a dedicated case worker,
often a clinical nurse specialist, who works to pre-agreed protocols
to case-find and assess fracture patients. The FLS can be based insecondary or primary care health care settings and requires support froma medically qualified practitioner, whether it be a hospital doctor withexpertise in fragility fracture prevention or a primary care physician with a
specialist interest.
11

ABOUT THE CAPTURE
THE FRACTURE ®
PARTNERSHIPThe Capture the Fracture® (CTF) Partnership, an IOF initiative supportedby Amgen and UCB, in collaboration with the University of Oxford, began
in late 2019. The CTF Partnership is a global program that helps toproactively implement FLS coordination programs in hospitals andhealthcare systems to help patients prevent subsequent fracturesdue to osteoporosis. This long-term program is supported by
the largest global corporate-non-governmental organization (NGO)partnership ever to be launched in the bone field. The official launch wasannounced by all partners on June 16th, 2020.

Objectives and geographic
areas of focus
This global program will focus on five key pillars of action: Policy, Coalition,
Mentorship, Scalable Solutions and Digitals Tools across 17 countries
in Asia-Pacific, Europe, Latin America and the Middle East.

a.
b.
c.
12

The Partnership’s key objectives are to:

Foster
The development and implementation of new CTF initiatives

DoubleThe number and quality of existing FLS programs by the end of 2022.

ReduceThe number of hip and vertebral fractures due to osteoporosis by 25%
by 2025.

DEVELOP &IMPLEMENTNEW CTF

DOUBLEINITIATIVES

EXISTINGFLS

PROGRAMSREDUCE

HIP & VERTEBRALFRACTURES

BY 25%
BY 2025
Pillar 1 - Policy
Bringing policy makers, regulators, professional and patient, organizations
and opinion leaders together around a defined call to action to drive
policy change to enable specific, impactful changes at the local, regionaland national level.

Pillar 2 - Coalitions
Uniting national societies with medical groups, Non-Government
Organizations (including patient societies) and other stakeholders toamplify the four additional program pillars at a national, regional andinternational level.

Pillar 3 - Mentorship
Providing customized educational, best practices and peer-to-peer
mentorship support and tools (both to established PFC programs andthose under development) to ensure long-term sustainability.

Pillar 4 - Scalable Solutions
Creating a central, go-to hub of resources, solutions and best practices
to enable PFC programs to more efficiently start and improve the deliveryof PFC services. This includes a PFC Benefit Calculator for decision
makers to understand the impact of implementing PFC in their country,
region or hospital.

Pillar 5 - Digital Tools
Capturing critical globally-recognized PFC key performance indicators
in a digital tool to help PFC programs improve the effectiveness of theirprogram and increase patient outcomes.
13

CALL TOACTION14

IT IS ESTIMATED
THAT BY

2025

13.5 MILLION

500 MILLION
WITH OSTEOPOROSISFRAGILITY FRACTURES

By 2025, it is estimated that 13.5 million fragility fractures, or brokenbones after a fall, will occur worldwide each year.
500 million people will be living with osteoporosis, a long-term disease
which weakens bones and leaves people at risk of a fragility fracture [1].
Few diseases affect so many of us as we grow older(4):

OVER

50
Up to one in two women and one in five men aged 50 years or over will
experience a fragility fracture in their lifetime – often leading to a loss ofmobility and independence [2].
This represents a huge economic burden.
With the ageing demographic and the emergence of hyperageing
societies with over 25% of the population over the age of 65 years, theimpact of fragility fractures will increase by 23% by 2030 [3].

healthcare systems $400 billion [1] andaccount for around 3% of healthcare
costs, significantly higher than for manyother leading chronic diseases [1].

Yet osteoporosis and fragility fractures have been ignored in healthpolicy and research agendas for too long [4,5].
Even policies, strategies and programs that focus on healthy ageing andwomen’s health often ignore the impact of osteoporosis and bone fragility.
This has left millions of people – mostly women – without access to thecare and support they need to live full, independent lives.
Fragility Fracture Cost
400
300
Billions of Dollars

Fragility fractures cost global

200
100
50

Fragility Fractures
15

Active research and clinical trials, have led to effective treatments.
These have been developed, tested and shown to strengthen bones
and reduce the risks of fractures by 30-70%. These treatments are now
established as cost-effective in many countries around the world, withbigger benefits for patients than many other treatments for other chronic
diseases.
One of the most important risk factors for a future fracture isa previous fracture [6].
There is clear evidence that focusing on secondary fracture prevention by
driving policy change that is affordable and implementable across nearly
all healthcare systems, will help prevent the next broken bone - and thus
return benefits quickly for patients, their families, the healthcare system,and society as a whole.
Post-fracture Care (PFC) Coordination Programs are the single
most important health service intervention to reduce the risk ofsubsequent fractures.
PFC Coordination Program is a small clinical team based in the local
healthcare system that works with patients to make sure they receive
effective bone and falls protection as soon possible after their sentinel
fracture. The International Osteoporosis Foundation (IOF) has developed anumber of resources to support PFC Coordination Programs so that they
can improve and deliver the expected benefits.
The due diligence, in terms of research and quality improvement
assessment, for secondary fracture prevention policy is complete
and globally accepted making it ripe for implementation.
The worldwide acceptance of this approach makes policy implementationin this a space a very low risk intervention, with the potential to see
improvement far out-stripping that of other disease areas.

Figure60%

long term care and expected benefit
from treatment.

Expected reduction from
Healthcare Intervention

Infographic comparing cause for

50%
40%
30%

Lung/
Home Oxygen

Stroke/Blood Pressure

Heart Disease/
Lipid Lowering

20%
10%

Fracture/
Anti Osteoporosis Drugs

Parkinson’s / Rasagaline
Lung / Inhalers

Frailty/Exercise

Dementia

0%
0%

5%

10%

15%

Reason for long care institutionalisation (%)

16

20%

Fragility fractures have a substantially greater impact on womenthan on men. Thus, by prioritizing post-fracture care, genderdifferences in health and wellbeing can be reduced. The quality oflife of older people can be improved and the financial sustainabilityof our healthcare systems can be strengthened.
Implementing a policy change that prioritizes prevention of the next
fracture through PFC Coordination Programs will lead to 80% of patients
at high risk of another fracture receiving basic healthcare and a reduction
in fractures in the next two to five years that will be felt by patients,
families, healthcare systems and societies around the globe.

As the authors, contributors and supporters of thispolicy toolkit, we cannot accept a future where
preventable fragility fractures are allowed to causesuch needless suffering and cost.
The time has come for urgent action on osteoporosis
and fragility fractures, uniting patient, carer andclinical leadership with wider societal and politicaladvocacy actors in order to strengthen the callfor change.
The International Osteoporosis Foundation (IOF) has developed arobust and comprehensive resource centre that supports PFC
Coordination Programs to deliver on their expectations.
This provides confidence to policy makers that the implemented
programs have a framework to local adaptation to allow delivery ofpatient benefit in an effective and efficient manner. It is based on learningfrom over 400 services in 48 countries across the globe.
We endorse the policy aspirations of the IOF and wish to play our part inbuilding wider societal and political awareness for progress and change.

PATIENTSBENEFIT IN AN

EFFECTIVE

MANNEROVER

400
SERVICES

48

COUNTRIES

17

NATIONAL
Inadequacies in the care ofosteoporosis and the prevention offragility fractures are profound.
Prevention of subsequent fractures
will not be achieved without
over-arching, political leadership.
We call on policymakers to ensure public policy on subsequent
fracture prevention is fit-for-purpose and sustainable.
We call on governments, parliaments, payers and national publichealth institutes to:

18

1

Integrate subsequent fracture prevention into high-level national
strategies and plans for health and healthcare.

2

Acknowledge the huge importance of subsequent
fracture prevention

3

Develop a national consensus on preventing subsequentfragility fractures

4

Adopt and encourage the implementation of national best care clinicalguidelines for subsequent fracture prevention and management

Including those which aim to address chronic diseases, ageing medicine
and women’s health.

By ensuring it is integrated into wider societal plans and policy.

Through more systematic identification of people with index fragility
fractures. The feasibility and cost-effectiveness of opportunistic fracture
screening via routine imaging studies should be addressed.

Which are endorsed by pertinent patient and professional groups. These
guidelines should be available in the national language, include nationallyapproved risk assessment tools, rapid referral pathways and access tonecessary diagnostic resources.

5

Ensure reimbursement structures reflect national scientificconsensus on detection, care and prevention for subsequentfragility fractures
Reimbursement decisions should reflect the true costs of subsequent
fractures to the wider healthcare system and society. At a minimum, there
should be reimbursement for nationally recommended treatments.

6

Develop nationwide fracture identification and secondary
prevention registries to enable local-level service benchmarking andimprovement
This will ensure PFC Coordination Programs deliver their expected
benefits and decision makers can see the benefits of supporting PFC
Coordination Programs. This should include collecting and monitoringdata on the identification and treatment of patients in line withinternationally agreed best practice and key performance indicators.
Policymakers should also consider how these data could be used toincentivize improvements in the quality of care.

7

Actively support efforts to improve public awareness ofosteoporosis, fragility fractures and falls prevention
This includes ensuring people have a clear understanding of their own
risk factors and the preventative options available to them.
19

REGIONAL AND LOCAL
Improvements to people’s lives
will ultimately be driven
by change at a local level;to identify and treat those at riskof subsequent fragility fractures
We call on health system leaders, including payers and the
medical community, to invest in PFC Coordination Programs,a sustainable, multidisciplinary care model for fragility fractures
which spans hospital and community settings. This will require:

1

Ensuring the availability of person-centred multidisciplinary models
of care with demonstrated impact on reducing the risk of repeat
fractures and deathAt the very least, every general hospital should offer orthogeriatricservices and a PFC Coordination Program so that every fracture patient
has the option to be treated or referred there for care and immediate
follow-up post-fracture. This care should be delivered in a way that
addresses people’s needs, concerns and preferences.

2

Primary care professionals to take a supporting role in theidentification and management of individuals at risk of subsequentfragility fractures
Specific roles and responsibilities in primary care should be developedwith professional bodies and payers.

320

Every locality to develop and adopt a secondary fracture prevention
care pathway
This should include implementation of established organizational andpatient level indicators to benchmark the efficacy of the pathway toidentify and treat at risk individuals. This approach will inform service
improvement and empower programs to deliver their expected results

4

Ensuring a comprehensive falls assessment is available for every
geriatric patient who sustains an index fragility fracture5

Liaising with regional and expert bodies to dove-tail a coherent androbust secondary fracture prevention policy within the global context

This should be available in clinical settings as well as community settingsand offer the opportunity for self-assessment. It should bring together
risk factor management for falls alongside detection and treatment offragility fractures.

Organizations such as the European Union have demonstrated an
intense interest in secondary fracture prevention through the creationof committees and reports. Such continental governance bodies arecomplemented by domain expert institutions including the International
Osteoporosis Foundation, the American Society for Bone and Mineral
Research and the IOF Regional Asia-Pacific Consortium.

21

MAKINGTHE CASE

22

WHAT ARE OSTEOPOROSISAND FRAGILITY FRACTURES?
Osteoporosis is a chronic disease
that weakens bones,
leaving them prone to fractures

Risk Factors and Age

24

Osteoporosis is typically a ‘silent’ disease which can often progress
without symptoms until its most severe consequence, a fragility
fracture, is experienced.
Fragility fractures are fractures which may occur with surprisingly modest
stresses and impacts that would not be expected to cause breakages inhealthy bones. The most common fragility fractures are [1]:FOREARM

Bone Loss

Risk Factors and Age as Factors in Bone Loss

HIP

contribute to more rapid bone loss [10].

SPINE

consumption and certain medications

VERTEBRAL

physical activity, smoking, alcohol

HUMERALage, but low body weight, inadequate

Osteoporosis is characterized by low bone mass, which is the resultof the peak bone accrual during childhood and how quickly bone islost through adulthood [7,8].
While bone development is influenced by genetic and biological factors,
such as sex and age (see page 26), a number of lifestyle factors also play arole including nutrition and physical activity [9].

UPPER ARM

Bone mass naturally decreases in older

MAKING THE CASE: WHAT ARE OSTEOPOROSIS AND FRAGILITY FRACTURES?

Fragility fractures can belife-changing events, with severe physicaland psychological consequences

80%
WOMEN AT

HIGH

RISK

HIP
OF DEVELOPINGFRACTURE

WOULD

RATHER

DIE

Pain and limited mobility following a fragility fracture mean people
are often at risk of losing their independence.
In a study, 80% of women at high risk of developing a hip fracture statedthat they would rather die than experience the loss of independence
attributed to a hip fracture [12]. The experience of a fracture can cause
anxiety due to a fear of falling, self-image issues and the limitations
associated with carrying out day-to-day activities [2,11].
Family and friends can suddenly find themselves becoming carers
with often limited support.
National programs are often insufficient or difficult to access, leaving
people to manage the emotional and financial burden of becoming an
informal carer without the necessary support.

25

Older women are most at riskof osteoporosis and associatedfractures, but men are also at risk
While lifestyle factors can influence the development of
osteoporosis, the most common risk factors are being female andolder age.
With advancing age, bone structures become weaker and bone massdecreases progressively; due to the ageing of the population, theproportion of people with osteoporosis is increasing. Additionally, older
people are also at greater risk of falls, making them particularly prone tofragility fractures [12].
Being female is a considerable risk factor, but both sexes experiencefragility fractures.
Women undergo a deterioration in bone structure and alterations in bonemetabolism as a result of loss of oestrogen following the menopause [13].
Men initially experience a slower decline in bone mass than women, but by
the age of 65 the rate of bone loss mass is the same for both sexes.
As men are often older when they experience a fragility fracture, theconsequences can be more severe, including a higher risk of death [14].
The burden of osteoporosis and fragility fractures is significant
and growing.
Globally, as many as one in two women and one in five men over 50 will
experience a fragility fracture in their lifetime [15] causing an estimated 8.9
million fragility fractures every year [16].

Figure
The incidence of osteoporotic fracture
by age for men and women [20].

Incidence per 10,000/year

Men
400
300
200
100

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+

70-74

75-79

80-84

85+

Age Group
Hip
FractureRadiographic
Vertebral
Fracture
Incidence per 10,000/year

Forearm
Fracture

ClinicalVertebral
Fracture

Women
400
300
200
100

50-54

55-59

60-64

65-69
Age Group

Sambrook P, Cooper C (2006) Osteoporosis. Lancet 367 (9527):2010.2018. doi:10.1016/s0140-6736(06)68891-0

26

MAKING THE CASE: WHAT ARE OSTEOPOROSIS AND FRAGILITY FRACTURES?

The burden of fractures does differ between continents with more
fractures occurring in European countries compared to Africa (Nigeria,
South Africa and Tunisia) and South America (Ecuador) [17].
The burden of fragility fractures varies across continents, with much higher
rates in northern European countries compared to countries in the south
such as Spain and Portugal [1]. The problem is not going away, with fracture
rates either stable or on the increase, particularly in Asia [18,19].

Fragility fractures are a major driverof preventable deaths and disability
Fragility fractures are associated with increased risk of death anddisability, and more frequent hospital admission [21].
Globally, the burden of years lived in poor health due to osteoporosis
is greater than that caused by cancers (except for lung cancer) and iscomparable to or greater than that of many other non-communicablediseases, such as asthma and hypertension-related heart disease [15].
In 2010, 43,000 deaths in the EU weredirectly caused by fractures

[23]

.

Hip fractures have been found to at least double the risk of death forboth men and women [14,22].

HIP FRACTURESHAVE BEEN FOUNDTO AT LEAST DOUBLE
THE RISK OF DEATH

2010
2010
EU

43.000
DEATHS

DIRECTLY CAUSED BY

FRACTURES

THE COST OF INACTION:
THE ECONOMIC CASE
FOR CHANGE
The economic impact of fragility fractures is significant and is set to
rapidly rise if no action is taken.
By supporting the implementation of available cost-effective prevention
strategies, policymakers can help reduce the burden of fractures on
health systems and the wider economy.

Fragility fractures represent asignificant cost to health systems
Fragility fractures incur substantial medical costs each year, putting
significant pressure on health systems [24].
On average, fragility fractures represent 3% of countries’ healthcare
spending, estimated at €37.4 billion across the EU in 2010 – rising to€98 billion when taking into account the impact on health-related qualityof life [1]. This financial burden is higher than for many other noncommunicable diseases. For example, the EU’s direct healthcare costs in2015 were estimated at €20 billion for stroke and €19 billion for coronary
heart disease. In Australia, the cost of hip fracture alone is estimated toreach $1 billion per year by the year 2022 [25].
What is more, the costs of fragility fractures are set to double by theyear 2050 [26].

COST
BURDENEUFRAGILITY
FRACTURES€37.4
BILLION

28

CORONARYSTROKE€20
BILLIONHEART

DISEASE€19

BILLION

THE COST OF INACTION: THE ECONOMIC CASE FOR CHANGE

The global population is ageing
and will increasingly
be affected by fragility fractures
The rapid growth of ageing populations is a global concern withsignificant implications for healthcare spending.
FigureUnited Nations probabilistic projection
for percentage of global population
aged 60 and over (https://population.
un.org/wpp/Graphs/Probabilistic/PopPerc/60plus/900).

According to the United Nations, the global percentage of individuals
aged over 60 is set to rise from 13% to almost a quarter of the world
population. As a result, health expenditure will continue to increase. In
this context, the number hip fractures alone is expected to increase by
310% in men and 240% in women, by 2050 compared to rates in 1990 [27].
World: Percentage of Population Aged 60 Years or Over60
Samples Trajectories

400

MedianPercentage

80%
Prediction Interval

300

95%
Prediction Interval

300

200

100
Observed
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 2060 2070 2080 2090 2100
©2019 United Nations, DESA, Population Division. Licensed under Creative Commons license CC BY 3.0 IGO.
United Nations, DESA, Population Division. World Population Prospects 2019. http://population.un.org/wpp/

Changes in the proportion of elderly individuals will have asignificant impact on fragility-fracture related healthcare costs.
In Europe, healthcare costs associated with fragility fractures are
expected to rise by 22% between 2010 and 2025. This will vary bycountry, ranging from an increase in healthcare costs due to fragility
fractures of between 5% in Bulgaria and 44% in Ireland [1].
FigureFragility fracture costs in the EU.

In New Zealand, costs are expected to rise by over 30% (over 13 years
up to 2020) [28].

2010

2025

+22%
29

In an ageing population with anageing workforce, fragility fractures
have a significant and growing
impact on workforce productivity
As the global population ages, the proportion who are of working
age and paying taxes is shrinking, increasing financial pressure
on health and social care services to cover the increasing costs ofosteoporosis and fragility fractures.
At present, there are approximately 15 persons aged 65+ for every 100
people aged 16-64. By 2050, this will have approximately doubled and by 2100
could be nearing 50 (persons aged 65+ for every 100 people aged 16-64).

FigureGlobal old-age dependency ratio(United Nations).

Median80%
Prediction Interval

95%
Prediction Interval

Observed

Old-Age Dependents (65+) per 100 Persons Age 20-64

60
Samples Trajectories

World: Old-Age Dependency Ratio

Age 65+
Age 16-64

45

40

35

30

25

20

15

10
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 2060 2070 2080 2090 2100
©2019 United Nations, DESA, Population Division. Licensed under Creative Commons license CC BY 3.0 IGO.
United Nations, DESA, Population Division. World Population Prospects 2019. http://population.un.org/wpp/

At the same time, the workforce is ageing, as a growing number ofolder people remain in work beyond the age of 65.
While this will, to some extent, mitigate the financial pressure on healthservices noted above, it will also increase the prevalence of chronic
conditions – including osteoporosis and fragility fractures – among theworking population. Unless action is taken to prevent fragility fractures,
this will have a significant impact on workforce productivity as sickness
absence rates are highest among workers aged 65 and over.
In addition, individuals who have experienced a fracture may
rely on informal care from friends and family [3,29].
Many of these carers may need to cut down their working hours or cease
any form of paid work due to difficulties in balancing paid employment
and care responsibilities [3,29].
30

THE COST OF INACTION: THE ECONOMIC CASE FOR CHANGE

Cost-effective ways to prevent fragility
fractures and improve patient
outcomes include osteoporosis medicationand integrated post-fracture care

Benefits of implementing a nationwide
FLS model in the UK, and how it
impacts the increase in savings and thedecrease in fractures.

Responding to the fragility fracture crisis requires more consistent
implementation of cost-effective and cost-saving screening,
treatments and services [30,31].
In general, osteoporosis medication is cost-effective (and even cost-saving)when given to individuals at high risk of fracture and taken consistently [30,32,33].
However, cost-effectiveness relies on treatment being continued [33-35],
so implementing services that support people to take their medication
regularly is cost-effective (and even cost-saving), when drug compliance ismaintained in individuals at high risk of fracture [36].
A simulation model in Sweden, for example, showed that if people who
were prescribed osteoporosis medication stayed on treatment for 50%
longer, a total of €3.3 million would be saved over 10 years [37].
Implementing models of integrated post-fracture care is vital to
improving treatment outcomes in a cost-effective way [30].
A number of proven programs [38,39] and orthogeriatric services [30] havebeen shown to increase the likelihood that people will continue to take their
medication and prevent fractures while also being cost-effective [36].
Fracture liaison services (FLS), the most widely evaluated model, areconsistently shown to be cost-effective or cost-saving [31,40,41]. In the UK,
for example, nationwide implementation of FLS significantly improves thequality of care and reduces fractures with no additional cost to the healthsystem; in fact, cost savings would be highly likely.

YE

AR

S

MORE

COST

SAVINGSFEWERFRAGILITY
FRACTURES
31

THE BUILDING BLOCKSOF AN EFFECTIVE
POLICY RESPONSE

32

A SYSTEM THAT WORKS
To safeguard an effective global
response to the expanding burdenof subsequent fragility fractures,
health and social care services must
respond with robust identificationand swift management of those at risk.

a.
b.
c.
34

To address these aims, a trio of cross-cutting themes is required to
optimise patient care:

Integrate international fragility fracture policy:
Strong strategic leadership in policy development is vital to ensure longterm accountability and investment, as is accurate measurement andprediction of the current and future demands on the healthcare system,and the setting of justifiable and measurable targets to navigate thejourney to achieve long-term goals.

Establish comprehensive registries and audits:
The creation and curation of high-quality data on subsequent fragility
fractures will allow accurate benchmarking of performance and pave theway for feedback and improvement both locally and nationally. This willallow services to deliver on their expected benefits through establishedorganizational and patient level Quality Improvement Indicators.

Adequate reimbursement structures:
Requisite reimbursement must be mobilized to ensure access to bestpractice care throughout the patient journey. This should be consideredagainst the backdrop of the costs ensuing from failure to prevent
subsequent fragility fractures within the healthcare system.

THE BUILDING BLOCKS OF AN EFFECTIVE POLICY RESPONSE: A SYSTEM THAT WORKS

Integrate international policy
Fragility fractures and secondary fracture prevention are highly
relevant for global policy initiatives and strategies concerned with
non-communicable disease, healthy ageing, women’s health, healthinequalities and social care.
Too often, however, these initiatives have not adequately contained orprioritized secondary fracture prevention [5].

Secondary fracture prevention hasreceived limited attention in global
health policy to date and has notbeen marked as a priority in mostcountries [23].

Osteoporosis and fragility fracture are
not viewed as an urgent priority despite
the significant burden they impose on
every healthcare system [23,42,43].

Most countries have not identified
secondary fracture prevention as apolicy priority [23].

Recognizing secondary fracture prevention as an importantcomponent of national policy will support the development andimplementation of vital PFC Coordination Programs.
National strategies and action plans often support implementation of
population-wide programs such as education and awareness campaigns[23]. The recognition which comes with national level policy initiatives will
also garner greater investment in PFC Coordination Programs, registries,
diagnostic tools such as DXA scanning [42] and preventative strategies
including medication and lifestyle interventions [23].
Secondary fracture prevention is rarely featured in national policies
for chronic disease, healthy ageing and women’s health.
Health strategies worldwide have recognized the critical role ofreducing frailty and maintaining mobility as part of healthy ageing andprevention. Yet osteoporosis, let alone secondary fracture prevention,
seldom materializes in national prevention strategies. A recent analysis
showed that musculo-skeletal health, including osteoporosis and fragility
fractures, was only included in half of non-communicable diseasestrategies for OECD countries [5].

IN ONLY 1/2
MUSCULO-SKELETALHEALTHIS INCLUDEDOF NON/COMMUNICABLEDISEASESTRATEGIES IN
Governments should encourage national consensus on secondary
fracture prevention to provide a clear unified perspective on
the required policy changes and how different sectors can work
together. The formation of alliances encourages greater dialogue
between different stakeholders including policymakers, healthprofessional societies, the private sector and non-governmentalorganizations [41,44]. This alliance formation is already underway,
spearheaded by the Fragility Fracture Network (FFN) and the International
Osteoporosis Foundation (IOF).
35

Comprehensive registries
Policymakers require quality data on secondary fracture
identification and prevention which they can use to plan and assess
services. These data, however, tend not to be comprehensive,
comparable or evenly spread within countries or across the globe.
Fracture registries are hugely helpful in this regard, but while they tend
to be well established in some countries (including northern Europe,
Australia and New Zealand [45], Hong Kong [46], Mexico [47], US [48]) they are
not in other geographic regions.
Additionally, most countries do not collect data on all types of fracture[23]with the majority focusing on hip fractures, meaning that vertebral orforearm fractures remain under-reported [49,1].

Regular clinical audit can act as a driver to rapidly improvesecondary fracture prevention [49]. This has been amply
demonstrated as a result of regular hip fracture audits in the UK
and Spain [50-53].
Introducing such audits for secondary fracture prevention (encompassing
all fracture types) could result in similar improvements, as observed in acomparison between China and the UK [54].
Across the globe, there is great variation in terms of how dataon secondary fracture prevention is collected and analyzed. This
limits the ability of policymakers to compare performance between
countries.
National reports vary in the quality, granularity and extent of the data
they capture, for example regarding inclusion criteria or case definitions[50,49]. In order to homogenize the approach recent initiatives havedeveloped standard indicators including the IOF Capture the Fracture Best
Practice Framework and the FFN Minimum Common Dataset which havebeen adopted by several countries [50,55].
36

THE BUILDING BLOCKS OF AN EFFECTIVE POLICY RESPONSE: A SYSTEM THAT WORKS

Adequate reimbursement structures
Availability of adequate funding and reimbursement structures
is essential in supporting high-quality delivery of secondary
fracture prevention.
Due to a paucity in secondary fracture prevention focused policies thecurrent services are limited in scope and are underfunded. However,strategies which are contextualized to a national outlook (and adequately
resourced) can allow for the cost-effective delivery of secondary fracture
prevention best practice.
Reimbursement for diagnosis of osteoporosis is often lacking
or restricted [30].
DXA scanning is a key step to diagnosing osteoporosis and identifying
those at substantial risk of fractures [23], however, reimbursement for theuse of this tool is insufficient in many countries [1].
Reimbursement for osteoporosis medication is also often restricted,
likely contributing to the concerningly low treatment rates forosteoporosis across the globe [1].
The proportion of osteoporosis care costs associated with medication
is minimal, amounting to less than 5% in many countries [24]. Limited
reimbursement can move treatment beyond the realm of affordability formost patients leading to restricted access for those above a certain age
or other risk factor profiles [23].

BONE

HEALTHAGE

The blocks required to build an effective secondary
fracture prevention policy include measures
to identify those at risk as soon as possible,
manage and treat them effectively, ensure thatthe population does everything possible to reduce
fractures from cradle to grave, and that public andpatient engagement is maximized.
These steps are described on the following page.
37

CATCH IT EARLY:
DETECTION AND MANAGEMENTOF SUBSEQUENT FRACTURES
5 Things to Know

1
2
3
4
5
38

Fractures beget fractures
People who have sustained a fragility fracture, compared to people whohave not fractured, are at five times greater risk of having asecond fracture [56]. It is crucial to identify these people and prevent
subsequent fractures.

Time = Avoidable fractures
Fractures occur in clusters, with the risk highest in the two years following
the index fracture. Urgent intervention is therefore required to halt themarch towards further fractures [57].

PFC Coordination Programs are effective at identifying individuals
with index fragility fractures;
These can can work effectively in either secondary or primary care.

PFC Coordination Programs services pay for themselves, and more.
PFC Coordination Programs are cost-effective in locations and healthcare
systems across the globe [36,37,41].

Automated processing of routine medical images is experimental;
Although experimental at present, in the future this may deliver
efficiencies in fracture identification and secondary prevention and slow
the march towards further fractures [57].

THE BUILDING BLOCKS OF AN EFFECTIVE POLICY RESPONSE: CATCH IT EARLY

39

What is it and why is it important?

FigureAfter an initial fracture, the risk ofsubsequent fracture is particularly highfor approximately the next 2 years [61].

Identifying people at high risk is vital to prevent fractures andenable individuals to maintain independence and quality of life [3].
A fracture often leads to a substantial loss of independence which may
prohibit a patient from regaining their pre-fracture quality of life [58].
An initial fracture is also a herald for future fractures [6], especially in theimminent short term [59]. Thus, identifying and treating those who havesustained fractures in the past is an important step toward tacklingthe downstream effects of osteoporosis. Once people at high risk are
identified, a raft of often simple, low-cost interventions can contributeto improved bone health and reduce fracture risk. Osteoporosis
medications alone can reduce the risk of future fractures by 30-70% [60].
Risk of Subsequent Fracture

Hip
Fracture

Spine
Fracture

Forearm
Fracture

HumerusFracture

7
6

Hazard Ratio

5

4

3

2

1

2

4

6

8

10

Time (Years after first fracture)

Time is bone. Rapid identification of an index fragility fracture isimportant as subsequent fractures often occur soon after the firstbroken bone.
There is an urgency to the identification and treatment of those
who have fractured as 80% of subsequent fractures occur within a yearof initial fracture [57].
Secondary care professionals can play a crucial role inidentifying people who have sustained a fragility fracture andin commencing treatment.
Initial fragility fractures, particularly hip and forearm fractures, present toa secondary care setting for emergency treatment and care providers in
hospitals are well-placed to recognize the occurrence of fragility fracturesand kick-start treatment, for example through the initial prescription of
osteoporosis medication. Vertebral fractures may be identified throughroutine imaging and should be highlighted to primary or secondary careproviders to further assess the patient for treatment.
40

THE BUILDING BLOCKS OF AN EFFECTIVE POLICY RESPONSE: CATCH IT EARLY

Primary care professionals can play a supporting role in detecting
and managing people at high risk of fragility fractures [62].
As the first point of contact for community healthcare and providers ofroutine care, primary care professionals often have the opportunity todetect osteoporosis. In many countries, they can also play a critical role inprescribing and monitoring treatments which reduce the risk of sustaining
a fragility fracture [23,63]. Models for primary care positioned PFC
Coordination Programs can be effective and have been proven to be so in
the UK [64,65].

How do we know it works?
Implementing targeted identification of index fragility fracturesoffers the opportunity to effectively prevent further fragility
fractures from occurring.
Introducing initiatives to identify index fractures and prevent subsequent
fractures are known to result in significant reductions in fracture rates
and mortality [66].
PFC Coordination Programs have a proven, cost-effective trackrecord in mediating future fracture risk and reducing the burden of
subsequent fractures across the globe.
Health economic models vary depending on the geography andcomparisons used but there is clear evidence of the cost-saving ability of
PFC Coordination Programs worldwide. In Sweden [37], Canada [36] andJapan [67] the cost-effective and financial benefits of PFC Coordination
Programs and secondary fracture prevention have been demonstrated,
and these benefits appear to increase with age [67].

INCREASE

WITH

AGE
FINANCIAL

BENEFITS

PFC
41

What is the current situation?

HIP
FRACTURE

TREATED

FUTUREFRACTURE

PATIENT

WITH

HIP

RISK

ASSESSED

Risk of Secondary Fracture Increase

Worldwide, the opportunity to treat individuals who have sustainedfragility fractures is squandered. This is due to fragility fractures
being unidentified when patients present with acute fracturesin a hospital setting.
The focus of treatment for a patient arriving with a fractured hip is the
management of the hip. This addresses the present issue but not the
future fracture risk. In healthcare systems which do not directly address
secondary fracture prevention the assessments of bone health and falls
risk are less than 4% [54]. This rises to over 90% in healthcare settings withsecondary fracture prevention in place.

HIP
FRACTURE

TREATED

FUTUREFRACTURE

RISK

Risk of Secondary Fracture Decrease

FRACTURE

ASSESSED

Too often vertebral fractures are overlooked on medical images
representing a substantial missed opportunity for index
fracture identification.
Some vertebral fragility fractures have very slight symptoms which arebarely noticed by the patient, but which massively increase the risk offurther fractures. Routine imaging can include views of bones (especiallythe spine) even when they are not the focus of the test. Incidental
fractures are missed, with an estimated 85% of vertebral fractures
unrecorded in radiology reports [68-70].
42

THE BUILDING BLOCKS OF AN EFFECTIVE POLICY RESPONSE: CATCH IT EARLY

What needs to be done?
It is crucial that policymakers support the development of clear
national guidance on identifying subsequent fragility fractures
and treating osteoporosis, which is informed by national scientificconsensus.
In countries which have applied this approach the rates of osteoporosis
and falls assessments are over 90%. In those which have not followed
this approach, the rates are below 4% [54].

FigureRates of osteoporosis and falls

PFC Coordination Programs should receive priority funding in orderto address the epidemic of subsequent fragility fractures.
Numerous studies have demonstrated significant cost-effectivenessthrough the adoption of PFC Coordination Programs [36,67,71].

assessment across the world.

Percentage

100
75
50

Automated methods of fracture identification on routine medical
imaging should be the subject of further research.
Deep learning and computer vision are areas of great interest andare having some success in the automated identification of vertebral
fractures on CT scans [72-74].

25

Countries with clear national
guidances on identificationand treatment

Countries without clear
national guidances on
identification and treatment

43

TREAT IT WELL:
FACILITATING
MULTI-DISCIPLINARY
POST-FRACTURE CARE
5 Things to Know

1
2
3

Fractures are dangerous.
Up to 10% of people with hip fractures die whilst in hospital and only half
will regain the same function that they had before the fracture.
This can be reduced by best-practice care.

Health systems have so far failed to close the osteoporosis
treatment gap.
Most people who are eligible do not receive the risk-reducing treatment
they need [23,1].

Excellent care and rehabilitation following a fracture involves
a multidisciplinary team of orthopedists, traumatologists,
geriatricians, primary care doctors, nurses, physiotherapists
and other health professionals,
This is the first step to ensuring positive outcomes [3,75].

44

4

There is an effective framework for multidisciplinary, co-ordinatedpost-discharge care to reduce long-term fracture risk.

5

Investment in proven best-practice models is needed globally toincrease access to high-quality post-discharge care;This is effective, efficient and provides a good patient experience.

This will improve long-term patient outcomes.

THE BUILDING BLOCKS OF AN EFFECTIVE POLICY RESPONSE: TREAT IT WELL

What is it and why is it important?
The care people receive in hospital following a fragility fracture will
impact on their recovery and their independence after discharge [76].
Among people with hip fractures, up to 10% are likely to die while
in hospital, and only half will regain the same function that they had
before the fracture [77]. This can, in part, be remedied through theimplementation of best-practice in-hospital care [76].
Following treatment of a fragility fracture, it is vital that patients
have access to services which can prevent subsequent fractures.
People who have sustained a first fragility fracture are at a significantly
higher risk of a subsequent fracture once they have been discharged,
including more severe fractures in other parts of the body [3]. Services
to prevent subsequent fractures may involve osteoporosis screening,
initiation of treatment and referral to specialist services such as
rehabilitation and falls prevention programs. In addition to specialist
services, primary care should be involved in the long-term managementof fracture risk [78].
Existing and proven models of integrated care seek to assess
fracture patients in hospital settings and support the coordinationof their care and prevention, both before and after they have beendischarged.
PFC Coordination Programs are a widely implemented coordinatorbased model of care aiming to identify people at risk of subsequent
fractures and signposting them to preventive follow-up care services [55].
While there is considerable variation in the services delivered by PFC
Coordination Programs, they generally include at least one of three key
components: identification, investigation and initiation of interventions[30]. Not surprisingly, PFC Coordination Programs models that deliver
more of the key components result in a greater proportion of people
being investigated for osteoporosis and giving treatment [79].

How do we know it works?
Delivery of orthogeriatric services [80,81].
Orthopedics

OrthogeriatricServices
Other
Specialties

Geriatrics

There are various components of in-hospital care that have asignificant impact on outcomes including the risk of subsequent
fractures and death [3,75].
International guidelines for the management of fragility fractures in
hospitals include standards for ‘time to surgery’, assessment of futurerisk and early introduction of post-fracture rehabilitation [76]. In addition,a crucial component of in-hospital post-fracture care is the deliveryof orthogeriatric services, which involve orthopedics, geriatrics andother specialties working together to care for fracture patients [80,81].
For example, timely surgery and coordinated treatment plans led byorthogeriatricians have been shown to significantly reduce the risk ofdeath in the short- and long-term and the likelihood of complications
and prolonged hospital stays [76]. In addition, orthogeriatric services can
reduce the length of hospital stay and the need for rehabilitation services,
resulting in considerable cost savings [82].
45

PFC Coordination Programs are consistently shown to be costeffective and sometimes cost-saving [31].
Substantial initial investment is required [71], which may deter somepolicymakers from making investment decisions in a climate of increasingpressure on healthcare budgets.

EXPECTED IMPACT AFTER IMPLEMENTING POST FRACTURE
CARE (PFC) SERVICES*WITH OUR

X00,000
ADULTS WITH
BROKEN BONES
EVERY YEAR
IN COUNTRYCURRENTSTATUSPFCSERVICE

X00,000

IDENTIFIED

20%

TREATED

20%

FRACTURES
BY 5 YEARSIDENTIFIED

90%

X00,000

TREATED80%

FRACTURES
BY 5 YEARSCOSTS AND FRACTURES AVOIDED OVER 5YEARS WITH PFC SERVICESFRACTURES (TOTAL)= X0,000
Bed Days = X00,000
Operations = X,000
Clinical Appointments = X0,000
Care Home = X00 Patient Years

PFC COSTS
Staff = $X.X billion
Investigarions = $X.X billion

Total Cost
$X.X billion

5 year medication costs = $X00 billion
NET Cost over 5 years including
medication = $X00 billion
46

Hospital = $X.X billion
Comms/Social Care = $X.X billion

TOTAL COSTS AVOIDED= $X,X000

NET SAVING

AFTER
5 YEARS$X.X billion* Dedicated clinical service
that identifies tests andtreats adults over 50 years
with broken bones

THE BUILDING BLOCKS OF AN EFFECTIVE POLICY RESPONSE: TREAT IT WELL

What is the current situation?
Alarmingly, most people do not receive risk-reducing treatment
after a first fracture. This significantly increases the likelihood ofsustaining a subsequent fracture.
An estimated 60-80% of women with osteoporois do not receive
treatment within one year of a fracture [3].

60%
TO

WITH

DO NOTOSTEOPOROSISRECEIVE

80%

TREATMENTWITHIN

1 YEAR

OF A FRACTURE

The implementation of multidisciplinary, integrated models of carevaries both within and between countries. Very few hospitals appear
to have structured services in place to prevent future fractures.
This is because responsibility for preventing subsequent fractures caneasily fall through the gaps between medical specialities and primary/secondary care.
Differences in practice are observed regionally across the European
continent. Finland has developed nurse-led post-fracture services, which
are recommended in national guidelines. In Germany, however, only aminority of hospitals have a referral pathway for post-fracture patients inplace, leaving up to 88% of patients discharged without clear treatment
recommendations. In Romania, post-fracture follow-up investigation andtreatment is usually not carried out in the hospital where the fracture wastreated, but must be initiated in primary care and then undertaken by aspecialist, contributing to a significant gap in treatment [1]. In 2013, only
eight EU countries (Austria, Cyprus, Czech Republic, Estonia, Finland,
Hungary, the Netherlands and Sweden) had PFC services in over 10%
of hospitals, while six countries (Greece, Latvia, Luxembourg, Portugal,
Romania and Slovakia) had PFC services in under 1% of hospitals [23].
This is an active issue globally with new recommendations emanatingfrom the United States in 2020 [83] and PFC Coordination Programs
actively encouraged through initiatives in other countries, for example via
the Osteoporosis Canada ‘FLS Hub’.

8 EU*

COUNTRIESHAD PFC

COORDINATIONPROGRAMSIN OVER

10%

6 EU**
2013

OF HOSPITALSCOUNTRIESHAD PFC

COORDINATIONPROGRAMSIN UNDER

1%

OF HOSPITALS* AUSTRIA, CYPRUS, CZECH REPUBLIC, ESTONIA, FINLAND, HUNGARY, THE NETHERLANDS, SWEDEN** GREECE, LATVIA, LUXEMBOURG, PORTUGAL, ROMANIA, SLOVAKIA
47

What needs to be done?
There are several best-practice case studies at the national levelfrom which other countries can learn.
The UK has been at the helm of PFC Coordination Programs development
and provides valuable lessons in terms of driving best-practice delivery oforthogeriatric care of hip fracture patients. The UK FLS Database, which isused to audit hospital performance in fracture care and prevention of asubsequent fracture [53], has been instrumental in improving managementof hip fractures in hospital. The Best Practice Tariff has been instrumental in
improving the management of hip fractures in hospital, as have financial
incentives [77].
Orthogeriatric models of carehave been established in various
countries, including Spain, Germany,
the Netherlands [84], and China [85]although practice and outcomes varysignificantly between hospitals.

Important efforts are also underway to promote the establishmentof PFC Coordination Programs globally and to ensure greater
adherence to best-practice standards.
To this end, a global recognition scheme, IOF Capture the Fracture®, hasbeen developed [66].

partnership

NATIONALLYREFINEDSERVICE DELIVERYEFFECTIVE LOCALCARE PATHWAYSMODELONGOING CLINICAL SUPPORTAND MENTORSHIPREAL-TIMEQUALITY IMPROVEMENTEMBEDDEDQUALITY ASSURANCEEMBEDDED HEALTHECONOMIC IMPACT

FOR PATIENTSAND FAMILIES
48

PLANNING &IMPLEMENTATION

SUCCESSFUL

DELIVERY

OF EXPECTEDHEALTHCAREPROFESSIONAL AND
PATIENT RESOURCES

IMPACT

FOR DOCTORS AND
HEALTHCARE INSTITUTIONSFOR HEALTHECONOMYTHE BUILDING BLOCKS OF AN EFFECTIVE POLICY RESPONSE: TREAT IT WELL

Capture the Fracture®’s Best-Practice Framework sets out quality
standards to prevent subsequent fractures and provides a suite ofresources to support their implementation in different healthcare
settings [55]. Within the first year, 60 hospitals signed up for the scheme,of which 27 achieved a gold rating, the highest level of recognition [86].
Member organizations are offered mentorship, a financial benefit
calculator, suitable scalable solutions, a benefit calculator, FLS digitalcomparative tool and FLS management digital tool and expertise in orderto accelerate the closure of the care gap.

1ST YEAR60

OF WHICH

27
Policymakers should ensure the implementation of best-practice inhospital care for fracture patients so that people can quickly regain
their independence and mobility.
All options for encouraging widespread implementation of best-practicecare should be considered, including the use of incentives to encourage
clinicians to deliver specific components of high-quality care.
Policymakers need to support coordination between existing
services, to ensure more patients have access to multidisciplinary
care models such as PFC Coordination Programs [30].
This will ensure patients at high risk of a fracture benefit from theseamless transition to follow-up care and receive all necessary services.
This will require consistent collaboration between primary care,orthopedics, rheumatologists, geriatrics and other services [30].
Policymakers need to embed organizational and patient levelindicators to ensure implemented services deliver the expected
benefits [55,86].
These resources and support with implementation are available
through the International Osteoporosis Foundation’s Capture theFracture® program.
49

HEALTHY ACTIVE AGEING:PREVENTING FALLS AND
FRACTURES IN LATER LIFE
THROUGH GOOD HEALTHEARLIER IN LIFE
5 Things to know

1

The consequences of fragility fractures are more severein older people;

2

Maintaining quality of life, supporting mobility and safe-guarding
the independence of older people must be a priority;

3

Services that aim to prevent falls must be coordinated withmultidisciplinary and comprehensive fracture prevention services.

4

Fragility fractures in older people result in reduced independence,
immobility or transition into long-term care [77,12].

Care planning and health promotion in this population is vital tomaintaining quality of life.

They should consider the complex needs of the older population andreflect other personal risk factors, such as balance and potential trip
hazards in the home.

Simple interventions – such as modifications at home or ina long-term care setting – can prevent falls and therefore reduce
the risk of fracture.
All too often, however, these needs are not identified
or adequately addressed.

550Innovative falls prevention programs have been established invarious countries;
These should be made available to all older people at risk of falls andassociated fractures [87].

THE BUILDING BLOCKS OF AN EFFECTIVE POLICY RESPONSE: HEALTHY ACTIVE AGEING

What is it and why is it important?
In the older population, falls are an important risk factor for
major fractures and often mark a watershed moment in rapid
deterioration of health and functioning [12].
Among women, 80% of fractures occur over the age of 70 and, of these,
90% are the result of a fall [77].

80%
FRACTURES

OVER

AGE

70

The risk of dying in the first year after a
hip fracture can be as high as 30% for
people over the age of 60 [88].

THE RISK OF

DYINGDURING

1ST YEAR90%
RESULT OF A

FALL

After the first fall, people often become afraid of falling again, leading
to reduced strength and mobility and further increasing the risk ofsubsequent falls. For older people, major fragility fractures can result in
rapid physical decline even with best-practice care in hospital. In manycases, a major fragility fracture marks the end of independent living [77]:
one in four hip fracture patients who were previously independent are
discharged to a care home.

AFTER

HIP

FRACTURE30%
FOR PEOPLE+60

Integrating falls prevention and promotion of bone health into
health and social care services could help older people maintaintheir independence and enhance their quality of life [76].
Given the high costs of falls and care for associated fractures, often in
expensive residential care settings, prevention provides an opportunity tosave costs for health and social care [89].
This involves a comprehensive assessment including the risk of falls
and interventions to adequately respond to a person’s care needs [76,90].
Key measures to prevent falls and fractures comprise: multimodal
exercise, including strength resistance training; a critical review of current
medication; and initiation of treatment for osteoporosis and otherconditions. These may reduce the risk of falls and the muscle wasting
condition, sarcopenia [91].
The assessment should also include an analysis of behavioural andenvironmental aspects which have led to the fall, and the removal ofpotential hazards that could cause the fall such as inadequate handrails,poor lighting and inappropriate footwear [91].
51How do we know it works?

A safer living environment, including
home adaptations and the use of aidsand supportive devices, has been
demonstrated to further reduce therisk of falls [90].

Multidisciplinary care – including early comprehensive
rehabilitation, adaptation of the living environment and ongoingsupport to promote functioning and independent living – has beenshown to be key to preventing future falls.
Measures which have been shown to reduce falls risk include
muscle strengthening, improving balance, reducing the burden ofpolypharmacotherapy and psychotic drugs [92], addressing psychologicalfactors such as depression and improving safety of the living environment.

ENSUREA SAFE

HOME

What is the current situation?
In recent years, falls prevention has received increasing attention aspart of a global drive for healthy ageing policy.
Various falls and fracture prevention programs have contributed to thedevelopment of new models of care and monitoring for older people.
The European Innovation Partnership on Active and Healthy Ageing (EIP on
AHA) was launched in 2012 to respond to the demographic challenges
Europe is facing. Several programs have been launched as part of its
Action Group on personalised health management and prevention of
falls, such as ProFouND, an initiative promoting exercise and adaptationof the physical environment. ADVANTAGE, a European Joint Action of 22
Member States and more than 33 organizations, is developing a common
approach to manage frailty in health and social care in Member States.
It encompasses a range of activities, including the use of technology toenable the detection of frailty-related symptoms and events such as falls.
Similarly, the European long-term study FrailSafe is assessing the useof wearables, sensors and telemedicine to foster self-management andprevent falls.
52

THE BUILDING BLOCKS OF AN EFFECTIVE POLICY RESPONSE: HEALTHY ACTIVE AGEING

ATG

VCT

BRB

COM
W. Africa

DMA

GRD

MDV

MUS

LCA

TTO

TLS

SYC

Persian
Gulf

Caribbean

E. Med

MHL

FIJI

WSM

DMA

SLB

KIR

TOM

LCA

VUT

FSM

Balkan Peninsula

Global burden of disease for falls(Age-standardized incidence rates per
100 000 of falls in 2017) [93].

0-10005000-6000

1000-2000

6000-7000

2000-3000

7000-8000

3000-4000

8000-9000

4000-5000

9000+

53

SERVICES& TOOLS

TO MANAGE

FRAGILITY AND

PREVENT

MULTIFACTORIAL

RISK

FALLS

ASSESSMENTTO IMPROVEBONE

HEALTHIN CARE HOMES

SMARTPHONEBASEDGERIATRICASSESSMENTS &FALLSPREVENTION

FIVE-WEEKPROGRAMS

EXERCISE

PROGRAMFOR PEOPLERISKFALLINGAt a national level, some countries have spearheaded services andtools to support healthcare professionals and patients in managing
frailty and preventing falls, but access is often limited.
Best-practice examples include the use of smartphone-based
Comprehensive Geriatric Assessment and falls prevention programs inGermany, though they are not yet widely implemented. In Scotland, amultifactorial risk assessment and action plan to improve bone healthin care homes improved outcomes significantly where it was used
and, in some cases, falls were reduced by around 36%. The ongoing
Dutch Nijmegen Falls Prevention Program, a five-week exercise programfor people at high risk of falls, has reduced falls by 46%. Innovativetechnologies, such as a wearable device to assess falls risk in real time,
are also being developed. These include video machine learning and theintegration of ‘The Internet of Things’, which is garnering great interest.
54

THE BUILDING BLOCKS OF AN EFFECTIVE POLICY RESPONSE: HEALTHY ACTIVE AGEING

What needs to be done?
Policymakers must ensure comprehensive falls risk assessment andmanagement is widely available and easily accessible to the publicand healthcare professionals.
The complex health status of older people often requires a range of careneeds to be addressed. Tools to assess mobility along with other healthneeds should be integrated in clinical practice but can also be used byolder people for self-assessment, freeing-up healthcare resources andextending access to more people at risk of falls.
Policymakers must enable and adequately fund collaboration
between health and social care services.
Falls and fracture prevention requires an integrated and personcentered model of care supported by a multidisciplinary team, involving
each member as and when necessary. Geriatricians and specialist
nurses must coordinate with physiotherapists and occupational
therapists to improve the person’s mobility through exercise programs
and assistive devices, with primary care professionals and pharmacists
for medication review and continuous monitoring, and with social careto adapt the physical environment. Patients and their informal carers
should be considered equal partners in planning and implementing
this multi-component approach. Public awareness of falls must also be
increased to encourage engagement with preventive measures before
the first fall.

55

ENHANCE ENGAGEMENT:
AWARENESS, ACTIVATION
AND SELF-MANAGEMENT
5 Things to know

1
2

56

The public need to comprehend their risk of osteoporosis andfragility fractures;
To ensure they are able to seek early diagnosis and care.

Misconceptions about osteoporosis are common;
And even those at high risk often underestimate the seriousness of thedisease and the danger of sustaining a fragility fracture [42,94,95].

3

Lack of knowledge significantly contributes to a large proportion ofpeople with osteoporosis discontinuing their treatment;

4

Globally, public awareness campaigns and patient/professional
associations have been formed;

5

Policymakers need to make sure people are given clear information
about fragility fracture prevention;

Which is one of the main barriers to improving bone health [11].

For the recognition of osteoporosis as a serious condition [30].

This enables them to take an active role in maintaining their bone healthand reducing their risk of sustaining a fracture [60].

THE BUILDING BLOCKS OF AN EFFECTIVE POLICY RESPONSE: ENHANCE ENGAGEMENT

What is it and why is it important?
Public awareness of osteoporosis and fragility fractures is key toensuring people recognize their risk of fracture and seek advice.
Unless a fracture has already occurred, proactive investigation of fracturerisk is often undertaken only when key risk factors are noted by healthand social care practitioners or by people themselves. By improving
awareness of the risk factors for osteoporosis and related fractures, aswell as increasing understanding of the potential consequences of leaving
osteoporosis untreated, more people may be empowered to seek early
diagnosis and treatment [96] . This may be particularly important for men
as their risk of osteoporosis is often underestimated [97], contributing
to a situation whereby men who sustain a hip fracture are less likely toreceive osteoporosis medication to prevent subsequent fractures [98].
People with osteoporosis can reduce their risk of fracture when they
actively engage with their own care.
This can involve changes to lifestyle and the living environment andcontinuing to take the medications prescribed for them [60]. To achievethis, people need information on osteoporosis and fracture risk, therisks and benefits of medication, self-management and the role of DXA
scanning and follow-up [96]. In addition, providing care that responds topeople’s preferences is essential to improving outcomes. It is therefore
important that therapy is adapted to individual care needs [30].

Various factors contribute toinequalities in medication use.

The population at risk of fracture is diverse, and inequalities inmedication use are apparent.
An international review found that personal factors such as age,education and the presence of other long-term conditions, as well as
systemic factors such as national insurance and co-payments, contributeto variation in the likelihood of patients continuing to take their
medication [99].

LONG-TERM
CONDITIONSEDUCATION

AFFECTING+65

MEDICATION

AGE

FACTORS
INSURANCEINTAKE OF

57

How do we know it works?
Improved public education and awareness can help support both
identification and management of osteoporosis [99,96].
Comprehensive management programs which include education can
support increased investigation of osteoporosis, leading to a reduction
in hip fractures among older women [100]. Following diagnosis, patient
education programs may also encourage more people to stay on
treatment [101].
To support people to continue taking their medication and maintainlifestyle changes in the long term, it is necessary to tailor theirtreatment plan as much as possible.
In addition to a bone healthy diet and exercise, there are numerous
pharmacological treatment options for osteoporosis, ranging from dailytablets to annual injections, and it has been shown that less frequent
dosing improves the likelihood that people will continue to take their
medication [30,99]. A systematic review found that age and the presenceof other chronic conditions impacted on the extent to which people
continued to take their medication as prescribed by their clinician [96].
It is important that people are prescribed the most appropriate option
and that this is determined based on shared decision-making [30].

EXERCISE
APPROPRIATETREATMENT

Treatment plans should be tailored to each patient’s
needs, which can be impacted by the presence ofother chronic conditions and age.
58

BONE HEALTHY
DIET

THE BUILDING BLOCKS OF AN EFFECTIVE POLICY RESPONSE: ENHANCE ENGAGEMENT

What is the current situation?
Worldwide, much of the general population appears to be either
misinformed or unaware of osteoporosis and its associated fracture risk.
Osteoporosis is often wrongly viewed as a natural consequence of ageingthat cannot be averted [11]. Even those at high risk – including people
already diagnosed with osteoporosis – often underestimate the danger ofsustaining a fracture [11]. As a result, people at risk of fracture may not be
detected or begin treatment until they have sustained a fracture.
Incorrect information in the media may have contributed to low
prioritisation of osteoporosis and misconceptions about the safety oftreatments [42,94]. It has been noted, for example, that some people
neglect to take their osteoporosis medication due to fear of side effects,
despite these being rare [95].

INCORRECTINFORMATION

In some countries, civil society is engaged in raising awareness ofosteoporosis and fragility fracture risk to address misconceptions
and general low levels of understanding around osteoporosis [30].
Organizations such as the Research and Information Group on Osteoporosis(Groupe de recherche et d’information sur les osteoporosis) in France, theSpanish Association for Osteoporosis and Osteoarthritis (Asociación Española
con la Osteoporosis y la Artrosis) in Spain, Osteoporosis Canada, Japan
Osteoporosis Society, the Royal Osteoporosis Society in the UK and others
aim to increase public awareness and produce resources for patientsand the public such as posters and leaflets. IOF operates a dedicatedwebsite with resources including patient stories and an osteoporosis risk
check for self-assessment. Related events and campaigns, including World
Osteoporosis Day, are also featured on the website.
59

What needs to be done?
Awareness of osteoporosis and fragility fractures as a serious
health concern must be improved.
The reach and impact of existing awareness efforts, which are primarily
operated by civil society organizations, should be expanded andsupported by governments. Campaigns should be used to debunk
myths and clearly outline the personal cost of inaction.
Policymakers must prioritize the delivery of person-centered care.
Such care should tailor risk-reducing treatment to an individual’s
circumstances, to ensure patient satisfaction and facilitate continuationof treatment and maintenance of lifestyle changes in the long term.
60THE BUILDING BLOCKS OF AN EFFECTIVE POLICY RESPONSE: ENHANCE ENGAGEMENT

61

GLOSSARY

62

DXA

Dual X-ray Absorptiometry (DXA) - an imaging modality used in bothclinical practice and research for the assessment of bone mineral density.

Falls

An event which leads to a person coming to rest on the ground or floor.
Individuals who fall are at an increased risk of fractures.

Fracture

A broken bone.

Fracture Cascade

When an individual experiences a fracture, they are at an increased risk offurther fractures. Without intervention, this could lead to a domino effectof fracture followed by fracture followed by fracture…

Fragility Fracture

A broken bone which occurs due to minor force, such as a fall fromstanding height.

Fracture Liaison Service (FLS)

See Post-Fracture Care Coordination Programme.

Geriatricians

Physicians specializing in medicine for older persons.

Hyperaging

The rapid growth of the ageing population.

Hypertension
Imminent Fracture Risk

Incidence

Index FractureHigh blood pressure, a chronic disease.
After a person has sustained a fracture they are at particularly high risk ofanother fracture in the immediate short term.
The number of people who experience a health event/disease over aparticular time period.
The first fragility fracture sustained by an individual.

Multidisciplinary

An approach which incorporates individuals from different disciplines
who contribute to a shared goal. In healthcare, this goal is patientcare and the team might incorporate doctors, surgeons, nurses,
physiotherapists, occupational therapist and managerial coordinators.

Musculoskeletal

Referring to muscles, bones, joints and interconnecting tissues.

Non-Communicable Disease

A disease or medical condition which is not infectious or transmissible
to other individuals. It encompasses a broad range of diseases including
many chronic, long-term conditions.

Orthogeriatrics

The medical care of patients who have fractured. In the context of hip
fractures this is often provided by a physician who specializes in medicine
for older persons.

64

Orthopedics

A surgical specialty specializing in musculoskeletal interventions.

Osteoporosis

Osteoporosis is a disease in which the mass, density and strength ofbone are reduced. As bones become more porous and fragile, the riskof fracture is greatly increased. The loss of bone occurs silently andprogressively.

Post-Fracture Care (PFC)
Coordination Programme

A model of care which seeks to rehabilitate individuals after they have
had a fracture and reduce the risk of them fracturing again in the future.
The term is interchangeable with Fracture Liaison Service (FLS).

Prevalence

The number of people who have a particular health characteristic at aparticular point in time.

Primary Care

Healthcare provided in the community which is often the first stop ona patient’s journey. This level of care is usually provided by ‘General
Practitioners’ or ‘Family Doctors’ in community ‘surgeries’.

Primary Prevention of Fractures

Initiatives to prevent a first/sentinel/initial fracture occurring.

Secondary Care

Healthcare provided by organizations which are usually not the firstcontact with a patient on their journey. It often refers to care provided ina hospital setting.

Secondary Preventionof Fractures

Initiatives to prevent second/subsequent/further fractures occurring after
the first fracture has occurred

Subsequent Fracture

Any fragility fracture sustained by an individual after the index (or first)
fracture.

Traumatologists
Vertebral Fractures

Clinicians who specialize in trauma surgery, including fracture repair
Fractures of the vertebrae, the bones which are the building blocks ofthe spine

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66

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