Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures

Abstract

This narrative review considers the key challenges facing healthcare professionals and policymakers responsible for providing care to populations in relation to bone health. These challenges broadly fall into four distinct themes: (1) case finding and management of individuals at high risk of fracture, (2) public awareness of osteoporosis and fragility fractures, (3) reimbursement and health system policy and (4) epidemiology of fracture in the developing world. Findings from cohort studies, randomised controlled trials, systematic reviews and meta-analyses, in addition to current clinical guidelines, position papers and national and international audits, are summarised, with the intention of providing a prioritised approach to delivery of optimal bone health for all. Systematic approaches to case-finding individuals who are at high risk of sustaining fragility fractures are described. These include strategies and models of care intended to improve case finding for individuals who have sustained fragility fractures, those undergoing treatment with medicines which have an adverse effect on bone health and people who have diseases, whereby bone loss and, consequently, fragility fractures are a common comorbidity. Approaches to deliver primary fracture prevention in a clinically effective and cost-effective manner are also explored. Public awareness of osteoporosis is low worldwide. If older people are to be more pro-active in the management of their bone health, that needs to change. Effective disease awareness campaigns have been implemented in some countries but need to be undertaken in many more. A major need exists to improve awareness of the risk that osteoporosis poses to individuals who have initiated treatment, with the intention of improving adherence in the long term. A multisector effort is also required to support patients and their clinicians to have meaningful discussions concerning the risk-benefit ratio of osteoporosis treatment. With regard to prioritisation of fragility fracture prevention in national policy, there is much to be done. In the developing world, robust epidemiological estimates of fracture incidence are required to inform policy development. As the aging of the baby boomer generation is upon us, this review provides a comprehensive analysis of how bone health can be improved worldwide for all.

Keywords: Case Finding; Disease Awareness; Fragility Fracture; Osteoporosis; Policy; Primary Prevention; Prioritisation; Secondary Prevention.

Figure 1

A systematic approach to fragility fracture care and prevention for New Zealand [66, 67] Reproduced with kind permission of Osteoporosis New Zealand

Figure 2

Post-fracture osteoporosis assessment and/or treatment in the United States [138] n.b. The data presented is for the Healthcare Effectiveness Data and Information Set (HEDIS^®) measure Osteoporosis Management in Women Who Had a Fracture. This represents the percentage of women aged 65 to 85 years who sustained a fracture and who had either a BMD test or a prescription for a drug to treat osteoporosis in the six months after the fracture. Reproduced with permission from The State of Health Care Quality Report 2015 by the National Committee for Quality Assurance (NCQA). HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA). To obtain a copy of this publication, contact NCQA Customer Support at +1-888-275-7585 or www.ncqa.org/publications.