Osteoporosis: setting a new agenda for Australia

OSTEOPOROSIS Australia recently convened the Inaugural National Consumer and Community Forum to tackle issues and address health care system barriers to improving bone health and reducing the burden of osteoporosis in Australia.

The Forum participants, representing GPs, various specialist groups, policy makers, professional associations, national health organisations, patients living with osteoporosis, community groups and other bone health-related organisations, collectively recommended:

• osteoporosis treatment reimbursement criteria to be reviewed and broadened;
• an increase in the number of fracture prevention clinics (also known as fracture liaison services or FLS) in hospitals Australia-wide to capture patients after fracture, investigate their underlying bone heath and initiate treatment;
• a substantial heightening of community awareness of risk factors for osteoporosis; and
• earlier intervention by GPs, including the investigation of bone health as part of a general health check.

Patient bone health has recently attracted significant attention in response to data revealing more than 1.2 million Australians are living with osteoporosis, and the prevalence is on the rise. Studies demonstrate osteoporosis-related fractures are costly to the health care system, at more than $3 billion per year. We also know these fractures can extensively affect the quality of life of not only those living with osteoporosis but also their families and carers.

In Australia, community understanding of the importance of bone health is limited, while awareness of risk factors for osteoporosis remains low (here and here). Progress is, however, encouraging, with evidence-based, online tools and information readily available to patients; reimbursed bone density testing; and several approved treatment options widely available to GPs. Innovations in treatment options have also helped, as well as the updating and reissuing of the recent Royal Australian College of General Practitioners (RACGP) Clinical Guidelines.

In late 2019, federal Minister for Health, the Hon. Greg Hunt MP, launched the National Strategic Action Plan for Osteoporosis 2019 providing an evidence-based roadmap with three key priorities (and specific actions) to guide a national response to osteoporosis.

As a key action under this plan, Osteoporosis Australia convened the Inaugural National Consumer and Community Forum to develop a concise position statement with recommendations and actions for the health care system to improve the diagnosis and management of osteoporosis and overall bone health in the community.

The Forum reflected on a range of patient stories and perspectives, including the less common occurrence of osteoporosis in younger adult populations (with specific risk factors) and the more common scenario of fractures in adults with low bone mineral density.

The Forum addressed current challenges and issues facing the health system, gleaning insights from GPs, specialist groups, hospitals and representatives of the broader community. The Forum participants concluded that bone health should be a much higher health priority, and that early diagnosis of osteoporosis reduces fracture rates, as well the overall associated impact and costs. With no appetite for “reinventing the wheel”, the participants agreed that efforts should henceforth focus on identifying gaps and issues able to deliver the most productive improvements.

GPs clearly serve as the primary health care group responsible for managing patients living with osteoporosis, and bone health in general, coordinating referrals to specialists only for more complicated cases.

The Forum further identified the following areas for improvement:

• bone health should be included in general prevention health checks (eg, in menopausal women and older men);
• higher recognition of the common risk factors in patients (including top tier medical conditions/medications and comorbid chronic conditions) which are known to affect bone health, and acting to prioritise bone health in these patients;
• prioritising patients with minimal trauma fracture;
• reducing delays in treatment initiation following patient diagnosis of osteoporosis/fracture;
• hospital-based system improvements, including:
  • better identification of minimal trauma fracture in emergency departments relating to patient presentation with acute pain; and
  • addressing the issue of prescribing restrictions within the hospital setting;
• targeting current disconnects between:
  • discharged hospital fracture patients and GPs; and
  • GPs and specialists; and
• GPs to focus on management care plans, noting the development of relevant decisions aids were flagged as important resources for performing informed discussions with patients.

The priorities pertaining to the preliminary Forum insights included:

• Pharmaceutical Benefits Scheme (PBS) and Medicare Benefits Schedule (MBS) subsidies – advocate to government to review current PBS and MBS eligibility for patients requiring treatment. Currently subsidies apply to patients following fracture or age alone at 70 years or over (without fracture). What about our adult and younger patients with known risk factors and no fracture? These consumers should take medication as directed to protect their bone health which is currently via non-subsidised private prescriptions (noting this raises issues of affordability and, as a result, inequity of access). Women aged under 60 years can also utilise menopausal hormone therapy for bone protection with greater confidence. In reality, consumers remain cautious about the benefit of treatment (bone treatments don’t alleviate symptoms and progress is gradual), and are confused by online searches, often lacking current evidence. The MBS DXA item for patients with prostate/breast cancer must also be discussed.
• FLS in hospitals have a proven role (here, here, here, here and here) in capturing patients following a minimal trauma fracture to diagnose osteoporosis and initiate treatment. Importantly, they provide a link with GPs for ongoing patient management and treatment. Yet these health services are not common across Australia, with only 32 in 1300 public hospitals offering them (with the majority in New South Wales).
• Community risk awareness – educating target populations within the community is critical to heightening the importance of bone health, including at the GP level. The Forum identified priority population groups for targeted messaging – people aged over 50 years with risk factors, younger adults with specific risk factors, and any patients following a minimal trauma fracture. Evidenced-based, consumer resources were seen as vital including core services – national website, a toll-free helpline, risk factor fact sheets, and online self-assessment tools. These resources remain critical, together with targeted awareness campaigns (including an increasing focus on digital execution). COVID-19 restrictions have demonstrated that online access to credible health information is highly valued, and essential for providing access to metro and rural/remote-based communities. Furthermore, alignment with other bone health-associated organisations was considered essential, particularly in areas of related risk conditions.
• Before the Forum, Osteoporosis Australia also raised with the Forum’s National Advisory Committee the ongoing barrier involving the use of the word “osteoporosis” in the organisation’s name and subsequent public confusion. The Committee recommended this issue be managed as an immediate priority. The organisation acted and, effective today, Osteoporosis Australia will now be known as Healthy Bones Australia, complete with a new website – http://www.healthybonesaustralia.org.au/ – and logo.

Where to next?

While patients living with multiple chronic health conditions are increasingly becoming the “norm”, osteoporosis is attracting minimal attention among this mix. While a common explanation for this is limited GP consult times required to “manage other, more pressing chronic conditions,” patients living with osteoporosis have a very different perspective on the topic:

• Why didn’t the emergency department think my pain was caused by a fracture?
• Why didn’t my specialist explain that my breast cancer treatment also affects my bones?
• Why wasn’t I checked for osteoporosis after breaking my wrist? I thought it was just an accident.
• Why did I fracture when I only have osteopenia? (N.B. more than half of all minimal trauma fractures occur in this range of low bone density).

The Forum participants concurred that while we already have many solutions, a multitargeted system approach will help to address existing gaps in the Australian health care system. The RACGP, the Endocrine Society of Australia, Healthy Bones Australia, the Australian and New Zealand Hip Fracture Registry, the Australasian Menopause Society and the Australian and New Zealand Bone and Mineral Society are just a few organisations focusing on this critical health issue. The Forum findings will enable the development of clear recommendations and specific actions for the Australian heath system to achieve this end.

Professor Peter R Ebeling AO is the Medical Director of Healthy Bones Australia and a Board member of the International Osteoporosis Foundation. He is also an Executive Committee member of the Asia Pacific Consortium on Osteoporosis and sits on the Editorial Board of Osteoporosis International.

Dr Weiwen Chen is a Specialist Endocrinologist and Deputy Chair of the Medical and Scientific Advisory Committee for Healthy Bones Australia. She is a Staff Specialist in Endocrinology at St Vincent’s Hospital, Sydney and a Visiting Medical Officer at Chris O’Brien Lifehouse cancer centre. She also consults from her specialist rooms in Macquarie Street, Sydney.

Dr Jane Elliott is a Women’s Health Specialist, General Practitioner and Clinical Senior Lecturer at the School of Paediatrics and Reproductive Health, University of Adelaide. She currently serves as a member of the Medical and Scientific Committee for Healthy Bones Australia, a Clinical Senior Lecturer in Obstetrics and Gynaecology at the University of Adelaide, and teaches medical students and GPs.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.