Healthcare Fails To Treat Osteoporosis

One in four individuals dies within a year of the fracture.

"That figure has remained relatively stable over the past 20 years. However, considering that today's hip fracture patients tend to be older and more frail, the prognosis is actually better than it was two decades ago. Nonetheless, the consequences of these fractures are severe - the suffering is great, and the societal costs are high," says epidemiologist Karin Modig , who conducts research at the Institute of Environmental Medicine at Karolinska Institutet.

She has been the coordinating researcher in studies showing that osteoporosis medications are not prescribed as often as they should be. Between 2018 and 2020, fewer than one in five women aged 70-79 received bone-specific medication following an osteoporosis fracture. Among older women, the prescription rate was even lower. For men in the same age group, the peak prescription rate was 7 per cent. The studies also reveal significant regional differences.

Karin Modig explains that tracking prescriptions is challenging because these medications are often administered via infusion in hospitals. These treatments are not visible in the Swedish National Board of Health and Welfare's drug register, which only includes medications dispensed at pharmacies. To obtain a more comprehensive overview, the researchers used sales data from another health authority.

'This backdoor approach enabled us to make a solid estimate of how osteoporosis medication is prescribed across different regions. It is consistently an underutilised treatment,' says Karin Modig.

She sees several reasons for this, one being that osteoporosis lacks a clear place within the healthcare system. Patients may be treated by endocrinologists, rheumatologists and geriatricians.

Often, the disease is only discovered after a fracture, which is handled in emergency care - giving orthopaedic surgeons a key role in the osteoporosis care chain.

Moreover, it is a widespread condition, typically managed in primary care.

This fragmentation creates ambiguity, where osteoporosis easily falls between the cracks in healthcare. Other common conditions, such as diabetes and high blood pressure, have clearer ownership within endocrinology and cardiology, with well-established collaborations with primary care.

Developing silently

Karin Modig, who also studies population trends in age-related diseases, like heart disease, sees parallels between high blood pressure and osteoporosis. Both conditions develop silently, often unnoticed, as part of normal ageing. Both can lead to serious complications - high blood pressure can cause stroke and heart attack, while osteoporosis can lead to bone fractures, particularly in the spine and hip joint.

However, while blood pressure medication is widely used, osteoporosis remains undertreated.

'Cardiologists have done a great job. The message about the evidence has reached primary care when it comes to lowering blood pressure. Unfortunately, the same cannot be said for fracture prevention,' says Karin Modig.

She points out that osteoporosis primarily affects women, especially older women.

"Sadly, I think that plays a role in this context. Historically, diseases that mainly affect women have not been taken as seriously,' says Karin Modig.

The same argument appears in the Swedish National Board of Health and Welfare's guidelines for musculoskeletal disorders. The agency addresses healthcare decision-makers directly: "When implementing these national guidelines for musculoskeletal disorders, bear in mind that osteoporosis is typically a low-status condition. This is partly because it primarily affects older women."

Patients fall between the cracks

The highest priority in the guidelines - even above prescribing medication to those who have already suffered a fracture - is to ensure that healthcare is organised in a way that prevents patients from falling through the cracks. Anyone who has suffered an osteoporotic fracture should have the risk of further fractures assessed in a structured manner, combined with an osteoporosis evaluation and followed by treatment.

For this to happen, someone needs to take ownership. The Swedish National Board of Health and Welfare calls for the establishment of fracture liaison services, where afracture coordinator ensures that patients are guided through a proper care pathway.

Physiotherapist Stina Ek is part of Karin Modig's research group at the Institute of Environmental Medicine at Karolinska Institutet. She has investigated the prevalence of such services across Sweden, and what is required to establish them. She has focused on orthopaedic surgeons, who meet patients in the acute phase following a fracture. The question is: how are patients followed up once the orthopaedic surgeons have completed the surgery, and the patient has returned home from hospital?

"There is an established order of priority, where orthopaedic surgeons refer patients to primary care for continued treatment after discharge. Some regions have a fracture coordinator who acts as a link between orthopaedic surgeons and primary care, but sometimes the orthopaedic surgeon refers the patient directly to primary care," says Stina Ek.

If primary care follows up on patients, this constitutes a simple yet effective fracture pathway. Primary care is then responsible for assessing osteoporosis, evaluating fracture risk, and initiating treatment.

"For this to work, primary care must have the capacity to receive all referred patients. They need to be able to assess them for assessment, carry out the right investigations, and initiate treatment within a reasonable timeframe. Achieving this is challenging in some areas,' says Stina Ek.

The difficulties vary between regions. They may include high workloads in primary care or long waiting times for the DXA scans, which measure bone density.

Orthopaedic surgeons have been asked to rate, on a five-point scale, how well they think collaboration with other healthcare providers works in relation to osteoporosis. Most gave a middle rating, but responses varied widely. In some regions, orthopaedic surgeons at certain emergency hospitals reported better routines than those at nearby hospitals. This means the hospital an ambulance takes you could affect whether you are picked up by a facture liaison service.

"Some respond said outright that there are no shared guidelines for managing osteoporosis patients after discharge from emergency care,' says Stina Ek.

Osteoporosis schools can go a long way

But there are also places where fracture liaison services function well. Region Västerbotten and Ängelholm Hospital are two such examples. In some areas, primary care has even launched osteoporosis schools, where patients learn about diet and exercise for bone health. Weight-bearing activity and balance training are particularly important.

"The Osteoporosis schools show how small efforts can go a long way. Örebro is a pioneer, but similar initiatives exist in several parts of the country,' says Stina Ek.

Frustration when patients repeatedly suffer from fractures

Margareta Hedström , adjunct professor at the Department of Clinical Science, Intervention and Technology at Karolinska Institutet, is also part of the research group investigating how osteoporosis medication is prescribed. As a senior consultant in orthopaedics, she expresses frustration at repeatedly treating the same patients for new, more serious fractures, without them ever receiving protective osteoporosis medication.

"Personally, I believe the solution lies in linking osteoporosis more clearly to financial reimbursement systems. If you treat a patient with an osteoporosis fracture, it should be your responsibility to ensure that the patient is assessed and treated. Tying this to financial incentives makes it clear who is accountable," says Margareta Hedström.

She notes that orthopaedic surgeons in Sweden are looking to Norway, where new routines for hip fractures have been introduced. The first dose of osteoporosis medication is administered in hospital, during the recovery period after surgery. This approach is also spreading in Sweden and has been in place at Södersjukhuset in Stockholm for several years.

The average hospital stay after a hip fracture is about six days. This provides a limited window for administering bisphosphonates infusions, which requires stable kidney function and post-operative recovery.

At Södersjukhuset's orthopaedic wards, about one in five patients with a hip fracture receives treatment. That is fewer than in Norway, where approximately half, who conducts research at the Department of Clinical Research and Education at Södersjukhuset.

"We try to treat all patients over 65 who have had a fragility fracture in the hip, have adequate kidney function, and have not already received osteoporosis treatment. Our goal is to increase the proportion of patients who receive treatment," says Karl-Åke Jansson.

Together with fellow researchers, he has launched a study to explore how patients experience bisphosphonate treatment, which can cause flu-like symptoms. Given that these patients have After a fall, fracture, fasting, surgery, and strong pain relief - how well do older, frail patients tolerate a treatment that adds further strain?

"Previous studies show that acute-phase reactions from bisphosphonates mainly affect younger people. It seems to be less common among older people. We want to investigate this as we implement the new routine,' says Karl-Åke Jansson.

Intravenous bisphosphonates are the first-line treatment for osteoporosis. The infusion is given once a year for three to five years. In this model, orthopaedic surgeons administer the first dose and discharge the patient with a referral to primary care, which is then responsible for continuing treatment.

"We have been doing this since 2023, so we do not yet know how well primary care is following up,' says Karl-Åke Jansson.