How New Zealand Puts Bone Health at the Center of Healthy Aging
By Michael Hodin
As we round the corner to the second full year of the Decade of Healthy Ageing — that UN Declaration that completes its Sustainable Development Goals and is now being implemented by the WHO — one of the more powerful, if too often overlooked lessons, is the need for a concerted, comprehensive approach to bone health. A recent article by Paul Mitchell, Christine Gill, and others, “Experience of a systematic approach to care and prevention of fragility fractures in New Zealand,” draws on New Zealand’s pioneering, decade-long effort to promote bone health, especially the prevention of costly, life-threatening second fragility fractures.
Since 2012, a broad coalition of organizations has built an integrated, multi-faceted strategy, called BoneCare 2020, that touches on all four aspects of the Decade of Healthy Ageing and addresses every stage of bone health, from assessment of osteoporosis and risk to prevention of a first fracture through improved care for the most severe hip fractures. In fact, the strategy begins with promoting bone health among children, recognizing bone health as a lifelong public health priority.
It offers an innovative model that should be at the center of healthy aging efforts. Globally, hundreds of millions of people live with osteoporosis, nearly 200 million people have new fractures each year, and more than 400 million people live with acute or long-term symptoms of a fracture. Yet prevention, risk reduction, diagnosis, and care lag far behind. It’s estimated that only 20% of patients receive adequate assessment and care after a first fracture, and 50% of people with one osteoporotic fracture will suffer another one. We know who these people are, yet are doing precious little to mitigate the impact; Mitchell and his colleagues point to experiences in New Zealand that can be applicable globally.
This long-standing oversight is caused in no small part by the ageist attitudes that the Decade of Healthy Ageing seeks to combat: people of all ages can receive the integrated care they need, including those suffering the first fracture. In every aging country, more must be done to promote bone health; identify and manage osteoporosis; and prevent, treat, and care for fragility fractures, especially after the first one afflicting older-adults. Here are some of the key lessons from New Zealand’s strategy that Mitchell and Gill so carefully and persuasively lay out in their new peer reviewed piece “Experience of a systematic approach to care and prevention of fragility fractures in New Zealand”:
· Start early and prioritize prevention. Critically, the effort engages at the primary care level to identify and treat high-risk older people before a fracture has occurred. Standardized risk assessment tools and guidelines for osteoporosis management ensure a systematic approach, rather than an ad-hoc, reactive, and ultimately costly one. Globally, a critical advance in this vein would be to update the WHO’s approach to osteoporosis with a healthy aging lens for more effective, standardized risk assessment before and, especially, after the first fracture.
· Apply an integrated, multisector approach. In New Zealand, multiple stakeholders now coordinate and provide a diverse set of services related to bone health. The plan brings together “government, healthcare professionals, charities and the health system” and reaches from strength and balance programs for falls prevention and visual acuity to supported hospital discharge. This aligns with the WHO’s Integrated care for older people (ICOPE) model. In an important symbiosis, bone health not only benefits from the best of the Decade guidance but itself is a driver of the Decade’s value.
· Scale Fracture Liaison Services. Fracture Liaison Services (FLS) to prevent secondary fracture is recognized as perhaps the most important step to protect bone health. New Zealand has scaled this proven model nationwide and developed best practices and a quality improvement program to further strengthen these services. While the value of FLS has long been discussed, countries need to do more for implementation, standardization, and scale.
· Recognize spending on bone health as an investment in healthy aging and healthcare system itself. Fragility fractures come at a steep cost to the people and families suffering, but, equally to health systems, estimated at $400 billion per year. Bone health programs and services should be viewed in light of this immense and rising cost to people and systems. By investing here, governments and health systems can do much to prevent fractures in the first place, but, clearly and especially avoid the secondary fractures, and therefore mitigate the resulting costs of acute care, hospitalization, and chronic fractures. Our 21st century health systems deserve nothing less, a critical goal of the Decade of Healthy Ageing.
Bone health is essential to healthy aging. As the WHO, national governments, and health systems embrace the Decade of Healthy Ageing, New Zealand’s important experience chronicled by Mitchell et al. indicates that bone health strategies can support every pillar of these efforts. Even better, the campaign is already entering its next phase, BoneCare 2030, which will explore digital health technologies and further efforts to advance the standard of care. This is exactly the kind of leadership and innovation we need for healthy aging; now the challenge is scaling globally. The Decade of Healthy Ageing is such a platform for the scaling of the New Zealand experience.
