Osteoporosis in France
New Law on Public Health aims to decrease number of falls and fractures
Athough critical issues of reimbursement are still to be resolved, the French health authorities are continuing to take important steps forward in improving the nationwide prevention, treatment and diagnosis of osteoporosis.
A significant step was making osteoporosis one of the national health priorities in the new Law on Public Health adopted on August 9, 2004 by the French Parliament. The goals are ambitious: A 10% decrease of femoral neck fractures by 2008 and a decrease of falls in the elderly (65 years and older) by 25% as well. These are specific targets within the broader goals of a general improvement of the levels of physical activity and nutritional status of the French population, including calcium and vitamin D intake.
One of the main goals of the national program – Nutrition for Health (PNNS), running from 2001 to 2005, and administered by the Ministry of Health, is to increase calcium intake. The program aims to reduce by 25% the number of people with insufficient calcium and vitamin D intake and to increase calcium and vitamin D status in children, teenagers and older people. A booklet, “Prevention of osteoporosis-related fractures: role of calcium, vitamin D and proteins” was launched in 2001 and widely disseminated, organized through a partnership by the French Health Ministry and AFLAR, the Association Française de Lutte Anti-Rhumatismale. It is the first publication of the PNNS, but other data information booklets on healthy nutrition, are being widely disseminated. A national campaign on the benefits of physical activity, “bouger, c’est la santé” ("moving is health”) was recently launched. The campaign underlines that lack of physical activity is detrimental to good bone health.
In addition the Governmental Program for Old People (2002-2006) is still running. It is devoted to improving the organisation of care and the prevention of diseases associated with old age. The prevention of falls has been highlighted through a public national campaign, including TV broadcasts and information booklets. The national program “Bien Vieillir” (“Healthy Ageing”) of 2003-2005 is promoting healthy nutrition and activity; and osteoporosis and osteoarthritis are the two musculoskeletal disorders that are highlighted, with reference to the Bone and Joint Decade.
In October 2004 the AFSSAPS (French agency for sanitary safety of health products) published updated recommendations for the treatment of postmenopausal osteoporosis. These guidelines are providing strategies based notably on the existence (or not) of a fracture, on age, results of bone densitometry (the indications of which are clearly stated), and number of associated risk factors of fracture, including the risk of falls; guidelines regarding follow-up are also provided. AFSSAPS will update them again in 2005.
The other published French guidelines are: “expertise collective: osteoporosis – strategies for prevention and treatment” (INSERM, National Inst. for Health and Medical Research, 1996) and guidelines on diagnosis, including bone densitometry (ANAES, National Agency for Accreditation and Evaluation, 2001).
Research into osteoporosis is being carried out at different levels. INSERM recently decided to fund research in the field of bone and joint disorders.
Where does progress need to be made?
DXA scanning systems are widely available in France with 20 DXA (hip) scanners per million population. However, DXA is not yet reimbursed by the public health care system. In 2002 the “Commission de la Nomenclature” officially agreed to include DXA scans in the list of reimbursements in the public health system for individuals at high risk. The implementation of this decision is eagerly awaited.
Bisphosphonates and SERMs are approved for the treatment of postmenopausal osteoporosis, but currently reimbursed only after fracture. Treatment by teriparatide is now available under precise conditions. Strontium ranelate has also recently been approved for the treatment of postmenopausal osteoporosis and it is expected to be available in France later in 2005.
Reimbursement before the first fracture for individuals at high risk is still under discussion.
It is expected that progress in regard to these and other issues, including preventive strategies and the collection of national fragility fracture statistics, will be made in the near future, following the adoption of the Law on Public Health.
Contributed by Prof. Liana Euller-Ziegler, Member of the International Steering Committee of the Bone & Joint Decade, Présidente de l’AFLAR, Association Française de Lutte Anti-Rhumatismale, reconnue d’utilité publique, Department of Rheumatology, University Hospital of Nice