A network against age-related fractures

What happens after a fracture has occurred? The Osteoporosis Network Cologne (KNO) promotes closely interlinked further treatment for patients. There is a sound argument for the approach encouraged by the committed physicians from the KNO: a significant reduction of subsequent fractures.

A case study: a 65-year-old woman is treated with prednisone for rheumatoid arthritis. The patient then suffers a spontaneous insufficiency fracture of the pubic bone. No measures are taken in terms of osteoporosis prevention, such as the administration of calcium or vitamin D. One piece of advice was to drink milk. When spontaneous back pain occurs, the patient is treated at three different hospitals: an infusion to relieve pain is administered in the first one, the possibility of a heart attack is ruled out and a chest x-ray is performed in the second. Vertebral fractures are detected. Nevertheless, the pain-ridden patient is discharged from the hospital. It is only in the third hospital that the correct diagnosis is made: glucocorticoid-induced osteoporosis.

Improving the flow of information, avoiding redundant examinations

“A handful of opportunities for clarification were missed in this case,” explains Dr. med. Erik Kelter, orthopedic specialist with an outpatient center for osteology in Cologne, Germany. The expert knows that this is not an isolated case. The resident orthopedic specialist has been looking into osteoporosis for 16 years now. He has seen thousands of patients. It worries him that the condition still tends to be detected too late. What’s more: “That a diagnosis is made does not necessarily mean that it is also communicated.” The problem is well known: “There is a lack of professionally managed interfaces between hospitals and the physicians in charge of further treatment. Too much information is lost or never sent in the first place,” says Dr. Kelter.

Transparency is provided by a simple patient folder

Dr. Kelter was involved in establishing the Osteoporosis Network Cologne (KNO) that shows that it is possible to interlink the different treatment levels successfully. The central treating and discharging hospital of the network is the Protestant Hospital in Cologne-Kalk, led by Chief Physician Dr. med. Henning Kunter (see interview). A simple folder is typical of the pragmatic approach followed in the hospital in Cologne. It contains analogue copies of the examination results that the patient can take to their osteologist that was selected while they were still in the hospital. “The folder also provides for transparency for patients, their family members and primary care physicians,” explains Dr. Kelter. “High-tech is not the only option. Redundant examinations and disruptions of the information flow are avoided, and the resident physician can get an overview quickly.”

“Pleasant , stabilizing wearing comfort”

Another case study: a patient event is held at the hospital in Cologne-Kalk just before World Osteoporosis Day on October 20, 2018. Affected individuals are able to seek information about the latest treatment methods. Among those taking this opportunity is
Werner Fröhlich (name changed, the true name is known to the editorial staff). The elderly man, who is walking with a cane, makes his way through the crowd. Following a vertebral fracture, osteoporosis was diagnosed quickly. The treatment and transfer took place based on the KNO schedule. He was also prescribed an orthosis, which is intended to reduce pain and to increase mobilization. Werner Fröhlich is now at the Bauerfeind booth, in front of him the Spinova Osteo. Only a few minutes later he is wearing the roughly adjusted straightening orthosis on his back. He grips the straps and pulls. The 78-year-old’s eyes widen: “It has a pleasant , stabilizing wearing comfort ,” says Werner Fröhlich. “My other orthosis is not like this.”

Significant decrease of recurrent fractures

The use of aids is just one of many measures coordinated within the KNO. All activities must contribute to one goal: to minimize the risk of subsequent fractures. This is the only decisive factor by which the success of the KNO is measured. The figures are unequivocal: both in hospitalized and in outpatient care organized through the KNO, recurrent fractures could be drastically reduced thanks to guideline-compliant treatment. This development is illustrated by the figures on p. 20. For context: only around 45 percent of patients in Germany with a previous fragility fracture were provided with specific follow-up treatment addressing osteoporosis1. Meanwhile, the number of cases continues to increase. “Osteoporotic bone fractures are among the most common conditions in women over 50, even more common than cardiovascular diseases and breast cancer,” Dr. Kelter warns: “The expected demographic development is going to lead to a further increase of the total costs related to osteoporotic fractures. Even radius fractures can be a first hint. The key event is the fracture of the vertebral body.”

“We hope that we can soon establish a position for an osteoporosis case manager
also within the KNO.”
Dr. med. Erik Kelter

Bauerfeind’s product range includes orthoses such as the Spinova Osteo that help to straighten and stabilize the spine, intended to reduce the risk of falls and fractures. These are well-suited for integration into multi-modal treatment concepts, and they meet the recommendations in the guideline issued by Dachverband Osteologie (DVO; Umbrella Association for ­Osteology).2 The manufacturer is dedicated to networks such as the KNO and is a partner of OSTEOLIGA, a cooperation of the DVO and its medical and scientific professional societies with companies from the industry. ­Bauerfeind also supports studies designed to gather further knowledge for the evidence-based S3 guideline (see here). What is the active role of primary care physicians as a decisive element of the treatment chain in osteoporosis therapy, also within the KNO? It does not take Dr. Kelter long to answer this question: “The first step is to identify patients suffering from osteoporosis and to make them aware of the necessity of a diagnostic work-up. Another important role is to take over patients with fragility fractures and high-risk patients from the hospital and to initiate or continue guideline-compliant treatment.”

Fracture Liaison Service

The holistic treatment of patients needs to be coordinated between the hospital and the specialist physicians. A specially trained nurse could take on a key role in this context. The “Fracture Liaison Service” (FLS) that originates from the Anglo-American countries, is a new approach for closing the coordination gap. This role could be taken over by a nurse or a professional from a related field. Except for Hamburg and Munich, there are only few networks based on the FLS model in Germany so far. This is surprising as it has been demonstrated in the originating countries that the FLS approach provides for great cost-benefit advantages – not to mention the possibility to prevent suffering in affected individuals. Dr. Kelter is optimistic: “We hope that we can soon establish a position for this type of osteoporosis case manager also within the KNO. Our network has one great advantage after all: if we reach one target , to adequately treat fractures, then our other target , to prevent future fractures, is realized virtually automatically.” Dr. Kelter and Dr. Kunter, his loyal partner at the hospital agree: “Patients suffering from osteoporosis must never be just left to their own devices again. We are happy about any new colleague that chooses to join our network.”

1 Peyman Hadji: Bone Evaluation Study (BEST), 2009.
2 For the non-surgical treatment of acute stable osteoporotic fractures of the vertebral body, the current DVO guideline (2017) recommends: “To allow for mobilization at a low level of pain, it should be considered that a spine straightening orthosis is prescribed” (see also: Newman, M. et al.: Spinal Orthoses for Vertebral Osteoporosis and Osteoporotic Vertebral Fracture: A Systematic Review. Arch Phys Med Rehabil. 97. 1013-25. 2016.)

Images: Michael Bause