Osteoporosis and fragility fracture prevention in Germany

Germany has several barriers to improving prevention of osteoporosis and fragility fractures, including restricted reimbursement and a lack of national data. While multidisciplinary care is well integrated into the treatment of fragility fractures, both fracture prevention and post-fracture follow-up are limited.

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Osteoporosis and fragility fracture prevention in Germany

Burden and impact of osteoporosis and fragility fractures

Germany had among the highest number of fragility fractures of any population in Europe in 2010.1  The cost of care and treatment for fragility fracture patients in Germany is significant and is predicted to increase substantially over the coming years.2 3 Healthcare costs for German women over 50 years of age who have osteoporosis ­– and are thus likely to sustain a fragility fracture – are more than three times the cost of care for those without osteoporosis.2 These costs present a considerable financial burden. This is largely driven by the costs associated with inpatient treatment and long-term care for those who have experienced a fragility fracture.2

Building a system that works: policies for scrutiny, accountability and investment

Building a system that works: policies for scrutiny, accountability and investment

The urgency of osteoporosis and fragility fractures does not appear to be recognised in health policy. It receives little attention in comparison to other chronic diseases such as diabetes, which seems to contribute to a lack of reimbursement and funding of care models for fragility fracture prevention.1 4 While a law for prevention (Präventionsgesetz) passed in 2015 – widely considered an important step towards a greater focus on prevention in Germany – it has been noted that this law has a narrow focus and does not encompass secondary or tertiary prevention, and neither osteoporosis nor bone health are included.5

Germany has some registries collecting information on different types of fracture6 7 but data entry is voluntary, which may jeopardise comprehensiveness.4 8 Fracture Registries are mainly run by the German Society for Orthopaedics and Trauma (Deutsche Gesellschaft für Orthopädie und Unfallchirurgie; DGOU), the German Geriatric Society (Deutsche Gesellschaft für Geriatrie) and the German Osteology Society (Dachverband Osteologie; DVO).4 6-8 However, there is currently no registry combining data on all types of fractures, and data on quality of fracture care and outcomes are often not collected, analysed or used systematically.4 To address this, there have been efforts to establish a patient-centred fracture registry collecting data based on results of patient questionnaires, which has been shown to be feasible.9

There are significant financial barriers to providing comprehensive fragility fracture prevention and care.4 10 Experts interviewed for this country profile noted that healthcare professionals are, for example, often only marginally compensated for fragility fracture prevention, if at all.4 As part of a pilot project which aims to reduce overall fragility fracture costs, some health insurance providers have increased payments to healthcare professionals for the delivery of osteoporosis-related services.11

Catching it early: detection and management in primary care

Catching it early: detection and management in primary care

People at high risk of sustaining a fragility fracture are often not identified or adequately managed in routine care in Germany.10 12-15 Routine investigation of fracture risk and osteoporosis in people with known risk factors is not well-established.10 14 Management of people with an existing fracture appears equally deficient, with primary care professionals rarely following the specialists’ treatment recommendation after a fracture.4 13 Gaps in knowledge among primary care professionals,16 an absence of referral systems3 and a lack of adequate compensation for investigating fracture risk contribute to the gap in diagnosis and management.4 10 For example, while the tariff paid to healthcare professionals for performing a dual-energy X-ray absorptiometry (DXA) scan has recently been raised, it still fails to fully cover costs.17 It has further been noted that many people may not fulfil the strict criteria for referral, meaning they will need to pay for a scan out-of-pocket if they wish to investigate their fracture risk.17

We have preventive check-ups for breast cancer, diabetes and many other conditions. The same could be easily introduced for osteoporosis, for example as a simple, low-cost risk assessment offered to women over the age of 65.’ ANDREAS KURTH, GERMAN OSTEOLOGY SOCIETY

Efforts to improve the management of osteoporosis in primary care through greater multidisciplinary collaboration are underway.18 The planned introduction of a disease management programme, which has already improved care for other chronic diseases, could foster greater collaboration between specialists and primary care, and create incentives for delivering best-practice care.19 20 Furthermore, the DVO is certifying doctors in primary care to become osteologists, to increase their qualification to treat people with osteoporosis.21

Getting people back on track: facilitating multidisciplinary post-fracture care

Getting people back on track: facilitating multidisciplinary post-fracture care

Germany performs well in providing hospital-based multidisciplinary care for patients after a fracture, but often fails to initiate measures to prevent subsequent fractures.21  Orthogeriatric care is widely recognised as an integral component of in-hospital care for older people who have sustained a fragility fracture, and has improved acute care post-fracture.12 22-25 However, a recent study from one area in Germany suggested doctors in orthopaedic and trauma departments are failing to diagnose osteoporosis following a fracture in as many as 70% of fracture patients.14 Germany is falling behind many other European countries such as France, Italy, Spain and the UK, where up to 80% of fracture patients are adequately treated for their underlying risk factors.21

There is currently no standardised pathway to ensure adequate post-discharge care and seamless transition to primary care, presenting a missed opportunity to reduce fracture risk in the long term.21 Only a minority of hospitals have a referral pathway in place for patients post-fracture, meaning the majority of people are discharged without clear treatment recommendations.14 This results in suboptimal management following discharge.26-27 Data from 2015 revealed that more than 90% of people did not receive any treatment for osteoporosis within 12 months of their first fracture.21

Efforts are underway to pilot models for improving multidisciplinary post-discharge care in Germany. To bridge the treatment gap following a fracture, two fracture liaison services (FLS) have recently been established,28 successfully improving outcomes by linking patients to registered physicians such as endocrinologists, geriatricians and general practitioners.21 29 The use of FLS at a German trauma centre led to more people being diagnosed with osteoporosis and 90% being prescribed a treatment to reduce their fracture risk.15

Supporting quality of life as part of healthy and active ageing: prevention of falls and fractures in later life

Supporting quality of life as part of healthy and active ageing: prevention of falls and fractures in later life

Germany has been spearheading research and initiatives around falls prevention30 31 but access to comprehensive programmes varies across the country.32 After a fragility fracture, most people have access to a four-week rehabilitation course including muscle strengthening and balance training.33 For residents in nursing homes, there are standards for falls prevention34 and, in some regions such as Bavaria, falls prevention programmes have been implemented successfully.30 Furthermore, in recent years, a range of innovative care models and technologies have been developed, such as a mobile-device-based geriatric assessment,35 looking to promote healthy and active ageing while reducing costs to the health system.

Engaging patients and public: awareness, activation and self-management

Engaging patients and public: awareness, activation and self-management

Germany has many patient-focused osteoporosis organisations which have contributed to improved knowledge, but gaps in self-management remain.4 36 They have established more than 300 patient support groups37 and often run physical activity programmes to help participants manage their osteoporosis, and have been shown to have a positive impact on long-term treatment and management.38 39 At the same time, patient organisations have highlighted that people often have too little guidance on finding an osteoporosis specialist and deciding on the most appropriate treatment.10 Many people do not seek investigation of osteoporosis40 and a large proportion of those who have been diagnosed struggle to stay on their osteoporosis medication. In a recent study, more than half of osteoporosis patients in Germany discontinued their treatment within the first year of being put on osteoporosis medication.41

 

This information is based on research conducted for the 2020 publication Osteoporosis and fragility fractures: a policy toolkit.
Date of preparation: October 2020.
Hub-PRO-0820-00003
References +
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