Changes in hip fracture rates in southeastern Australia spanning the period 1994-2007

What is the best method of fixation for minimally displaced subcapital neck of femur fractures? A systematic review

BACKGROUND

Femoral neck fractures are a common cause of morbidity and mortality in the community. Minimally displaced subcapital necks of femoral fractures are usually managed with internal fixation, although there is debate as to which method is superior. This systematic review aimed to compare the outcomes of different fixation methods in the management of this common fracture.

METHODS

This systematic review was conducted in accordance with PRISMA statement guidelines. The databases searched were MEDLINE (Ovid), Cochrane Central Register of Controlled Trials, and EMBASE (Ovid). The study quality and risk of bias were assessed using the Newcastle-Ottawa Quality Assessment Scale, and relevant data were extracted and synthesised.

RESULTS

Nine articles met the inclusion criteria. A total of 819 patients were included in this study. Eight of the nine studies were case series, and one was a randomised control trial. The mean risk of bias was 7.4/9 for non-randomised articles. The fixation methods used in the included studies were dynamic hip screw (DHS), cannulated screws, Smith-Peterson nail, hooknail, Moore's pins, and Knowle's pins. DHS was found to be a superior method of fixation and was supported by a clinical trial. It has high rates of union (99 %), low rates of avascular necrosis (<1 %), and low rates of fixation failure (<1 %).

CONCLUSIONS

Based on the available data, DHS appears to be the superior method of fixation for the minimally displaced subcapital neck of femoral fractures. Given the general low level of evidence currently available, additional clinical trials are needed in this area.

Prevalence of osteoporosis and incidence of related fractures in developed economies in the Asia Pacific region: a systematic review

Robust data on osteoporosis in the Asia Pacific region could improve healthcare decision-making. Osteoporosis affects 10-30% of women aged 40 + , and up to 10% of men in 7 developed economies in Asia Pacific. Fractures affect 500-1000 adults aged 50 + per 100,000 person-years. Policymakers and clinicians must address this problem.

PURPOSE

Osteoporosis and associated fractures result in considerable morbidity, loss of productivity, early mortality, and increased healthcare expenses. Many countries in the Asia Pacific (AP) region, especially middle- and higher-income economies, are faced with aging and increasingly sedentary populations. It is critical to consolidate and analyze the available information on the prevalence and incidence of the disease in these countries.

METHODS

We systematically reviewed articles and gray literature for Australia, China, Hong Kong, Japan, Singapore, South Korea, and Taiwan. We searched PubMed, ScienceDirect, JSTOR, Cochrane, Google Scholar, and other databases for data published 2009-2018. We included articles with prevalence or incidence estimates for adults with osteoporosis or related fractures.

RESULTS

All locations had data available, but of widely varying quantity and quality. Most estimates for osteoporosis prevalence ranged from 10 to 30% for women ages 40 and older, and up to 10% for men. Osteoporotic fracture incidence typically ranged between 500 and 1000 per 100,000 person-years among adults aged 50 and older. Both outcomes typically increased with age and were more common among women.

CONCLUSION

Osteoporosis and associated fractures affect significant portions of the adult population in developed economies in the AP region. Governments and healthcare systems must consider how best to prevent and diagnose osteoporosis, and manage affected individuals, to reduce healthcare costs and mortality associated with fractures.

Epidemiology of hospitalised traumatic brain injury in the state of New South Wales, Australia: a population-based study

OBJECTIVE

To describe the population-based incidence and epidemiological characteristics of hospitalised traumatic brain injury (TBI) in New South Wales (NSW), Australia.

METHODS

One-year statewide hospital admission data from the NSW Department of Health were analysed. TBI cases were identified using a combination of TBI-related diagnostic and external cause codes from the International Classification of Diseases (ICD-10th Revision). Sociodemographics, causes, associated factors, severity and medical details of hospitalisation were examined.

RESULTS

There were 6,827 hospitalised TBI cases that met review criteria. Incidence rate was 99.1/100,000 population. Incidence in persons older than 75 years of age and residents in remote areas was three times higher. Aboriginal and Torres Strait Islander peoples were 1.7 times more likely to sustain a TBI than the general population, and risk was greater for all NSW residents from areas that were remote and disadvantaged-socioeconomically. Older adults and those with severe injuries showed prolonged hospitalisation, higher morbidity and mortality.

CONCLUSIONS

Overall TBI incidence in NSW is lower than international estimates. Nevertheless, groups with higher incidence rates and/or poor in-hospital outcomes were identified, highlighting directions for prevention and future research. Implications for public health: There is a need for identifying risk factors/barriers and assessing the impact of recent policies on these population groups.

Do reductions in out-of-pocket expenses for dual energy X-ray absorptiometry scans translate to reduced fracture incidence amongst older Australians? A population-based study

This study aimed to compare fracture incidence in the elderly pre- and post-revision of bone density scan reimbursement guidelines, which changed in 2007. Fracture incidence by age group was calculated using population-specific data. Guideline changes did not appear to reduce fracture incidence in the study region located in south-eastern Australia.

PURPOSE

In 2007, Medicare Australia revised reimbursement guidelines whereby individuals aged 70 years and over received reduced out-of-pocket expenses for dual energy X-ray absorptiometry (DXA) scans. The current study aims to determine whether fracture incidence in the elderly has changed since the revision of reimbursement guidelines.

METHOD

Keyword searches of the two major radiological centres servicing the Barwon Statistical Division (BSD) were used to identify incident fractures for residents aged 75 years and over for 2006 and 2012. Pathological fractures were excluded. Fracture incidence by age strata (75-79 years, 80-84 years and 85+ years) were calculated using population-specific data from the Australian Bureau of Statistics (2006 and 2012). Standardised fracture ratios were calculated for men and women.

RESULTS

In total, 996 fracture events were identified for BSD residents during 2006 and 1260 identified in 2012. The standardised fracture ratios between 2006 and 2012 were 1.12 (95%CI 1.11, 1.25) for men and 1.08 (95%CI 1.11, 1.16) for women.

CONCLUSION

The change in reimbursement guidelines appears to have had little impact on reducing fracture incidence during this time frame for elderly men and women, in fact, fracture rates increased. Future research should investigate osteoporosis management following DXA over a longer time frame.

The epidemiology of hip fractures across western Victoria, Australia

BACKGROUND

Hip fractures are associated with considerable morbidity and mortality. Hip fracture incidence varies across different levels of accessibility/remoteness and socioeconomic status (SES). As part of the Ageing, Chronic Disease and Injury Study, we aimed to map the pattern of hip fractures across the western region of the Australian state of Victoria, which contains a range of remoteness levels and SES.

METHODS

Data on hip fractures resulting in hospital admission were extracted from the Victorian Admitted Episodes Dataset (VAED) for men and women aged 40+years during 2010-2013 inclusive. An age-adjusted incidence rate (per 10,000population/year) was calculated for the entire region. Crude incidence rates and length of acute care hospital stay (excluding rehabilitation) were calculated for each Local Government Area (LGA). The impact of aggregated age, accessibility/remoteness index of Australia (ARIA) and SES on hip fracture rates aggregated across LGAs was determined using Poisson regression.

RESULTS

For men, the age-standardised rate of hospitalisations for hip fracture across the whole region was 19.2 per 10,000population/year (95%CI 18.0-20.4) and for women, 40.0 (95%CI 38.3-41.7). The highest incidence rates for both sexes occurred in the less accessible LGAs of Yarriambiack and Hindmarsh, as well as the LGA with the lowest SES, Central Goldfields. In both sexes, approximately two thirds of individuals were discharged from acute hospital care within 14days. Increasing age, higher remoteness and lower SES were all associated with higher hip fracture rates.

CONCLUSION

Crude incidence rates varied by location. Given that a high proportion of patients had acute hospital care of ≤14days, and accessibility and SES were associated with hip fracture rates, these results can inform policy and provide a model for other groups to conduct similar research in their local environment.

Lower limb fracture presentations at a regional hospital

We found that lower limb fractures, which were largely the result of minimal trauma, had high levels of hospitalisation, length of stay and surgery. It is therefore important to prevent fractures at all sites to avoid the associated morbidity and mortality.

PURPOSE

Hip fractures are a major cause of morbidity and mortality, particularly in older women. In comparison, less is known about the epidemiology and burden of other lower limb fractures. The study aimed to investigate the epidemiology and burden of these fractures.

METHODS

Incident fractures of the hip, femur, tibia/fibula, ankle and foot in women (≥ 20 years) managed through the University Hospital Geelong, Australia, were ascertained from 1 Jan. 2014 to 31 Dec. 2014 from radiology reports. Age, cause of fracture, post-fracture hospitalisation, surgery, length of stay and discharge location were ascertained from medical records.

RESULTS

We identified 585 fractures of the lower limb (209 hip, 42 femur, 41 tibia/fibula, 162 ankle, 131 foot). Most fractures were sustained by women aged ≥ 50 years. Fractures were largely a result of minimal trauma. Most women with hip or femur fractures were hospitalised; fewer were hospitalised for fractures at other sites. Surgery for fracture followed the same pattern as hospitalisations. Length of stay was the highest for hip and femur fractures and the lowest for foot fractures. Women with hip or femur fractures were discharged to rehabilitation more often than home. Fractures at other sites were most commonly discharged home.

CONCLUSIONS

Fractures of the lower limb occurred frequently in older women. Hospitalisation and subsequent surgery were common in cases of hip and femur fractures. It is important for prevention strategies to target fractures at a range of skeletal sites to reduce costs, hospitalisations, loss of independence and reduced quality of life.

Secular Changes in Postfracture Outcomes Over 2 Decades in Australia: A Time-Trend Comparison of Excess Postfracture Mortality in Two Birth Controls Over Two Decades

CONTEXT

Hip fracture incidence has been declining and life expectancy improving. However, trends of postfracture outcomes are unknown.

OBJECTIVES

The objective of the study was to compare the refracture risk and excess mortality after osteoporotic fracture between two birth cohorts, over 2 decades.

DESIGN

Prospective birth cohorts were followed up over 2 decades (1989-2004 and 2000-2014).

SETTING

The study was conducted in community-dwelling participants in Dubbo, Australia.

PARTICIPANTS

Women and men aged 60-80 years, participating in Dubbo Osteoporosis Epidemiology Study 1 (DOES 1; born before 1930) and Dubbo Osteoporosis Epidemiology Study 2 (DOES 2; born after 1930) participated in the study.

MAIN OUTCOME MEASURE

Age-standardized fracture and mortality over two time intervals: (1989-2004 [DOES 1] and 2000-2014 [DOES 2]) were measured.

RESULTS

The DOES 2 cohort had higher body mass index and bone mineral density and lower initial fracture rate than DOES 1, but similar refracture rates [age-standardized refracture rates per 1000 person-years: women: 53 (95% confidence interval [CI] 42-63) and 51 (95% CI 41-60) and men: 53 (95% CI 38-69) and 55 (95% CI 40-71) for DOES 2 and DOES 1, respectively). Absolute postfracture mortality rates declined in DOES 2 compared with DOES 1, mirroring the improvement in general-population life expectancy. However, when compared with period-specific general-population mortality, there was a similar 2.1- to 2.6-fold increased mortality risk after a fracture in both cohorts (age-adjusted standardized mortality ratio, women: 2.05 [95% CI 1.43-2.83] and 2.43 [95% CI 1.95-2.99] and men: 2.56 [95% CI 1.78-3.58] and 2.48 [95% CI 1.87-3.22] for DOES 2 and DOES 1, respectively).

CONCLUSION

Over the 2 decades, despite the decline in the prevalence of fracture risk factors, general-population mortality, and initial fracture incidence, there was no improvement in postfracture outcomes. Refracture rates were similar and fracture-associated mortality was 2-fold higher than expected. These data indicate that the low postfracture treatment rates are still a major problem.

The Epidemiology of Incident Fracture from Cradle to Senescence

To reduce the burden of fracture, not only does bone fragility need to be addressed, but also injury prevention. Thus, fracture epidemiology irrespective of degree of trauma is informative. We aimed to determine age-and-sex-specific fracture incidence rates for the Barwon Statistical Division, Australia, 2006-2007. Using radiology reports, incident fractures were identified for 5342 males and 4512 females, with incidence of 210.4 (95 % CI 204.8, 216.2) and 160.0 (155.3, 164.7)/10,000/year, respectively. In females, spine (clinical vertebral), hip (proximal femoral) and distal forearm fractures demonstrated a pattern of stable incidence through early adult life, with an exponential increase beginning in postmenopausal years for fractures of the forearm followed by spine and hip. A similar pattern was observed for the pelvis, humerus, femur and patella. Distal forearm, humerus, other forearm and ankle fractures showed incidence peaks during childhood and adolescence. For males, age-related changes mimicked the female pattern for fractures of the spine, hip, ribs, pelvis and humerus. Incidence at these sites was generally lower for males, particularly among the elderly. A similar childhood-adolescent peak was seen for the distal forearm and humerus. For ankle fractures, there was an increase during childhood and adolescence but this extended into early adult life; in contrast to females, there were no further age-related increases. An adolescent-young adult peak incidence was observed for fractures of the face, clavicle, carpal bones, hand, fingers, foot and toe, without further age-related increases. Examining patterns of fracture provides the evidence base for monitoring temporal changes in fracture burden, and for identifying high-incidence groups to which fracture prevention strategies could be directed.

Incidence rates and trends of hip/femur fractures in five European countries: comparison using e-healthcare records databases

Hip fractures represent a major public health challenge worldwide. Multinational studies using a common methodology are scarce. We aimed to estimate the incidence rates (IRs) and trends of hip/femur fractures over the period 2003-2009 in five European countries. The study was performed using seven electronic health-care records databases (DBs) from Denmark, The Netherlands, Germany, Spain, and the United Kingdom, based on the same protocol. Yearly IRs of hip/femur fractures were calculated for the general population and for those aged ≥50 years. Trends over time were evaluated using linear regression analysis for both crude and standardized IRs. Sex- and age-standardized IRs for the UK, Netherlands, and Spanish DBs varied from 9 to 11 per 10,000 person-years for the general population and from 22 to 26 for those ≥50 years old; the German DB showed slightly higher IRs (about 13 and 30, respectively), whereas the Danish DB yielded IRs twofold higher (19 and 52, respectively). IRs increased exponentially with age in both sexes. The ratio of females to males was ≥2 for patients aged ≥70-79 years in most DBs. Statistically significant trends over time were only shown for the UK DB (CPRD) (+0.7% per year, P < 0.01) and the Danish DB (-1.4% per year, P < 0.01). IRs of hip/femur fractures varied greatly across European countries. With the exception of Denmark, no decreasing trend was observed over the study period.

Hip fractures among indigenous Western Australians from 1999 to 2009

BACKGROUND

Minimal trauma hip fractures are prevalent in Australia. The incidence rate and trend of hip fractures in Indigenous Western Australians have not been formally reported.

AIMS

To evaluate incidence rates and trend of minimal trauma hip fractures in Indigenous and other Western Australians aged 40 years and over in 1999-2009 METHODS: Hip fracture data were obtained from an administrative database for all hospitalisations in Western Australia. Age-standardised incidence rates were calculated using direct standardisation, and standardised rate ratios were calculated using the indirect method. Trend in incidence rates were calculated using Poisson regression.

RESULTS

In 1999-2009, 11,844 admissions for minimal trauma hip fractures were reported among Western Australians aged 40 years and over, of which 201 were recorded as indigenous. The age-standardised hip fracture rate was 273.0 (95% confidence interval (CI) 230.7-315.4) per 100,000 person-years for indigenous adults and 148.8 (95% CI 146.1-151.5) per 100,000 person-years for non-indigenous adults. The standardised morbidity ratio was 2.2 (95% CI 1.9-2.5). Over this period, age-standardised rates increased by an average of 7.2% per year among indigenous adults (P = 0.006), whereas non-indigenous rates fell by an average of 3.4% per year (P < 0.001). The relatively higher rates among indigenous adults were more evident in the younger age groups.

CONCLUSION

There is a widening gap in minimal trauma hip fracture rates between indigenous and other Western Australians. This study demonstrates a need for public health review and management strategies to reduce falls and hip fracture in the indigenous community.

Examining the impact of reimbursement on referral to bone density testing for older adults: 8 years of data from the Barwon Statistical Division, Australia

In 2007, Medicare Australia revised rei:mbursement guidelines for dual energy X-ray absorptiometry (DXA) for Australians aged ≥70 years; we examined whether these changes increased DXA referrals in older adults. Proportions of DXA referrals doubled for men and tripled for women from 2003 to 2010; however, rates of utilization remained low.

INTRODUCTION

On April 1, 2007 Medicare Australia revised reimbursement guidelines for DXA for Australians aged ≥70 year; changes that were intended to increase the proportion of older adults being tested. We examined whether changes to reimbursement increased DXA referrals in older adults, and whether any sex differences in referrals were observed in the Barwon Statistical Division.

METHODS

Proportions of DXA referrals 2003-2010 based on the population at risk ascertained from Australian Census data and annual referral rates and rate ratios stratified by sex, year of DXA, and 5-year age groups. Persons aged ≥70 years referred to the major public health service provider for DXA clinical purposes (n = 6,096; 21 % men).

RESULTS

DXA referrals. Proportions of DXA referrals for men doubled from 0.8 % (2003) to 1.8 % (2010) and tripled from 2.0 to 6.3 % for women (all p < 0.001). For 2003-2006, referral ratios of men/women ranged between 1:1.9 and 1:3.0 and for 2007-2010 were 1:2.3 to 1:3.4. Referral ratios <2007:≥2007 were 1:1.7 for men aged 70-79 years (p < 0.001), 1:1.2 for men aged 80-84 years (p = 0.06), and 1:1.3 for men 85+ years (p = 0.16). For women, the ratios <2007:≥2007 were 1:2.1 (70-79 years), 1.1.5 (80-84 years), and 1:1.4 (85+ years) (all p < 0.001).

CONCLUSIONS

DXA referral ratios were 1:1.6 (men) and 1:1.8 (women) for 2007-2010 vs. 2003-2006; proportions of referrals doubled for men and tripled for women from 2003 to 2010. Overall, rates of DXA utilization remained low. Policy changes may have had minimal influence on referral; thus, ongoing evaluation over time is warranted.

Monitoring progress in the management of hip fractures in South Australia, Australia

The aim of this study was to assess trends in hip fracture rates and outcomes following hospitalisation for hip fracture. Hip fracture admissions increased over the study period. Men fared worst in terms of higher absolute mortality. Refracture rates and male health outcomes require further attention.

PURPOSE

The aim of this study was to assess trends in hip fracture rates and outcomes following hospitalisation for hip fracture in South Australia (SA).

METHODS

Analysis of routinely collected, linked hospital separations data, of patients admitted to public and private hospitals in SA with a principal diagnosis of femoral neck fracture between July 2002 and June 2008 was done. Main outcome measures include number and rates of hospital admissions, 30-day in-hospital and 1-year mortality following a first hip fracture and subsequent event rates, by age and sex.

RESULTS

Unadjusted hip fracture admissions increased in SA from 2002 to 2008 by 20 %, age-standardised (adjusted) admission rates increased overall (+5 %, p = 0.215) and significantly amongst males (+26 %, p = 0.001), while there was no change among women (−1 %, p = 0.763). Within 1 year of a hip fracture, 7 % had broken another bone (5 % had refractured a hip). At 1 year post-fracture, unadjusted mortality was consistently and considerably higher amongst men compared to women (33 versus 19 %, p < 0.001). Age-standardised mortality from admission to 1 year fell but not statistically significantly by 15 % in women (p = 0.131) and 8 % in men (p = 0.510). Women had a reduction in age-standardised in-hospital mortality over time (p = 0.048); there was a non-significant decline in men (p = 0.080).

CONCLUSIONS

Hip fracture admissions in SA increased over the study period and this appears to be driven by an increase in admissions amongst men. Men fared worst in terms of higher absolute mortality. There is some evidence to suggest refracture rates and male health outcomes require further attention.

Geographic differences in fractures among women

Osteoporotic fracture is associated with considerable morbidity and mortality in women throughout the world. However, significant variation in hip fracture rates among women from different nations has been observed and is likely to represent a combination of real and apparent differences due to ascertainment bias. Higher rates are observed in Caucasian women, with lowest rates observed in black women and intermediate rates among Asian women. These differences are likely to represent a combination of genetic and environmental differences; for example, among European women, the highest fracture rates are observed in Scandinavian women where vitamin D insufficiency is common. In all groups, an increase in absolute fracture numbers is anticipated due to demographic changes.

Prospective randomized controlled trial comparing dynamic hip screw and screw fixation for undisplaced subcapital hip fractures

BACKGROUND

Neck of femur fractures (NOFFs) are a common cause of morbidity and mortality in our community. Minimally displaced intracapsular fractures are treated with internal fixation by a two-hole dynamic hip screw (DHS) or three partially threaded cancellous screws. Data to support the superiority of one are limited. This prospective randomized controlled trial compares outcomes with these two fixation methods.

METHODS

We prospectively recruited patients over 50 years, with an acute fracture subcapital NOFF, who walked and lived independently, and were cognitively intact. They were randomized into DHS or cancellous screw groups and followed up for 2 years (overall 75.9%). Outcomes of mortality, revision, loss of fixation, avascular necrosis, surgical complications, WOMAC, Harris hip score and SF-12 were measured.

RESULTS

We recruited 62 patients (31 DHS, 29 cancellous screws, 2 failed consent). Six deaths (19.3%) were seen in each group. A total of 3.2% of DHS (1 out of 31) and 10.3% (3 out of 29) of cancellous screw patients required re-operation (P = 0.272). There was no statistical significant difference in patient satisfaction, quality of life (QoL), radiological union or osteonecrosis. There are trends towards better functional scores and QoL in cancellous screws, particularly at 1 year (P = 0.0061), but with a higher re-operation rate. There was a combined mortality and transition to institutional care of 40.0% (24 out of 60) at 2 years.

CONCLUSIONS

This study found no difference in outcomes between DHS and cancellous screws in the treatment of subcapital NOFFs in a fit, independent population, but we found a high level of physical decline in previously fit, independently ambulating patients. A large, multicentre trial will be required to differentiate between these two fixation methods.

Declining incidence of osteoporotic hip fracture in Australia

Between 1997-1998 and 2006-2007 in Australia, the age-standardised incidence rates of hip fractures declined by 20 and 13 %, in females and males, respectively. Although this may be related to the rollout of public health campaigns and strategies addressing osteoporosis, absolute numbers of hip fractures continued to increase.

BACKGROUND

Previous reports described an increasing trend in osteoporotic hip fracture incidence in Australia in the 1980s with a stabilisation over the 1990s.

AIM

The aim of this study was to describe national trends in the incidence of osteoporotic hip fracture in Australia between 1997-1998 and 2006-2007.

METHODS

Data on low-trauma hip fractures in persons aged 50 years and over were obtained from the National Hospital Morbidity Database. Cases where the patient was transferred in from another hospital were excluded. Age-standardised incidence rates were calculated and a linear test for trend applied.

RESULTS

Although the absolute number of hip fracture cases has continued to increase, from 14,769 in 1997-1998 to 16,412 in 2006-2007, these numbers are lower than previous predictions based on population ageing. Over the 10-year period, the age-standardised incidence rates in females declined by 20 %, from 370 to 295 per 100,000, while the age-standardised incidence rates in males declined by 13 %, from 200 to 174 per 100,000. Both declines were statistically significant. The sex difference in incidence rates narrowed between 1997-1998 (females 85 % higher) and 2006-2007 (females 70 % higher).

CONCLUSIONS

The age-standardised incidence of osteoporotic hip fracture in Australia is falling. This may be related to the uptake of bisphosphonates as well as the rollout of public health campaigns and strategies addressing osteoporosis.

Cross-sectional analysis of association between socioeconomic status and utilization of primary total hip joint replacements 2006-7: Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND

The utilization of total hip replacement (THR) surgery is rapidly increasing, however few data examine whether these procedures are associated with socioeconomic status (SES) within Australia. This study examined primary THR across SES for both genders for the Barwon Statistical Division (BSD) of Victoria, Australia.

METHODS

Using the Australian Orthopaedic Association National Joint Replacement Registry data for 2006-7, primary THR with a diagnosis of osteoarthritis (OA) among residents of the BSD was ascertained. The Index of Relative Socioeconomic Disadvantage was used to measure SES; determined by matching residential addresses with Australian Bureau of Statistics census data. The data were categorised into quintiles; quintile 1 indicating the most disadvantaged. Age- and sex-specific rates of primary THR per 1,000 person years were reported for 10-year age bands using the total population at risk.

RESULTS

Females accounted for 46.9% of the 642 primary THR performed during 2006-7. THR utilization per 1,000 person years was 1.9 for males and 1.5 for females. The highest utilization of primary THR was observed in those aged 70-79 years (males 6.1, and females 5.4 per 1,000 person years). Overall, the U-shaped pattern of THR across SES gave the appearance of bimodality for both males and females, whereby rates were greater for both the most disadvantaged and least disadvantaged groups.

CONCLUSIONS

Further work on a larger scale is required to determine whether relationships between SES and THR utilization for the diagnosis of OA is attributable to lifestyle factors related to SES, or alternatively reflects geographic and health system biases. Identifying contributing factors associated with SES may enhance resource planning and enable more effective and focussed preventive strategies for hip OA.

Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: a randomized controlled trial

RATIONALE

Excess mortality and residual disability are common after hip fracture.

HYPOTHESIS

Twelve months of high-intensity weight-lifting exercise and targeted multidisciplinary interventions will result in lower mortality, nursing home admissions, and disability compared with usual care after hip fracture.

DESIGN

Randomized, controlled, parallel-group superiority study.

SETTING

Outpatient clinic

PARTICIPANTS

Patients (n = 124) admitted to public hospital for surgical repair of hip fracture between 2003 and 2007.

INTERVENTION

Twelve months of geriatrician-supervised high-intensity weight-lifting exercise and targeted treatment of balance, osteoporosis, nutrition, vitamin D/calcium, depression, cognition, vision, home safety, polypharmacy, hip protectors, self-efficacy, and social support.

OUTCOMES

Functional independence: mortality, nursing home admissions, basic and instrumental activities of daily living (ADLs/IADLs), and assistive device utilization.

RESULTS

Risk of death was reduced by 81% (age-adjusted OR [95% CI] = 0.19 [0.04-0.91]; P < .04) in the HIPFIT group (n = 4) compared with usual care controls (n = 8). Nursing home admissions were reduced by 84% (age-adjusted OR [95% CI] = 0.16 [0.04-0.64]; P < .01) in the experimental group (n = 5) compared with controls (n = 12). Basic ADLs declined less (P < .0001) and assistive device use was significantly lower at 12 months (P = .02) in the intervention group compared with controls. The targeted improvements in upper body strength, nutrition, depressive symptoms, vision, balance, cognition, self-efficacy, and habitual activity level were all related to ADL improvements (P < .0001-.02), and improvements in basic ADLs, vision, and walking endurance were associated with reduced nursing home use (P < .0001-.05).

CONCLUSION

The HIPFIT intervention reduced mortality, nursing home admissions, and ADL dependency compared with usual care.