Incidence of hip fracture in the Republic of Ireland and future projections: a population-based study

Changing trends in hip fracture epidemiology in the Republic of Ireland: a follow-up study

A national, population-based study of hip fracture epidemiology is reported following a previously published study for the same population to ascertain the accuracy of projected incidence rates. Results suggest a decline in age-specific incidence rates in females but not males, and an over-estimation of same in the previously reported projections.

PURPOSE

Accurate estimates of hip fracture numbers and incidence rates are necessary for health service resource planning. A study in 2009 estimated projected figures for 2016 and 2026, for the Republic of Ireland. The purpose of the current study was to scrutinize these projections, based upon actual population and fracture statistics for the year 2016.

METHODS

Population data was obtained from the Central Statistics Office, and hip fracture data was obtained from the National HIPE Database for the year 2016, using similar search criteria to the previously published study. Hip fracture numbers and incidence rates were calculated. The calculated figures were compared to projected figures from the previous report.

RESULTS

Population projection models used in the 2009 paper accurately reflected the 2016 Irish population. For younger age groups, projected number of fractures closely estimated actual numbers, however, for those over 70 years of age, hip fracture projections overestimated the actual fracture numbers observed. There was a significant difference in the age-specific hip fracture rates in the over 70 s sub-groups compared to the published results of the 2009 study.

CONCLUSIONS

Hip fracture numbers continue to increase, though the age-specific incidence rates in the Republic of Ireland are reducing in the older age groups. The previously published study over-estimated hip fracture projections for the year 2016 (and potentially 2026) due to a false assumption of a stable age-specific incidence rate in the Republic of Ireland, which is in fact reducing.

Impact of the COVID-19 pandemic on the trauma and orthopaedic department at level one Major Trauma Centre in the republic of Ireland

The Coronavirus Disease (COVID-19) has been identified as the cause of a rapidly spreading respira- tory illness in Wuhan, Hubei Province, China in early December 2019. Since then, the free movement of people has decreased. The trauma-related injuries and the demand on the trauma and orthopaedic service would be expected to fall. The aim of this study to examine the impact of the COVID-19 pandemic on a level 1 Trauma Centre in the Republic of Ireland (ROI). Patients admitted to the Trauma & Orthopaedic (T&O) Department at Cork University Hospital (CUH) and the South Infirmary Victoria University Hospital (SIVUH), and their associated fracture patterns and management, between 01/03/20 and the 15/04/20 were documented and compared to the patient admissions from the same time period one year earlier in 2019. The total number of T&O operations performed decreased by 10.15% (P= 0.03)between the two time periods. The number of paediatric procedures fell by 40.32% (P= 0.15). Adult Distal radius and paediatric elbow fractures (excluding supracondylar fracture) increased by 88% and 13% (P= 0.19), (P= 0.04) respectively. Hip fractures remained the most common fracture-type admitted for surgery. The COVID-19 crisis has to lead to a decrease in the total numbers of trauma surgeries in a major trauma centre in the ROI. This decline is most evident in the number of paediatric and male adult patients presenting with fractures requiring operative management. Interestingly, fractures directly related to solo outdoor activities, such as running or cycling, as well as simple mechanical falls like ankle, distal radius, elbow, and hand fractures all increased. Irish males were more compliant with outdoors restrictions than females.

The decline of hip fracture incidence rates over a 10-year period: A single centre experience

AIMS

Accurate epidemiological hip fracture data is essential for healthcare planning and targeted prevention strategies. Limited reports of hip fracture incidence rates in the Republic of Ireland (ROI) exist. The aim is to calculate the current age- and gender-specific incidence of hip fractures in a level 1 Trauma Centre in the ROI, and the difference in these rates over a 10 year period.

MATERIALS AND METHODS

This was a retrospective, population-based, observational study. The local Hospital In-Patient Enquiry (HIPE) database was used to generate data for analysis; capturing all patients admitted for hip fracture in three time periods over 10 years. Patients < 55 years old, pathological fractures, and periprosthetic fractures were excluded. Age- and gender-specific incidence rate was calculated using HIPE and national census data.

RESULTS

Absolute number of hip fractures rose by 8.5% between 2008/09 (n = 800) and 2018/19 (n = 868) time periods. Cervical hip fractures dominated in all 3 time periods. The average age of patients remained at 80 years but length of stay for patients was reduced by 16% 5 years later and by 21% 10 years later from the initial study point. Both the entire and susceptible (> 55 years) population numbers increased by 13% and 30%, respectively, yet overall hip fracture incidence rate declined 10 years on. Hip fracture incidence rate in the entire population fell by 3.23 per 100,000 population, and by 65.11 per 100,000 population in the susceptible population. The majority of both male and female age groups exhibited declining annual incidence rates over the 10 year study period.

CONCLUSION

Results are consistent with the global experience of declining overall incidence rate of hip fractures, despite rising susceptible population numbers. This report adds to the sparse hip fracture incidence data available in the ROI which can be applied in future healthcare planning strategies.

Assessment of previous fracture and anti-osteoporotic medication prescription in hip fracture patients

INTRODUCTION

Hip fracture prevention is an essential component in elderly patient care. History of prior fracture is a significant risk factor for subsequent hip fracture. There are variable rates of treatment for these groups of patients. The aims of this study were to make an assessment of how many hip fracture patients over a 1 year period had a previous fracture and to assess whether or not these patients were on anti-osteoporotic medication.

METHODS

Assessment on whether or not patients had a prior fracture using the national radiology imaging system checking radiology reports for all previous imaging performed. Checking patients bone health status using the hip fracture database for our hospital.

RESULTS

There were 225 hip fractures in 221 patients over a 1-year period. About 42.6% of females and 35.9% of males had a history of previous fracture. Vertebral fractures were the most common type of fracture. We found 7% of patients had a contralateral hip fracture. There were 81% of patients with prior fracture, and 71% of those without prior fracture were on anti-osteoporotic medication.

DISCUSSION

Vertebral fractures were the most common preceding fracture in hip fracture patients. There were many patients with a history of fragility fractures that were not on preventative medication. Overall there were good prescription rates of anti-osteoporotic medication. There were significantly higher rates of prescription amongst females compared with males.

Hip fractures in the elderly Chilean population: a projection for 2030

Using national databases, we projected the magnitude of hip fractures among the elderly Chilean population by 2030. Hip fractures will increase by 27.5% from 2018 to 9862 cases (95% CI = 8760 to 10,965). The most substantial growth is expected to occur in patients older than 80 years of age.

INTRODUCTION

There is scarce information regarding the magnitude of hip fractures that will be observed in Latin American countries in the near future. The aim of this study is to project the volume of hip fractures in the elderly Chilean population by the year 2030.

METHODS

The database of the Chilean Department of Statistics and Health Information, which includes all hospital discharges within Chile, was employed to evaluate the volume of hip fractures observed from 2012 to 2018 in the elderly population (≥ 65 years old). The annual incidence was determined by combining the volume of fractures with census data. Linear regression analysis was performed to determine the projected volume of hip fractures for 2030.

RESULTS

For 2030, hip fractures among the elderly population are projected to grow 27.5% (R² = 0.92) to 9862 cases (95% CI = 8760 to 10,965). In the group from 65 to 79 years old, hip fractures are expected to grow 21.6% (R² = 0.87) to 3046 cases (95% CI = 2686 to 3405). In patients ≥ 80 years of age, hip fractures are expected to grow 30.1% (R² = 0.9) to 6817 cases (95% CI = 5889 to 7744).

CONCLUSIONS

A substantial growth in the volume of hip fractures is expected for the next decade among the elderly Chilean population, especially in patients ≥ 80 years of age. A national healthcare strategy should consider efforts to mitigate the impact of the future burden related to patients' care.

Bypass: an integrated hip fracture care pathway

BACKGROUND

The incidence of hip fractures is expected to increase over the coming years, placing a greater burden on limited resources. A high volume of patients is brought to hospitals that do not have the resources necessary to provide definitive care. Optimal care involves a coordinated and integrated system of trauma care. The hip fracture care pathway introduced between a referring peripheral hospital and our institution represents a coordinated multidisciplinary approach to patient care.

AIMS

To describe and report on the outcomes over an 18-month period of the integrated hip fracture care pathway between referring peripheral hospitals and our institution.

METHODS

A retrospective analysis of the prospectively maintained hip fracture database over an 18-month period.

RESULTS

Between March 2017 and September 2018, 86 consecutive patients were referred to our institution through a new referral pathway. Of these, 69 patients came from the Emergency Department of the referring hospital and 17 arrived via bypass. All 86 patients were managed on a specialist orthopaedic ward. The average length of stay was 4.28 days, with maximum of 13 and minimum of 2 days. Over 84% of patients underwent definitive treatment within 48 h of a diagnosed hip fracture.

DISCUSSION

The fragmented approach to the management of trauma patients both in a pre-hospital and hospital care setting is a cause for concern. Our integrated hip fracture referral pathway, incorporating bypass of the referring hospital, represents a multidisciplinary care pathway for the management of patients with fractured neck of femur and can have potential benefits including improved patient outcomes, allowing the optimal allocation of resources and providing training opportunities.

Current applications of machine learning in the screening and diagnosis of glaucoma: a systematic review and Meta-analysis

AIM

To compare the effectiveness of two well described machine learning modalities, ocular coherence tomography (OCT) and fundal photography, in terms of diagnostic accuracy in the screening and diagnosis of glaucoma.

METHODS

A systematic search of Embase and PubMed databases was undertaken up to 1^st of February 2019. Articles were identified alongside their reference lists and relevant studies were aggregated. A Meta-analysis of diagnostic accuracy in terms of area under the receiver operating curve (AUROC) was performed. For the studies which did not report an AUROC, reported sensitivity and specificity values were combined to create a summary ROC curve which was included in the Meta-analysis.

RESULTS

A total of 23 studies were deemed suitable for inclusion in the Meta-analysis. This included 10 papers from the OCT cohort and 13 from the fundal photos cohort. Random effects Meta-analysis gave a pooled AUROC of 0.957 (95%CI=0.917 to 0.997) for fundal photos and 0.923 (95%CI=0.889 to 0.957) for the OCT cohort. The slightly higher accuracy of fundal photos methods is likely attributable to the much larger database of images used to train the models (59 788 vs 1743).

CONCLUSION

No demonstrable difference is shown between the diagnostic accuracy of the two modalities. The ease of access and lower cost associated with fundal photo acquisition make that the more appealing option in terms of screening on a global scale, however further studies need to be undertaken, owing largely to the poor study quality associated with the fundal photography cohort.

Predisposing Factors and Outcomes After Prolonged Admission Following Hip Fracture

Introduction Hip fractures are increasingly prevalent and can result in substantial morbidity, mortality, and cost. Despite the existence of enhanced management strategies, prolonged hip fracture admissions persist. This study's objective was to ascertain characteristics associated with a prolonged length of stay (LOS) and quantify return to baseline once discharged. Methods A retrospective audit of hip fractures over a four-year period was conducted, identifying patients with a LOS over 100 days. Demographics, comorbidities, pre- and post-admission function, and status were assessed. Patients sustaining inpatient hip fractures were excluded to negate the effect of initial admission on LOS. Results Seven hundred and eleven hip fractures were treated, of which 48 (6.8%) were suitable for inclusion. The patients' median age and LOS was 83.5 years and 153 days, respectively. Preoperative American Society of Anesthesiologists - Physical Status (ASA-PS) Grades II and III predominated at 41.7% and 39.6%, respectively. Eighteen of patients had a diagnosis of dementia before admission, increasing to 29 on discharge (P = 0.0026). One patient was in long-term care prior to admission, rising to 30 on discharge (P < 0.0001), with only 25.6% returning to pre-admission residential status (P < 0.0001). Nineteen patients were mobilising unaided prior to admission, decreasing to only two following discharge, with a mere 37.1% returning to their pre-admission mobility baseline (P < 0.0001). Discussion Hip fracture patients with multiple comorbidities or a diagnosis of dementia were most likely to have a prolonged LOS which, in turn, impacted upon return to baseline mobility, cognitive status, and independence. Early identification and management of this cohort may help reduce the potential disease burden and economic effects that a prolonged LOS creates.

Patient-reported quality of life and hand disability in elderly patients after a traumatic hand injury - a retrospective study

Background

Hand injuries occur at any age and cause disability in hand and arm function as well as impaired quality of life, but no study has focused on hand disability and quality of life in the elderly after a hand injury. Globally, the population over 60 years of age is expected to double by 2050 and more hand injuries are estimated among the elderly population. Our goal is to obtain more information and a better understanding of problems elderly patients experience after a hand injury to be able in the future to optimally relocate resources in the health care sector with respect to numbers and injury pattern as well as to health status of these patients.

Methods

Patients aged more than 65 years with a traumatic hand/wrist/forearm injury treated (July 1st 2013 - June 30th 2014) at department of Hand Surgery, Malmö, Sweden were included. Health-related outcome questionnaires, i.e. QuickDASH, SF-36, Visual Analogue Scale (VAS), Cold Intolerance Severity Score (CISS), and general information were mailed to the patients (time from injury: > 1.5–2.5 years). The participants were compared in groups according to age, gender, cold intolerance, injury severity and previous occupation.

Results

One hundred and thirty-seven participants responded [response rate 55%; non-responders (n = 113); only difference between groups was that non-responders were older]. Women were older than men at the time of injury (p = 0.04) and differed regarding living conditions. The main differences in QuickDASH, all VAS questions, and the majority of SF-36 subscales (p < 0.05) were found in the participants with CISS > 50, who experienced more impairment. More serious injuries (Modified HISS) were found to have higher QuickDASH and CISS score as well as more functional impairment (p < 0.05). Few differences were found in groups divided according to age, gender (although men experiencing less functional impairment in QuickDASH), previous occupation and injured hand.

Conclusions

Patients aged more than 65 years at the time a hand injury was sustained, generally experience a high-level quality of life and limited functional problems after such an injury, but patients with CISS > 50 and with a more serious injury were more severely affected.

Mitochondria and cellular senescence: Implications for musculoskeletal ageing

Musculoskeletal ageing and its associated diseases are major contributors to the loss of independence and reduced quality of life in older people. Several recent studies indicate that cellular senescence is a contributor to age-related loss of function in various organs including muscle, bones and joints. Importantly, these studies indicate that therapies targeting specifically senescent cells have great therapeutic potential in improving musculoskeletal health during ageing. Senescent cells are characterised by dramatic changes in mitochondrial function, metabolism and homeostasis. Mitochondrial dysfunction has been shown to contribute to senescence and the SASP. Here we review the role of cellular senescence in musculoskeletal ageing as well as the potential mechanisms by which mitochondrial dysfunction may impact on the induction and development of the senescent phenotype.

A falls case summary: Application of the public health nursing intervention wheel

BACKGROUND

The Public Health Intervention Wheel (PHIW) is a population-based practice model that encompasses three levels of practice (community, systems, and individual/family) and 17 public health interventions. Each intervention and practice level contributes to improving population health. Public health nurses (PHNs) provide care at the three levels of practice. Prevention of falls is a public health issue and the majority of falls happen at home. Therefore, prevention and management of falls in the community could benefit from a public health systems approach by PHNs underpinned by the PHIW.

CASE PRESENTATION

A hypothetical case is presented of a 78-year-old gentleman who had a fall which resulted in a fractured right acetabulum and surgery before being discharged home.

METHODS

The aim of this paper was to use a case summary to illustrate PHN practice in the context of the PHIW as applied to falls management and prevention. This paper focuses on fall incidence and PHN response in Ireland and Norway. The PHIW is described and relevant interventions from the PHIW are applied to PHN practice in managing the case.

CONCLUSIONS

The PHIW model provides insight into the potential scope of public health nursing in falls, articulating PHN practice in the community.

The effect of time to surgery on functional ability at six weeks in a hip fracture population in Mid-West Ireland

Patients with a hip fracture may be appropriately delayed for surgery as they require optimisation or clinical interventions to treat acute medical illnesses (Moja et al., 2012). Other patients are inappropriately delayed due to hospital factors (Brener, 2013; Lee & Elfar, 2014). Timely efficient admission and surgery is well documented as the best course of management for these patients. The aim of this prospective cohort longitudinal follow-up study was to establish if a relationship existed between duration of time spent in the Emergency Department (ED), time to surgery and functional ability in patients with hip fractures and to examine the effect prolonged waits may have on ability to return home. Functional ability for fifty one patients with a hip fracture was evaluated using the Barthel Index Score (BIS) on admission and at six weeks post-surgery. Data were analysed by using SPSS version 20. The findings reveal a change in BIS at 6 weeks for patients whose surgery is delayed. Patients who experienced long delays awaiting admission (>12 h) in the ED functioned less well (Kruskal-Wallis test p = 0.033). Correlation existed between time to surgery and returning to pre-fracture place of residence, (p = 0.000 Pearson chi-square), which also remained significant while controlling for age. Prolonged waits had an overall negative impact on patients' post-fracture functional ability. This study highlights the deleterious effects on functional ability when surgery is delayed.

Falling age-related incidence of hip fractures in women, but not men, in Northern Ireland: 2001-2011

Hip fractures place a large burden on healthcare and determining the variation in incidence is important to plan resources. We found, in Northern Ireland, that the age-related incidence for women is declining but the incidence for men and the total number of fractures remains static as the elderly population increases.

INTRODUCTION

Hip fractures place a significant burden on healthcare systems throughout the world. Recent studies have shown that the incidence is starting to decline or plateau. We aimed to study the incidence of hip fractures in 2001 and 2011 within Northern Ireland and hope to guide further service provision.

METHODS

The years 2001 and 2011 were selected as accurate census population data was available. The Hospital Inpatient System (HIS) database was used to collect the data and the search was carried out by a statistician using ICD codes S72.0 and S72.1.

RESULTS

The total incidence of hip fractures in the population aged 50 and over fell from 358 per 100,000 to 274 per 100,000. In females, the incidence fell from 513 to 412 per 100,000. In males, the incidence increased from 172 to 178 per 100,000. The total number of hip fractures remained static (1737 in 2001 and 1739 in 2011) as a result of an increase in the elderly population. Incidence and total number of femoral neck fractures (S72.0) declined while the incidence and total number of pertrochanteric fractures (S72.1) increased.

CONCLUSIONS

Our results are in keeping with the declining trend in hip fracture incidence in many Western countries, though we found that this is only true for women. The exact reasons for this remain unclear but are likely to be multifactorial. In the future, the number of fractures may increase further given the increasingly elderly population and further provision particularly for patients with pertrochanteric fractures will be required. Increased awareness, diagnosis and treatment of males with osteoporosis should be prioritised.

Current trends and future projections of hip fracture in South Korea using nationwide claims data

Incidence of hip fracture increased in Korean populations over age 50 between 2008 and 2012, and the number of fractures was predicted to increase by 1.4 times by 2025. This is important information for public health planning.

INTRODUCTION

The purposes of this study were to evaluate the trends in the incidence and mortality of hip fracture between 2008 and 2012 and predict the number of hip fractures in Korea through 2025 using nationwide claims data.

METHODS

The data managed by the National Health Insurance Service were used to identify the hip fractures in patients aged >50 years between 2008 and 2012. Projections of hip fractures were conducted using the Poisson distribution from 2016 to 2025 in Korea.

RESULTS

The incidence of hip fractures (per 100,000) increased by 14.1 % over the 5 years of the study, by 15.8 % in women and 10.9 % in men; the older age group showed a steep rise and shift in the incidence from 2008 to 2012. The cumulative mortality rates at 1 year after hip fractures were 17.2 % (3575/20,849) in 2008 and 16.0 % (4547/28,426) in 2012. Overall standardized mortality ratios (SMRs) for hip fracture were higher in men (11.93) than in women (11.22) and were higher than those in the general population in all age groups. In 2016, the total number of hip fractures was estimated to increase an overall of 1.4 times by 2025.

CONCLUSIONS

The incidence of hip fracture continues to increase, and the related mortality is still high, although it has decreased over time. The socioeconomic burden of hip fracture is expected to increase in Korea along with the increased estimated number of fractures. Nationwide strategies should include attempts to reduce the future socioeconomic burdens of hip fractures.

Osteoporosis: the evolution of a diagnosis

The global trend towards increased longevity has resulted in ageing populations and a rise in diseases or conditions that primarily affect older persons. One such condition is osteoporosis (fragile or porous bones), which causes an increased fracture risk. Vertebral and hip fractures lead to increased morbidity and mortality and result in enormous healthcare costs. Here, we review the evolution of the diagnosis of osteoporosis. In an attempt to separate patients with normal bones from those with osteoporosis and to define the osteoporosis diagnosis, multiple factors and characteristics have been considered. These include pathology and histology of the disease, the endocrine regulation of bone metabolism, bone mineral density (BMD), fracture type or trauma severity, risk models for fracture prediction, and thresholds for pharmacological intervention. The femoral neck BMD -2.5 SDs cut-off for the diagnosis of osteoporosis is arbitrarily chosen, and there is no evidence to support the notion that fracture location (except vertebral fractures) or severity is useful to discriminate osteoporotic from normal bones. Fracture risk models (including factors unrelated to bone) dissociate bone strength from the diagnosis, and treatment thresholds are often based on health-economic considerations rather than bone properties. Vertebral fractures are a primary feature of osteoporosis, characterized by decreased bone mass, strength and quality, and a high risk of another such fracture that can be considerably reduced by treatment. We believe that the 2001 definition of osteoporosis by the National Institutes of Health Consensus Development Panel on Osteoporosis is still valid and useful: 'Osteoporosis is defined as a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture'.

Nationwide cohort study of hip fractures: time trends in the incidence rates and projections up to 2035

SUMMARY

A growing elderly population is expected worldwide, and the burden of hip fractures on health care system will continue to increase. By 2035, there will be a 2.7-fold increase in the number of hip fractures in Taiwan. The study provides quantitative basis for the future distribution of medical resources.

INTRODUCTION

Hip fractures have long been recognized as a major public health concern. The study aimed to determine time trends in the incidence of hip fractures and to forecast the number of hip fractures expected in Taiwan up to 2035.

METHODS

A nationwide survey was conducted using data from the Taiwan National Health Insurance Research Database from 2004 to 2011. A total of 141,397 hip fractures were identified, with a mean of 17,675 fractures/year. Annual incidences of hip fractures were calculated and tested for trends. Projections of the incidence rates of hip fractures and bed days associated with hip fractures were calculated using Poisson regression on the historical incidence rates in combination with population projections from 2012 to 2035.

RESULTS

The incidence rates of hip fracture during 2004-2011 were 317 and 211 per 100,000 person-years among women and men, respectively. Over this 8-year period, the age-standardized incidence of hip fracture decreased by 13.4% among women and 12.2% among men. Despite the decline in the age-standardized incidence, the absolute number of hip fractures increased owing to the aging population. The number of hip fractures is expected to increase from 18,338 in 2010 to 50,421 in 2035-a 2.7-fold increase. The number of bed days for 2010 and 2035 was estimated at 161,248 and 501,995, respectively, representing a 3.1-fold increase.

CONCLUSIONS

The socioeconomic impact of hip fractures will be high in the near future. This study provides a quantitative basis for future policy decisions to serve this need.

The incidence of hip fractures in Estonia, 2005-2012

The incidence of hip fractures among individuals aged over 50 in Estonia and trends over time were assessed for 2005-2012. The incidence among women is relatively low, with the declining trend, but the rate among men is among the highest in Eastern and Central Europe.

INTRODUCTION

The aim of this study was to assess the incidence and trends of hip fractures among individuals over 50 years in Estonia in 2005-2012 and to increase understanding of the incidence of hip fractures in Eastern Europe.

METHODS

We identified all patients aged 50 years or older with hip fracture (ICD-10 codes S72.0, S72.1 and S72.2) in 2005-2012 using medical claims data from the Estonian Health Insurance Fund. Crude and age-specific incidence rates were calculated for men and women using the population of Estonia in 2005-2012. To adjust for age differences in the population, standardized incidence rates (SIR) were estimated.

RESULTS

The SIR per 100,000 for the entire observation period was 209.2 (95% CI 204.2 to 214.2) in women and 215.6 (95%CI 208.2 to 223.1) in men, resulting in a female to male rate ratio of 0.97 (95% CI 0.84 to 1.11). Over the period of 2005-2012 the estimated SIR/100,000 ranged from 211.5 (95% CI 196.8-226.3) in 2005 to 183.7 (95% CI 170.8-196.7) in 2012 in women, and from 238.5 (95% CI 215.4-261.7) in 2005 to 187.9 (95% CI 169.0-206.8) in 2012, in men. For women, the decrease in SIR for the study period approached statistical significance (p = 0.058), and for the period of 2009-2012, we observed an accelerated 16% decrease (p = 0.008).

CONCLUSIONS

The incidence of hip fractures among Estonian women is relatively low, whereas the rate among men is among the highest in Eastern and Central Europe. In line with many countries, we found a recent decline in incidence among women.

Current and future burden of incident hip fractures in New South Wales, Australia

Population ageing presents significant challenges for many developed nations. Accurately forecasting the likely future burden of age-related medical conditions, such as hip fracture, is critical. In this study, we present estimates of the current and future burden of hip fracture in NSW, Australia, providing crucial information for future health care planning.

PURPOSE

The aims of this study were to investigate the burden of hip fracture in Australia's largest state, New South Wales (NSW), and to build a prediction model to forecast the likely future burden of hip fracture from 2016 to 2036 in persons aged 50 years or more.

METHODS

A retrospective population-based cohort study was conducted using NSW hospitalisation data. Standardised incident hip fracture rates and hip fracture-related acute care length of stay and costs were estimated. Predictive negative binomial regression modelling using age, gender and local health district and year covariates together with projected NSW populations was applied to forecast future hip fractures.

RESULTS

Total incident hip fractures increased 8.8 % over a 12-year period from 2000/2001 to 2011/2012 despite declining age-standardised rates. Estimates of acute care length of stay for the treatment of hip fracture ranged from 10 to 15 days and acute care costs ranged between 21 and 29,000 Australian dollars per fracture. By 2036, incident hip fractures are projected to rise by 35.2 %, assuming a continued decline in the rate of hip fracture or by 107.5 % if the current decline in the rate does not continue. Acute care length of stay and costs are each predicted to rise between 37.1 and 110.4 % by 2036.

CONCLUSION

An ageing population and changing demographics will continue to drive the increasing burden of incident hip fractures in NSW and Australia in the foreseeable future. These anticipated changes provide important information for the planning and management of future hip fracture care.

Comparative cost-effectiveness of bazedoxifene and raloxifene in the treatment of postmenopausal osteoporosis in Europe, using the FRAX algorithm

Bazedoxifene and raloxifene were evaluated in the treatment of postmenopausal osteoporosis from health economic perspective in Europe. Based on a computer-based algorithm calculating efficacy of the treatments, bazedoxifene appears to be a cost-effective strategy compared to raloxifene, particularly in patients at high fracture risk.

INTRODUCTION

The purpose of this study was to compare cost-effectiveness of bazedoxifene and raloxifene in eight European countries: Belgium, France, Germany, Ireland, Italy, Spain, Sweden, and the UK.

METHODS

The Fracture Risk Assessment Tool, which is a computer-based algorithm to calculate fracture probability using clinical risk factors alone or with bone mineral density, was incorporated in a Markov Tunnel model to evaluate cost-effectiveness of bazedoxifene 20 or 40 mg vs. raloxifene 60 mg in postmenopausal osteoporotic women. The efficacy of bazedoxifene and raloxifene for vertebral and non-vertebral fractures was measured as a function of the 10-year probability of a major osteoporotic fracture. The model estimated the incremental cost-effectiveness ratio and net monetary benefit (NMB) from a healthcare perspective, given the willingness to pay <euro>30,000.

RESULTS

In postmenopausal osteoporotic women, bazedoxifene was a cost saving strategy compared to raloxifene in the countries studied. The median NMB of bazedoxifene compared to raloxifene increased monotonically with the 10-year fracture probability. In general, the median NMB became greater than 0 in women with 10-year probabilities of a major osteoporotic fracture between 5 and 10% or above. The impact on results by varying the assumptions in the model was examined in sensitivity analysis.

CONCLUSION

Bazedoxifene appears to be a cost-effective strategy compared to raloxifene for the treatment of postmenopausal osteoporotic women in Europe, particularly in patients at high fracture risk.

Improving hip fracture care in ireland: a preliminary report of the irish hip fracture database

Introduction. Hip fractures are common injuries in the older persons, with significant associated morbidity and mortality. The Irish Hip Fracture Database (IHFD) was implemented to monitor standards of care against international standards. Methods. The IHFD is a clinically led web-based audit. We summarize the data collected on hip fractures from April 2012 to March 2013 from 8 centres. Results. There were 843 patients with the majority being (70%) female. The 80-89-year age group accounted for the majority of fractures (44%). Most (71%) sustained a fall at home. Intertrochanteric fractures (40%) were most common. Only 28% were admitted to an orthopaedic ward within 4 hours. The majority (97%) underwent surgery with 44% having surgery within 36 hours. Medical optimization (35%) and lack of theatre space (26%) accounted for most of the surgical delay. While 29% were discharged home, 33% were discharged to a nursing home or other long-stay facilities. There was a 4% in-hospital mortality rate. Conclusions. Several key areas in both the database and aspects of patient care needing improvement have been highlighted. The implementation of similar databases has led to improved hip fracture care in other countries and we believe this can be replicated in Ireland.

Hospitalisations for fracture and associated costs between 2000 and 2009 in Ireland: a trend analysis

In Ireland, the absolute numbers of hospitalisations for all osteoporotic-type fractures including hip fractures increased between 2000 and 2009 along with the mean length of stay. The cost of hospitalisations for these fractures also increased between 2003 and 2008.

INTRODUCTION

The purposes of the study were to carry out a trend analyses of the total number of osteoporotic-type fractures in males and females aged 50 years and over in Ireland between 2000 and 2009 and to project the number of osteoporotic-type fractures in the Republic of Ireland expected by 2025.

METHODS

Age- and gender-specific trends in the absolute numbers and direct age-standardised rates of hospitalisations for all osteoporotic-type fractures in men and women ≥ 50 years were analysed, along with the associated hospitalisation costs and length of stay using the Hospital In-Patient Enquiry system database. Future projections of absolute numbers of osteoporotic-type fractures in years 2015, 2020 and 2025 were computed based on the 2009 incidence rates applied to the projected populations.

RESULTS

Between 2000 and 2009, the absolute numbers of all osteoporotic-type fractures increased by 12 % in females and by 15 % in males while the absolute numbers of hip fractures increased by 7 % in women and by 20 % in men. The age-specific rates for hip fractures decreased in all age groups with the exception of the 55-59-year age group which showed an increase of 4.1 % (p = 0.023) within the study period. The associated hospitalisation costs and length of stay increased. Assuming stable age-standardised incidence rates from 2009 over the next 20 years, the number of all types of osteoporotic-type fractures is projected to increase by 79 % and the number of hip fractures is expected to increase by 88 % by 2025.

CONCLUSIONS

Hospitalisations for osteoporotic-type fractures continued to increase in Ireland. Hip fractures increased by 7 % in women and 20 % in men.

Accuracy of evidence-based criteria for identifying an incident hip fracture in the absence of the date of injury: a retrospective database study

OBJECTIVES

Hospital discharge data (HDD) in many health systems do not capture the date of injury (DOI); the absence of this date hinders researchers' ability to distinguish repeat from incident injury admissions. Various approaches using somewhat arbitrary criteria have been explored to increase the accuracy of incident injury identification. However, these approaches have not been validated against a data source which contains DOI. The aim of this study was to determine the accuracy of evidence-based criteria for identifying fall-related incident hip fractures in the absence of DOI using HDD containing DOI as the reference standard.

DESIGN

Retrospective database study.

SETTING

New Zealand.

PARTICIPANTS

8761 patients aged 65+ years admitted for fall-related hip fracture between 1 July 2005 and 30 June 2008, inclusive.

OUTCOME MEASURES

We defined person-identifying HDD containing DOI as the reference standard and calculated measures of the accuracy of evidence-based criteria for identifying fall-related incident hip fractures from HDD not containing DOI. The criteria were principal diagnosis of hip fracture, mechanism of injury indicating a fall, admission type emergency, admission source other than a transfer and presence of hip operation code(s). For a subsequent fall-related hip fracture, additional criteria were time between successive hip fractures ≥120 days, and all external cause-of-injury codes being different to those for the previous hip fracture.

RESULTS

The sensitivity and specificity of the criteria for identifying fall-related incident hip fractures from data not containing DOI were 96.7% and 99.3%, respectively, compared with the reference standard. The application of these criteria resulted in a slight underestimation of the percentage of patients with multiple hip fractures.

CONCLUSIONS

Although it is preferable to have DOI; this study demonstrates that evidence-based criteria can be used to reliably identify fall-related incident hip fractures from the person-identifying HDD when DOI is unavailable.

Linked versus unlinked hospital discharge data on hip fractures for estimating incidence and comorbidity profiles

Background

Studies comparing internally linked (person–identifying) and unlinked (episodes of care) hospital discharge data (HDD) on hip fractures have mainly focused on incidence overestimation by unlinked HDD, but little is known about the impact of overestimation on patient profiles such as comorbidity estimates. In view of the continuing use of unlinked HDD in hip fracture research and the desire to apply research results to hip fracture prevention, we concurrently assessed the accuracy of both incidence and comorbidity estimates derived from unlinked HDD compared to those estimated from internally linked HDD.

Methods

We analysed unlinked and internally linked HDD between 01 July 2005 and 30 June 2008, inclusive, from Victoria, Australia to estimate the incidence of hospital admission for fall-related hip fracture in community-dwelling older people aged 65+ years and determine the prevalence of comorbidity in patients. Community-dwelling status was defined as living in private residence, supported residential facilities or special accommodation but not in nursing homes. We defined internally linked HDD as the reference standard and calculated measures of accuracy of fall-related hip fracture incidence by unlinked HDD using standard definitions. The extent to which comorbidity prevalence estimates by unlinked HDD differed from those by the reference standard was assessed in absolute terms.

Results

The sensitivity and specificity of a standard approach for estimating fall-related hip fracture incidence using unlinked HDD (i.e. omitting records of in-hospital deaths, inter-hospital transfers and readmissions within 30 days of discharge) were 94.4% and 97.5%, respectively. The standard approach and its variants underestimated the prevalence of some comorbidities and altered their ranking. The use of more stringent selection criteria led to major improvements in all measures of accuracy as well as overall and specific comorbidity estimates.

Conclusions

This study strongly supports the use of linked rather than unlinked HDD in injury research. In health systems where linked HDD are unavailable, current approaches for identifying incident hip fractures may be enhanced by incorporating additional evidence-based criteria.

Trends in hip fracture incidence and in the prescription of antiosteoporosis medications during the same time period in Belgium (2000-2007)

OBJECTIVE

To examine the secular trend of hip fracture incidence in Belgium between 2000 and 2007 and the concomitant change in the prescriptions of antiosteoporosis medications.

METHODS

The incidence of hip fractures and the number of prescriptions were determined using national databases. A logistic regression including years and 5-year age range was performed to assess the secular trend of hip fracture incidence, and Pearson's correlation coefficient was calculated to examine the relationship between hip fracture incidence and the prescriptions of antiosteoporosis medications.

RESULTS

The annual number of hip fractures increased in Belgium from 13,512 in 2000 to 14,744 in 2007, with a more marked increased in men (20.4%) than in women (5.7%). The age-adjusted incidence of hip fractures was significantly decreased by 1.12% per year in women, but declined nonsignificantly by 0.34% per year in men. An increase in the prescriptions of antiosteoporosis medications in women was observed during the same time period.

CONCLUSION

Despite an increase in the number of hip fractures in Belgium between 2000 and 2007, there was a significant decrease in age-adjusted incidence in women but not in men. Although our results suggest that the decrease may be related to the extent of antiosteoporosis medications, a causal relationship cannot be ascertained and many other factors may have contributed to the decrease in age-adjusted incidence.

Patterns of comorbidity in community-dwelling older people hospitalised for fall-related injury: a cluster analysis

BACKGROUND

Community-dwelling older people aged 65+ years sustain falls frequently; these can result in physical injuries necessitating medical attention including emergency department care and hospitalisation. Certain health conditions and impairments have been shown to contribute independently to the risk of falling or experiencing a fall injury, suggesting that individuals with these conditions or impairments should be the focus of falls prevention. Since older people commonly have multiple conditions/impairments, knowledge about which conditions/impairments coexist in at-risk individuals would be valuable in the implementation of a targeted prevention approach. The objective of this study was therefore to examine the prevalence and patterns of comorbidity in this population group.

METHODS

We analysed hospitalisation data from Victoria, Australia's second most populous state, to estimate the prevalence of comorbidity in patients hospitalised at least once between 2005-6 and 2007-8 for treatment of acute fall-related injuries. In patients with two or more comorbid conditions (multicomorbidity) we used an agglomerative hierarchical clustering method to cluster comorbidity variables and identify constellations of conditions.

RESULTS

More than one in four patients had at least one comorbid condition and among patients with comorbidity one in three had multicomorbidity (range 2-7). The prevalence of comorbidity varied by gender, age group, ethnicity and injury type; it was also associated with a significant increase in the average cumulative length of stay per patient. The cluster analysis identified five distinct, biologically plausible clusters of comorbidity: cardiopulmonary/metabolic, neurological, sensory, stroke and cancer. The cardiopulmonary/metabolic cluster was the largest cluster among the clusters identified.

CONCLUSIONS

The consequences of comorbidity clustering in terms of falls and/or injury outcomes of hospitalised patients should be investigated by future studies. Our findings have particular relevance for falls prevention strategies, clinical practice and planning of follow-up services for these patients.

An intervention study exploring the effects of providing older adult hip fracture patients with an information booklet in the early postoperative period

AIM

To determine whether the provision of an information booklet on mobilisation improves early mobility postsurgical repair of hip fracture.

BACKGROUND

Hip fracture among older people can have long-lasting consequences with the majority of patients failing to achieve their prefracture functional status. Early postoperative mobility may have a positive effect on long-term recovery. The importance of providing postoperative information on mobility has been highlighted. It is suggested that patients remain passive in their recovery when they do not understand the importance of mobilisation.

DESIGN

The study used a pretest-post-test design of two treatments and a usual care control group.

METHODS

Eighty-three adults postsurgical repair of hip fracture, aged 65 years and older, were recruited to the study. Participants were assigned to one of three groups, a usual care group, treatment group 1 (T(1)) usual care plus basic information booklet or treatment group 2 (T(2)) usual care plus detailed information booklet. Data collection three days postsurgery and prior to discharge included the Mini-Mental State Examination, a Demographic Questionnaire, the Elderly Mobility Scale and a Numerical Pain Scale.

RESULTS

Greatest improvements in Elderly Mobility Scale scores occurred in T(1), with least changes observed in T(2). Changes did not reach significance level (p=0·105).

CONCLUSION

The results of the study suggest that the provision of basic information is preferable and highlights a deficiency of education in usual care.

RELEVANCE TO CLINICAL PRACTICE

Hip fracture patients should be provided with an educational booklet containing basic information on mobility to promote optimal recovery.

Analysis of rehabilitation activities within skilled nursing and inpatient rehabilitation facilities after hip replacement for acute hip fracture

OBJECTIVE

To characterize rehabilitation services in two types of postacute facilities in patients who underwent hip replacement following a hip fracture.

DESIGN

Multisite prospective observational cohort from 6 freestanding skilled nursing facilities and 11 inpatient rehabilitation facilities. Patients (n = 218) with hip fracture who had either hemiarthroplasty or total hip arthroplasty followed by rehabilitation at skilled nursing facilities or inpatient rehabilitation facilities were enrolled. Using a point-of-care methodology, we recorded data from actual physical therapy and occupational therapy sessions completed including functional outcomes during the postacute admission.

RESULTS

Onset time from surgical repair to rehabilitation admission was not significantly different between sites. Average skilled nursing facilities length of stay was 24.7 +/- 13.6 days, whereas inpatient rehabilitation facilities was 13.0 +/- 5.7 days (P < 0.01). Total hours of physical therapy and occupational therapy services per patient day were 1.2 in skilled nursing facilities and 2.0 in inpatient rehabilitation facilities. For weekdays only, these data changed to 1.6 in skilled nursing facilities and 2.6 hrs per patient in inpatient rehabilitation facilities (P < 0.01). Patients in inpatient rehabilitation facilities accrued more time for gait training and exercise in physical therapy, which was found to be 48% and 40% greater, respectively, through day 8. In occupational therapy, patients of inpatient rehabilitation facilities had more time allocated to lower body dressing and transfers.

CONCLUSIONS

Significant differences in rehabilitation activities were observed, and intensity was notably different within the first 8 therapy days even though baseline demographics and medical complexity were comparable across facility types. Our data suggest that after more complex hip replacement surgery, hip fracture patients can tolerate more intensive therapy earlier within the rehabilitation program.