Hip fractures in Singapore: ethnic differences and temporal trends in the new millennium

Incidence of fragility hip fracture across the Asia-pacific region: A systematic review

PURPOSE

This systematic review aimed to update fragility hip fracture incidences in the Asia Pacific, and compare rates between countries/regions.

METHOD

A systematic search was conducted in four electronic databases. Studies reporting data between 2010 and 2023 on the geographical incidences of hip fractures in individuals aged ≥50 were included. Exclusion criteria were studies reporting solely on high-trauma, atypical, or periprosthetic fractures. We calculated the crude incidence, age- and sex-standardised incidence, and the female-to-male ratio. The systematic review was registered with PROSPERO (CRD42020162518).

RESULTS

Thirty-eight studies were included across nine countries/regions (out of 41 countries/regions). The crude hip fracture incidence ranged from 89 to 341 per 100,000 people aged ≥50, with the highest observed in Australia, Taiwan, and Japan. Age- and sex-standardised rates ranged between 90 and 318 per 100,000 population and were highest in Korea and Japan. Temporal decreases in standardised rates were observed in Korea, China, and Japan. The female-to-male ratio was highest in Japan and lowest in China.

CONCLUSION

Fragility hip fracture incidence varied substantially within the Asia-Pacific region. This observation may reflect actual incidence differences or stem from varying research methods and healthcare recording systems. Future research should use consistent measurement approaches to enhance international comparisons and service planning.

Combined Effect of Dietary Acid Load and Cardiometabolic Syndrome on Bone Resorption Marker among Post-Menopausal Women in Malaysia

Background

This study aimed to investigate factors associated with bone resorption status and determine the independent and interactive effects of dietary acid load (DAL) and cardiometabolic syndrome (CMS) on bone resorption in post-menopausal women.

Methods

Overall, 211 community-dwelling post-menopausal women were recruited from the National Council of Senior Citizens Organization, Malaysia. DAL was estimated using the potential renal acid load from the food frequency questionnaire. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and smoking behaviour was assessed using the Global Adult Tobacco Survey 2011. Serum 25(OH) vitamin D levels were determined using the ADVIA Centaur vitamin D assay and serum C-terminal telopeptides of type I collagen (CTX1) were used as surrogate markers to assess bone resorption. CMS was determined based on the harmonised criteria.

Results

Age (β = -0.145, t = -2.002, P < 0.05) was negatively associated while DAL (β = 0.142, t = 2.096, P < 0.05) and sleep quality (β = 0.147, t = 2.162, P < 0.05) were positively associated with CTX1. Height was positively correlated with CTX1 (r = 0.136, P <0.05). Conversely, other variables (CMS traits, CMS, serum 25(OH) vitamin D level, years of menopause, years of education and physical activity) were not significantly associated with CTX1 levels. There was no significant interaction between DAL and CMS on bone resorption.

Conclusion

Our findings propose that high DAL, but not CMS, is a potential risk factor for bone resorption. The analysis did not demonstrate the combined effects of DAL and CMS on bone resorption.

Prevalence and risk factors associated with low bone mineral density in Asian adolescents with anorexia nervosa and atypical anorexia nervosa

OBJECTIVE

This retrospective study aimed to evaluate the prevalence and risk factors for low bone mineral density (BMD) at diagnosis in Asian adolescent females with anorexia nervosa (AN) and atypical AN.

METHOD

We analyzed the BMD results for 213 patients between 10 and 18 years of age, with AN and atypical AN receiving care at a pediatric hospital in Singapore. We used linear regression analyses to determine if type of eating disorder, premorbid weight, and duration of amenorrhea were risk factors for low BMD. For a subset of patients with repeat BMD evaluation, we used paired t-tests to assess the impact of weight or menstrual restoration on the change in BMD.

RESULTS

The prevalence of BMD height-for-age Z-scores <-2 at presentation was higher in patients with AN (13.0%) than atypical AN (2.3%) (p = .034). In multivariate regression, a diagnosis of atypical AN was protective against low BMD at the lumbar spine (B = 0.394, p = .009) and total body less head (B = 0.774, p = .010). Duration of amenorrhea was not associated with BMD across all sites. For those with repeat BMD measures, there was significantly less deterioration in the BMD Z-scores for patients with weight or menstrual restoration (R = -0.22 ± 0.59, NR = -0.69 ± 0.43, p = .029).

CONCLUSIONS

Duration of amenorrhea was not associated with BMD in this sample. A diagnosis of AN was correlated with lower BMD than atypical AN. Further research is needed to better understand the relationship between amenorrhea, weight status, and bone health in Asian adolescents with eating disorders.

PUBLIC SIGNIFICANCE

In this sample, 13% of Asian adolescents with AN and 2.3% of Asian adolescents with atypical AN have low BMD. In our study population, duration of amenorrhea was not correlated with BMD. Among adolescents with AN, a history of being underweight at the highest pre-morbid BMI, is correlated with low BMD. It is important for physicians to take a thorough weight history in evaluating bone health in this population.

Association of Social Support with Rehabilitation Outcome among Older Adults with Hip Fracture Surgery: A Prospective Cohort Study at Post-Acute Care Facility in Asia

OBJECTIVES

There is growing interest in the role of social support during the recovery after hip fractures. The research to date has been mainly focused on structural support, with few studies concerned with functional support. This study examined the effects of both functional and structural aspects of social support on rehabilitation outcomes among older adults with hip fracture surgery.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

Consecutive older adults (≥60 years) with hip fracture surgery who underwent inpatient rehabilitation in a post-acute care facility in Singapore between January 11, 2021, and October 30, 2021 (n = 112).

METHODS

We administered the Medical Outcome Study-Social Support Survey (MOS-SSS) to assess perceived functional support of patients and used living arrangement as an indicator for structural support. Participants were followed up over the inpatient stay at the post-acute care facility until discharge; thereafter, rehabilitation efficiency (REy) and rehabilitation effectiveness (REs) were evaluated. Multiple linear regressions were performed to examine the associations of MOS-SSS score and living arrangement with REy and REs, respectively, adjusting for age, gender, ethnicity, comorbidity, body mass index, prefracture function, type of fracture, and length of stay.

RESULTS

Perceived functional support had positive associations with rehabilitation outcomes. A 1-unit increase in MOS-SSS total score was associated with 0.15 units (95% CI 0.03-0.3, P = .029) greater gain in physical function after a typical 1-month stay, and 0.21 units (95% CI 0.01-0.41, P = .040) higher achievement in potential functional improvement upon discharge. In contrast, no association was observed between structural support and rehabilitation outcomes.

CONCLUSIONS AND IMPLICATIONS

Perceived functional support may significantly impact the recovery of older adults with hip fracture during the inpatient rehabilitation process, independent of structural support. Our findings suggest the potential of incorporating interventions enhancing perceived functional support of patients into the post-acute care model for hip fracture.

SF-36 physical function and general health domains are independent predictors of acute hospital length of stay after hip fracture surgery

OBJECTIVE

The demographics and co-morbidities of individuals may impact healthcare consumption, but it is less understood how premorbid physical and mental function may influence these effects. The aim of this study is to determine patient's pre-fracture quality of life and mobility affect acute hospital burden in the management of hip fracture, using length of stay (LOS) as a proxy for healthcare resource.

MATERIALS AND METHODS

This is a retrospective study which investigated hip fracture patients who underwent surgery over the period of 2017-2020. Variables collected include LOS, age, gender, race, marital status, payer type, ASA score, time to surgery (TTS), type of surgery, fracture type, POD1 mobilization, discharge disposition, pre-fracture SF-36, EQ-5D and Parker mobility score (PMS) based on patient's recollection on admission. These variables were correlated with LOS using binary logistic regression on SAS.

RESULTS

There were 1045 patients, and mean age was 79.5 + 8.57 (range 60-105) years with an average LOS 13.64 + 10.0 days (range 2-114). On univariate analysis, PMS, EQ-5D and all domains of SF-36 except bodily pain (BP), emotional role and mental health were associated significantly with LOS. Amongst the QOL and PMS scores, only the domains of SF-36 Physical Function (PF) (OR = 0.993, p = 0.0068) and General Health perception (GH) (OR 0.992, p = 0.0230) remained significant on the multivariate model.

CONCLUSION

Our study showed that poor premorbid scores of SF36 PF and GH are independent factors associated with longer LOS in hip fracture patients after surgery, regardless of fracture type, age and ASA status. Hence, premorbid SF36 PF and GH can be used to identify patients that are at risk of prolonged hospital stay and employ targeted strategies to facilitate rehabilitation and discharge planning.

Osteoporosis management by primary care physicians in Singapore: a survey on osteoporosis guidelines utilisation and barriers to care

This study seeks to understand the knowledge/utilisation of osteoporosis guidelines among PCPs in Singapore, their confidence in and barriers to osteoporosis management. Knowledge and usage of guidelines was associated with confidence in management. Effective guideline adoption is therefore crucial. PCPs also need systemic support to overcome barriers to osteoporosis care.

PURPOSE

Primary care physicians (PCPs) are at the forefront of offering osteoporosis screening and treatment. However, osteoporosis remains under-treated in primary care, despite the existence of osteoporosis clinical practice guidelines for PCPs. This study aims to determine the self-reported knowledge and utilisation of local osteoporosis guidelines and associated sociodemographic factors and to determine the confidence and barriers to osteoporosis screening and management among PCPs in Singapore.

METHODS

An anonymous web-based survey was conducted. PCPs in public and private practice were invited to participate in the self-administered survey via e-mail and messaging platforms. Chi-square test was performed for bivariate analysis; multivariable logistic regression models were used for factors with p value < 0.2.

RESULTS

Three hundred thirty-four complete survey datasets were processed for analysis. Two hundred fifty-one PCPs (75.1%) had read the osteoporosis guidelines. 70.5% self-reported good knowledge, and 74.9% use the guidelines. PCPs who self-reported good guideline knowledge (OR = 5.84; 2.96-11.49) and utilisation (OR = 4.54; 2.21-9.34) were more likely to perceive confidence in osteoporosis management. PCPs' perception that patients had other medical priorities during the consultation (79.3%) was the commonest barrier to screening. Limited anti-osteoporosis medication (54.1%) in the practice was a hindrance to management. Polyclinic-based PCPs frequently cited the lack of consultation time as a barrier; more systemic barriers were faced by PCPs in private practices.

CONCLUSION

Most PCPs know and use the local osteoporosis guidelines. Knowledge and usage of guidelines was associated with confidence in management. Strategies to address the prevalent barriers to osteoporosis screening and management faced by PCPs are needed.

Increased incidence among the very elderly in the 2020 Niigata Prefecture Osteoporotic Hip Fracture Study

INTRODUCTION

A 2015 study showed a decreasing trend in the incidence of osteoporotic hip fractures in Niigata Prefecture, Japan, which had been increasing. This study aimed to investigate the incidence of osteoporotic hip fractures in 2020, determine the long-term change in the incidence of hip fractures from 1985 to 2020, and assess whether the decline in fracture incidence since 2010 has continued.

MATERIALS AND METHODS

We obtained data from the registration forms submitted by hospitals and clinics of patients who lived in Niigata Prefecture and were diagnosed with osteoporotic hip fracture through a survey conducted from January 1, 2020 to December 31, 2020.

RESULTS

In 2020, 3,369 hip fractures were recorded in Niigata Prefecture. Although the overall incidence of age-specific hip fractures decreased, it increased in patients aged ≥ 90 years, regardless of sex. The proportion of patients receiving anti-osteoporosis drugs prior to hip fracture increased from 7.6% in 2004 to 17.3% in 2020. Notably, surgical treatment should be performed as early as possible, and the preoperative waiting time was 2.9 days, which was mainly due to holidays.

CONCLUSION

The incidence of hip fractures in Niigata Prefecture has gradually increased over the past 35 years, with an increasing change observed in the very elderly recently in 2020. Although the treatment of osteoporotic hip fractures in Niigata Prefecture is adequate, improvements may include increasing the rate of adoption of osteoporosis treatment further and decreasing the number of days of preoperative waiting.

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.

Variation in bone mineral density and fractures over 20 years among Canadians: a comparison of the Canadian Multicenter Osteoporosis Study and the Canadian Longitudinal Study on Aging

International variations in osteoporosis and fracture rates have been reported, with temporal trends differing between populations. We observed higher BMD and lower fracture prevalence in a recently recruited cohort compared to that of a cohort recruited 20 years ago, even after adjusting for multiple covariates.

PURPOSE

We explored sex-specific differences in femoral neck bone mineral density (FN-BMD) and in prevalent major osteoporotic fractures (MOF) using two Canadian cohorts recruited 20 years apart.

METHODS

We included men and women aged 50-85 years from the Canadian Multicentre Osteoporosis Study (CaMos, N = 6,479; 1995-1997) and the Canadian Longitudinal Study on Aging (CLSA, N = 19,534; 2012-2015). We created regression models to compare FN-BMD and fracture risk between cohorts, adjusting for important covariates. Among participants with prevalent MOF, we compared anti-osteoporosis medication use.

RESULTS

Mean (SD) age in CaMos (65.4 years [8.6]) was higher than in CLSA (63.8 years [9.1]). CaMos participants had lower mean body mass index and higher prevalence of smoking (p < 0.001). Adjusted linear regression models (estimates [95%CI]) demonstrated lower FN-BMD in CaMos women (- 0.017 g/cm² [- 0.021; - 0.014]) and men (- 0.006 g/cm² [- 0.011; 0.000]), while adjusted odds ratios (95%CI) for prevalent MOF were higher in CaMos women (1.99 [1.71; 2.30]) and men (2.33 [1.82; 3.00]) compared to CLSA. In women with prevalent MOF, menopausal hormone therapy use was similar in both cohorts (43.3% vs 37.9%, p = 0.076), but supplements (32.0% vs 48.3%, p < 0.001) and bisphosphonate use (5.8% vs 17.3%, p < 0.001) were lower in CaMos. The proportion of men with MOF who received bisphosphonates was below 10% in both cohorts.

CONCLUSION

Higher BMD and lower fracture prevalence were noted in the more recently recruited CLSA cohort compared to CaMos, even after adjusting for multiple covariates. We noted an increase in bisphosphonate use in the recent cohort, but it remained very low in men.

Bundled Payments for Hip Fracture Surgery Are Associated With Improved Access, Quality, and Health Care Utilization, but Higher Costs for Complex Cases: An Interrupted Time Series Analysis

OBJECTIVES

To study the impact of bundled payments for surgically managed hip fractures on care access, care quality, health care resource utilization, clinical impact, and acute care cost.

DESIGN

An observational retrospective cohort study using a quasi-experimental design comparing prebundled and postbundled payments through an interrupted time series analysis.

SETTING

A public acute care general hospital.

PATIENTS

Patients 60 years and older, with surgery for an isolated, unilateral, nonpathological hip fracture during 2014-first quarter of 2019 [diagnosis-related group codes: I03A, I03B, I08A, and I08B] and transferred to specific rehabilitation institutions were studied.

INTERVENTION

Bundled payments for funder-to-provider reimbursement.

MAIN OUTCOMES MEASUREMENTS

Care access, care quality, health care resource utilization, clinical impact, and cost.

RESULTS

Of 1477 patients, 811 were assigned to prebundled and 666 to postbundled payments. Although there was an improving trend of ward admission waiting times during postbundled payments [odds ratio (OR) = 1.14; 95% confidence interval (CI): 1.02-1.28], ward admission waiting times were longer when compared with prebundled payments (OR = 0.45; 95% CI: 0.23-0.85). Rates of 30-day all-cause readmissions were lower (OR = 0.08; 95% CI: 0.01-0.67), and trends of reducing inpatient rehabilitation and overall episode length of stay (OR = 1.26; 95% CI: 1.16-1.37 and OR = 1.17; 95% CI: 1.07-1.28, respectively) were demonstrated during postbundled payments. Acute care cost for complex cases were higher (OR = 0.49; 95% CI: 0.26-0.92) during bundled payments, compared with prebundled payments.

CONCLUSIONS

Bundled payments for surgically managed hip fractures were associated with benefits for several outcomes pertinent to clinical improvement initiatives. More work, especially concerning cost-effective surgical implants and better care cost computations, are critically needed to contain the growth of acute medical care cost for these patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Geriatric Services Hub - A Collaborative Frailty Management Model between The Hospital and Community Providers

BACKGROUND

Frailty is an important geriatric syndrome especially with ageing populations. Frailty can be managed or even reversed with community-based interventions delivered by a multi-disciplinary team. Innovation is required to find community frailty models that can deliver cost-effective and feasible care to each local context.

OBJECTIVES

We share pilot data from our Geriatric Service Hub (GSH) which is a novel frailty care model in Singapore that identifies and manages frailty in the community, supported by a hospital-based multi-disciplinary team.

METHODS

We describe in detail our GSH model and its implementation. We performed a retrospective data analysis on patient characteristics, uptake, prevalence of frailty and sarcopenia and referral rates for multi-component interventions.

RESULTS

A total of 152 persons attended between January 2020 to May 2021. Majority (59.9%) were female and mean age was 81.0 ± 7.1 years old. One-fifth (21.1%) of persons live alone. Mean Charlson Co-morbidity Index was 5.2 ± 1.8. Based on the clinical frailty risk scale (CFS), 31.6% were vulnerable, 51.3% were mildly frail and 12.5% were moderately frail. Based on SARC-F screening, 45.3% were identified to be sarcopenic whilst 56.9% had a high concern about falling using the Falls-Efficacy Scale-International. BMD scans were done for 41.4% of participants, of which 58.7% were started on osteoporosis treatment. In terms of referrals to allied health professionals, 87.5% were referred for physiotherapy, 71.1% for occupational therapy and 50.7% to dieticians.

CONCLUSION

The GSH programme demonstrates a new local model of partnering with community service providers to bring comprehensive population level frailty screening and interventions to pre-frail and frail older adults. Our study found high rates of frailty, sarcopenia and fear of falling in community-dwelling older adults who were not presently known to geriatric care services.

Cost-effectiveness of selective bone densitometry using the osteoporosis self-assessment tool for Asians in multi-ethnic Asian population

Early detection and treatment of osteoporosis can help to prevent debilitating fractures in the elderly. The osteoporosis self-assessment tool for Asians can be used as a screening tool to stratify patients for bone densitometry. It is most cost-effective for post-menopausal women aged 70 and males aged 75.

PURPOSE

To determine the cost-effectiveness of selective bone densitometry (SBD) using the Osteoporosis Self-Assessment Tool for Asians (OSTA) as a risk-stratifying tool for the three predominant races (Chinese, Malay and Indian) in Singapore.

METHODS

Decision analytical models were developed using a Markov model. Three scenarios were compared: no bone densitometry, SBD using the OSTA as a pre-screening tool and universal bone densitometry. Those diagnosed with osteoporosis were treated with five years of alendronate therapy. Data sources were from Singapore epidemiological studies, healthcare cost figures and published literature. Measurements include life years, quality-adjusted life years (QALYs), costs and incremental cost-effectiveness ratios (ICER).

RESULTS

Compared to no bone densitometry, SBD using the OSTA would cost between $40,679 and $73,909 per QALY gained for men aged 75-80 and $22,386 to $58,185 per QALY gained for post-menopausal women aged 70-80. Universal bone densitometry would cost $157,955 to $177,127 per QALY gained for men aged 75-80 and $40,179 to $66,112 per QALY gained for post-menopausal women aged 70 to 80 compared to SBD.

CONCLUSION

In general, osteoporosis screening was the most cost-effective for Malays and the least cost-effective for Indians. However, a general guideline should still be applied to the Singaporean population, as further explained later. Overall, the most cost-effective strategy for males would be using OSTA as a risk-stratifying tool at age 75. For post-menopausal women, SBD should be used for women aged 70, while universal bone densitometry should be used for women aged 75-80.

Quality improvement initiatives in the care and prevention of fragility fractures in the Asia Pacific region

This narrative review summarises ongoing challenges and progress in the care and prevention of fragility fractures across the Asia Pacific region since mid-2019. The approaches taken could inform development of national bone health improvement Road Maps to be implemented at scale during the United Nations 'Decade of Healthy Ageing'.

PURPOSE

This narrative review summarises recent studies that characterise the burden of fragility fractures, current care gaps and quality improvement initiatives intended to improve the care and prevention of fragility fractures across the Asia Pacific region.

METHODS

The review focuses on published studies, reports and quality improvement initiatives undertaken during the period July 2019 to May 2022.

RESULTS

Epidemiological studies conducted in countries and regions throughout Asia Pacific highlight the current and projected increasing burden of fragility fractures. Recent studies and reports document a persistent and pervasive post-fracture care gap among people who have sustained fragility fractures. Global initiatives developed by the Fragility Fracture Network and International Osteoporosis Foundation have gained significant momentum in the Asia Pacific region, despite the disruption caused by the COVID-pandemic. The Asia Pacific Fragility Fracture Alliance has developed educational resources including a Hip Fracture Registry Toolbox and a Primary Care Physician Education Toolkit. The Asia Pacific Osteoporosis and Fragility Fractures Society-a new section of the Asia Pacific Orthopaedic Association-is working to engage orthopaedic surgeons across the region in the care and prevention of fragility fractures. The Asia Pacific Consortium on Osteoporosis developed a framework to support national clinical guidelines development groups. Considerable activity at the national level is evident in many countries across the region.

CONCLUSION

Development and implementation of national Road Maps informed by the findings of this review are urgently required to respond to the epidemiological emergency posed by fragility fractures during the United Nations 'Decade of Healthy Ageing'.

Excess mortality after hip fracture: fracture or pre-fall comorbidity?

Comorbidity and hip fracture independently increased mortality risk for 9 years in both sexes, with a significant additive interaction in the first year among women and through 6 years among men.

INTRODUCTION

Hip fracture is associated with a persistently elevated mortality risk, but it is unknown whether the elevated risk is due to the fracture or to pre-fracture comorbidity.

METHODS

In a population-based study in Singapore with 9 years of follow-up, patients age > 50 with first hip fracture from 2008 to 2017 were pair-matched to a cohort without hip fracture by age, sex, ethnicity, and pre-fracture Charlson Comorbidity Index (CCI). We investigated additive interaction using the relative excess risk due to interaction (RERI) and multiplicative interaction using the ratio of relative risks.

RESULTS

Twenty-two thousand five hundred ninety of 22,826 patients with a first hip fracture in 2008-2017 were successfully matched. Hip fracture and comorbidity independently increased mortality risk for 9 years in both sexes. After adjustment for comorbidity, excess mortality risk continued to persist for 9 years post-fracture in both men and women. Women with a hip fracture and pre-fracture CCI > 4 had a higher relative risk (RR) of mortality at 9 years of 3.29 [95% confidence interval (CI) 3.01, 3.59] than those without comorbidity (RR 1.51, 95%CI 1.36, 1.68) compared to the referent without hip fracture or comorbidity. An additive interaction between hip fracture and pre-fracture CCI > 4 was observed in the first post-fracture year` [relative excess risk due to interaction (RERI) 1.99, 95%CI 0.97, 3.01]. For men with CCI ≥ 4, the positive additive interaction was observed through 6 years.

CONCLUSIONS

Excess mortality risks post-fracture are attributable to both the fracture and pre-fracture comorbidity. Early interventions in hip fracture patients with high comorbidity could reduce their excess mortality.

Prediction Model of Osteonecrosis of the Femoral Head After Femoral Neck Fracture: Machine Learning-Based Development and Validation Study

BACKGROUND

The absolute number of femoral neck fractures (FNFs) is increasing; however, the prediction of traumatic femoral head necrosis remains difficult. Machine learning algorithms have the potential to be superior to traditional prediction methods for the prediction of traumatic femoral head necrosis.

OBJECTIVE

The aim of this study is to use machine learning to construct a model for the analysis of risk factors and prediction of osteonecrosis of the femoral head (ONFH) in patients with FNF after internal fixation.

METHODS

We retrospectively collected preoperative, intraoperative, and postoperative clinical data of patients with FNF in 4 hospitals in Shanghai and followed up the patients for more than 2.5 years. A total of 259 patients with 43 variables were included in the study. The data were randomly divided into a training set (181/259, 69.8%) and a validation set (78/259, 30.1%). External data (n=376) were obtained from a retrospective cohort study of patients with FNF in 3 other hospitals. Least absolute shrinkage and selection operator regression and the support vector machine algorithm were used for variable selection. Logistic regression, random forest, support vector machine, and eXtreme Gradient Boosting (XGBoost) were used to develop the model on the training set. The validation set was used to tune the model hyperparameters to determine the final prediction model, and the external data were used to compare and evaluate the model performance. We compared the accuracy, discrimination, and calibration of the models to identify the best machine learning algorithm for predicting ONFH. Shapley additive explanations and local interpretable model-agnostic explanations were used to determine the interpretability of the black box model.

RESULTS

A total of 11 variables were selected for the models. The XGBoost model performed best on the validation set and external data. The accuracy, sensitivity, and area under the receiver operating characteristic curve of the model on the validation set were 0.987, 0.929, and 0.992, respectively. The accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve of the model on the external data were 0.907, 0.807, 0.935, and 0.933, respectively, and the log-loss was 0.279. The calibration curve demonstrated good agreement between the predicted probability and actual risk. The interpretability of the features and individual predictions were realized using the Shapley additive explanations and local interpretable model-agnostic explanations algorithms. In addition, the XGBoost model was translated into a self-made web-based risk calculator to estimate an individual's probability of ONFH.

CONCLUSIONS

Machine learning performs well in predicting ONFH after internal fixation of FNF. The 6-variable XGBoost model predicted the risk of ONFH well and had good generalization ability on the external data, which can be used for the clinical prediction of ONFH after internal fixation of FNF.

Shorter acute hospital length of stay in hip fracture patients after surgery predicted by early surgery and mobilization

Time to surgery, early mobilization, fracture type, and ASA grades independently affect acute hospital length of stay after hip fracture surgery. Modifiable factors can be audited to reduce length of stay, and non-modifiable factors can be used for consideration of a tiered bundled payment reimbursement model.

INTRODUCTION

As hip fracture incidence rises with our ageing global population, there will be an increase in consumption of healthcare resources. We hypothesized that hospital management and patient factors can affect healthcare burden load. Using length of stay (LOS) as a surrogate for consumption, the aim of this study is to elucidate the effect of hospital management and patient-related factors on length of stay (LOS) for patients after hip fracture surgery. We studied modifiable and non-modifiable factors influencing LOS, and identification of these modifiable factors accords opportunities for mitigating these factors.

METHODS

This retrospective study examines hip fracture data from a large tertiary hospital in Singapore over the period of 2017 to 2020. Data collected on the electronic medical record included age, gender, race, marital status, payer type, ASA score, TTS, type of surgery, fracture type, POD1 mobilization, discharge position, and presence of pressure sores, and they were correlated with LOS using binary logistic regression on SAS.

RESULTS

A total of 1045 patients were included in this study with 704 females and 341 males. The mean age was 79.5 ± 8.57 years (range 60-105) with an average LOS 13.64 ± 10.0 days (range 2-114). On binary logistic regression, ASA and trochanteric fracture remains a significant non-modifiable factor for LOS with OR = 1.486 (95% CI 1.106, 1.996, p = 0.0086) and OR 1.522 (95% CI 1.149, 2.015, p = 0.0034) respectively. Significant modifiable factors were TTS > 48 h (OR = 1.819, 95% CI 1.205, 2.746, p = 0.0044) and POD1 mobilization (OR = 0.441, 95% CI 0.257, 0.756, p = 0.0029).

CONCLUSIONS

Our analysis showed TTS and POD1 are significant modifiable factors for LOS, and resources can be diverted towards them for the management of hip fracture patients and pre-empting the increasing load on our healthcare system.

Randomized, double-blind, placebo-controlled trial to examine the safety, pharmacokinetics and effects of Epimedium prenylflavonoids, on bone specific alkaline phosphatase and the osteoclast adaptor protein TRAF6 in post-menopausal women

BACKGROUND

Fragility fractures due to menopausal osteoporosis are a major cause of morbidity and mortality. Osteoporotic medications have substantial side effects that limit long term use.

HYPOTHESES

Ingestion of a purified extract of Epimedium spp. (EP) is safe, can increase serum levels of prenylflavonoid metabolites, exert positive changes in bone specific alkaline phosphatase (BSAP), suppress of tumor necrosis factor receptor associated factor 6 (TRAF6) protein in osteoclast-precursor monocytes in peripheral blood and therefore have the potential to reduce post-menopausal bone loss.

STUDY DESIGN & METHODS

Healthy postmenopausal women were randomized in a double-blind fashion to consume either EP prenylflavonoid extract (740 mg daily) or placebo daily for 6 weeks. The main outcome measures were safety and pharmacokinetics of EP flavonoids. Fasting blood was collected at 3- and 6-weeks, and two weeks after stopping medication for safety evaluations and measurement of BSAP. Peripheral blood monocytes were harvested for measurement of TRAF6 levels. Serum levels of the EP metabolites icariin, icariside I & II, icaritin and desmethylicaritin were measured using tandem mass spectrometry, and non-compartmental pharmacokinetic analyses performed using WinNonlin software.

RESULTS

Between October 2018 and Jun 2020, 58 postmenopausal women, aged 57.9 ± 8.9 years, were randomized and completed the study. Consumption of EP prenylflavonoids was not associated with any significant adverse symptoms, with no changes in hepatic, hematological, and renal parameters observed. The main metabolites detected in sera after ingestion of EP prenylflavonoid capsules were desmethylicaritin, icaritin and icariside II. Icariin and icariside I were below detection levels. Ingestion of EP prenylflavonoids induced a median C_max and AUC_0→∞ for desmethylicaritin of 60.9 nM, and 157.9 nM ×day, respectively; and were associated with higher levels of BSAP (p < 0.05) and a trend (p = 0.068) towards lower levels of TRAF6 in peripheral blood monocytes eight weeks after commencing prenylflavonoid ingestion. Prenylflavonoid metabolites were not detected in the sera of placebo participants.

CONCLUSIONS

Despite the widespread consumption of EP extracts, the safety, mechanisms of action of their bioactive compounds, and therapeutic indications in humans are unknown. Daily consumption of EP prenylflavonoids for six weeks was safe. The predominant metabolite in sera was desmethylicaritin. Rise in prenylflavonoid metabolites was associated with higher levels of the bone anabolic marker BSAP, suggesting potential therapeutic value for post-menopausal osteoporosis.

Current status and distribution of hip fractures among older adults in China

China is a middle-risk country for hip fracture at present, which differs from previous data that it was low-risk. By 2050, the total number of hip fractures in people older than 65 years is predicted to be 1.3 million.

INTRODUCTION

To assess hip fracture incidence in China and examine the heterogeneity of hip fracture in seven geographical regions of China.

METHODS

There were 238,230 hip fracture patients aged 65 years or older from 2013 to 2016 from a large national in-patients database (HQMS) involving 30.6 million hospitalizations. Taking into account the total national hospitalization rate per calendar year, we estimated the incidence of hip fracture per 100,000 residents older than 65 years in China overall and in seven geographical Chinese regions.

RESULTS

The proportion of men and women older than 65 years with hip fractures was 1.00:1.95. Between 2013 and 2016, the number of hip fractures per 100,000 people age 65+ was 278. China has vast territories; the number of hip fractures per 100,000 people over 65 years old was 202 in Northeast China and 374 in Northwest China. Northwest has higher altitude, lower population density, is less developed with lower urbanization than Northeast China which is low altitude, and highly urbanized.

CONCLUSIONS

China should no longer be regarded as a low-risk country for hip fracture. By 2050, the total number of hip fractures in people older than 65 years in China is predicted to be 1.3 million. Higher altitude areas had higher hip fracture rates than lower altitude, higher urbanized areas.

Similar recovery in mobility and quality of life after cemented and cementless hemiarthroplasty for hip fractures

Summary: Patients who suffer hip fractures become immobile with reduced quality of life. Our study aims to assess which cemented or cementless hemiarthroplasty resulted in better mobility or quality-of-life scores. Our retrospective review showed that both have similar scores after matching for age, gender, body mass index and comorbidities. Introduction: Hip fractures have mortality rates of up to 10% at 1 month and 30% at 1 year, as well as significant morbidity. This paper seeks to compare mobility and quality-of-life scores of cemented against uncemented hemiarthroplasty for the displaced neck of femur fractures. Our hypothesis is that there is no difference between the mobility and quality of life of patients treated with cemented or uncemented bipolar hemiarthroplasty. Methods: A retrospective review of registry data on hemiarthroplasties performed in our institution between 2011 and 2019 was conducted. From this dataset, 70 cemented hemiarthroplasties and 238 uncemented hemiarthroplasties were identified. Patients were assessed pre- and post-operatively, at 6 weeks, 3 months, 6 months and 12 months to determine functional recovery through mobility and quality-of-life scores. Results: On propensity score matching, both groups showed a reduction in Parker mobility score from 6.5 to 4 ( p = 0.91), SF-36 physical function scores from 52.5 (cemented) to 30 and 57.5 (uncemented) to 25 ( p = 0.79). Comparing the delta changes from pre-fall after matching, no significant differences were observed. From the analysis of the matched set of data, treatment of neck of femur using cemented or non-cemented bipolar hip prosthesis resulted in similar mobility and quality-of-life scores. Conclusion: In our analysis, there was no statistically significant difference in the mobility or quality-of-life scores of the patients undergoing cemented versus uncemented hemiarthroplasty for the displaced neck of femur fractures.

Assessing the knowledge, attitude and practice of osteoporosis among Singaporean women aged 65 years and above at two SingHealth polyclinics

INTRODUCTION

Singapore has one of the world's most rapidly ageing populations. Osteoporosis is associated with significant morbidity and mortality from hip fractures in the elderly. This pilot study aims to evaluate the knowledge, attitude and practice of osteoporosis among Singaporean women aged ≥ 65 years, and assess barriers to osteoporosis screening.

METHODS

We conducted a cross-sectional survey of 99 English-speaking women aged ≥ 65 years at two SingHealth polyclinics by convenience sampling. The validated Osteoporosis Prevention and Awareness Tool was used to assess their knowledge about osteoporosis prevention and awareness and perceived barriers to osteoporosis screening. Osteoporosis health education was provided, and bone mineral density (BMD) screening was offered to all participants.

RESULTS

The response rate was 91.6%. The majority of the participants (54.5%) had low knowledge of osteoporosis, and only 12.1% had high knowledge scores. Higher education levels were associated with higher knowledge scores (p = 0.018). Although participants with higher knowledge scores were more willing to undergo osteoporosis screening, these findings did not reach statistical significance (p = 0.067). The top reasons for declining BMD testing were misconceptions that lifestyle management is sufficient to prevent osteoporosis, poor awareness and knowledge of the disease, and the perceived high cost of BMD testing.

CONCLUSION

Interventions should focus on osteoporosis education and, eventually, BMD screening for less-educated patients. Health education should rectify common misconceptions of the disease, increase awareness of osteoporosis and improve screening rates.

Menopausal osteoporosis: screening, prevention and treatment

Screening for osteoporosis in women can be based on age and weight, using the Osteoporosis Screening Tool for Asians and assessment for other risk factors such as early menopause, Chinese ethnicity and other secondary factors. Based on the resulting risk profile, women can be triaged to dual-energy X-ray absorptiometry (DEXA) scanning for definite diagnosis of osteoporosis. Treatment should be considered in women with previous fragility fractures, DEXA-diagnosed osteoporosis and high risk of fracture. Exercise improves muscle function, can help prevent falls and has moderate effects on improvements in bone mass. Women should ensure adequate calcium intake and vitamin D. Menopausal hormone therapy (MHT) effectively prevents osteoporosis and fractures, and should be encouraged in those aged < 50 years. For women aged < 60 years, MHT or tibolone can be considered, especially if they have vasomotor or genitourinary symptoms. Risedronate or bisphosphonates may then be reserved for those aged over 60 years.

Current and Future Burden of Hip and Vertebral Fractures in Asia

The increase in the incidence of hip fractures over time disappeared in Northern European and North American Caucasians after 2000, while an increase was observed in Asian countries including Japan until 2010. However, a decrease in the incidence was observed after 2010. The prevalence of vertebral fractures in Asians, Europeans, and American Caucasians is similar, and the incidences of clinical and morphometric vertebral fractures are higher in Asians compared with European Caucasians. The decrease in the incidence of vertebral fractures over time has been observed in Japan. Although the stabilization or decrease over time in the incidence of hip and vertebral fractures have been observed, the number of patients with these fractures is expected to increase rapidly with increases in the elderly population. Multidisciplinary measures to prevent fragility fractures are an urgent issue in Asia at this time. This narrative review outlines the recent trends in incidence and future burdens of hip fracture and vertebral fracture in Asia.

Predictors of circulating vitamin D levels in healthy mid-life Singaporean women

Vitamin D levels were lowest in Indian and Malay compared to Chinese women, and in younger and employed women. The main reason for hypovitaminosis D in study women was deficient cutaneous production. Supplementation in regions with abundant sunshine should consider ethnicity and opportunities for exposure to sunlight.

INTRODUCTION

Little is known about variations in circulating vitamin D levels in multiethnic mid-life women living in communities with year-round sunlight. Our study describes the circulating vitamin D levels and their sociodemographic predictors in mid-life Singaporean women.

METHODS

Prospective cross-sectional study of healthy Singaporean women, age 45-69 years, who were not consuming vitamin D supplements. Total 25-hydroxyvitaminD [25(OH)D], the sum of 25(OH)D₂ and 25(OH)D₃, was measured by liquid chromatography-tandem mass spectrometry.

RESULTS

The analytic cohort of 721 women, mean age 55.2±6.0 (±SD) years, was of Chinese (82%), Indian (11%), and Malay (7%) ethnicity. Their mean 25(OH)D level was 24.8±7.8ng/mL. One-third (32.6%) of the women had deficient 25(OH)D (≤20ng/mL) and 3.5% were severely deficient (<12ng/mL). 25(OH)D₃ comprised 98% of the total circulating 25(OH)D level. Adjusted mean total 25(OH)D levels were significantly lower for women of Indian and Malay (vs Chinese) ethnicity, who were premenopausal or working outside the home. Indian and Malay women had higher odds (adjusted OR 5.58 (95% CI 3.22, 9.87) and 3.83 (95% CI 1.97, 7.57), respectively) of low 25(OH)D compared to Chinese women. Obesity was not an independent predictor of low 25(OH)D, as its strong crude association was confounded by ethnicity. The adjusted odds of low 25(OH)D was reduced in women ≥65 years (adjusted OR 0.37 (95% CI 0.14, 0.87)) compared to those aged 45-55 years.

CONCLUSION

One-third of mid-life Singaporean women were 25(OH)D deficient, and the major independent predictors of deficiency were Indian or Malay ethnicity and younger age. Vitamin D supplementation in mid-life women should be targeted to those with documented deficiency or limited cutaneous production.

Cost-effectiveness of FRAX®-based intervention thresholds for management of osteoporosis in Singaporean women

Cost-effectiveness analysis of FRAX® intervention thresholds (ITs) in Singaporean women > 50 years of age showed that generic alendronate was cost-effective at age-dependent major osteoporotic fracture (MOF) IT from the ages of 65 years for both full and real-world adherence whilst hip fracture (HF) ITs were cost-effective from the ages of 60 and 65 years. Alendronate was cost-effective irrespective of age only at fixed MOF IT of 14% and HF IT of 3.5%.

INTRODUCTION

FRAX®-based intervention thresholds (ITs) were recently identified for osteoporosis management in Singapore. This study aimed to assess the cost-effectiveness of ITs in Singaporean women over the age of 50 years.

METHODS

A validated Markov microsimulation model was used to estimate the lifetime healthcare costs (SGD2019) per quality-adjusted life-years (QALY) of generic alendronate compared with no treatment. Cost-effectiveness of age-dependent FRAX® major osteoporotic fracture (MOF) and hip fracture (HF) ITs was explored. In addition, ITs that would lead to cost-effectiveness were computed. Fracture incidence and cost data were obtained from the Ministry of Health and a previously published Singaporean study. A cost-effectiveness threshold of SGD 62,500/QALY gained was used, based conservatively on 0.7 times the Singapore GDP per capita.

RESULTS

Generic alendronate was shown to be cost-effective at MOF ITs from the ages of 65 years, while HF ITs were cost-effective from the ages of 60 and 65 years, assuming full and real-world adherence, respectively. A 14% MOF and a 3.5% HF ITs were required for alendronate to be cost-effective above 50 years.

CONCLUSION

This study suggests that the treatment of Singaporean women with alendronate is cost-effective at age-dependant FRAX® intervention thresholds at 65 years and older. Furthermore, identifying women at any age above 50 years with a 10-year risk of MOF or HF of 14% or 3.5% would lead to efficient use of resources. Cost-effective access to therapy for patients at high fracture probability based on FRAX® could contribute to reduce the growing burden of osteoporotic fractures in Singapore.

Trends in hip and distal femoral fracture rates in Italy from 2007 to 2017

Osteoporosis-related fractures are a growing public health concern worldwide due to high societal and economic burden. The study aims to assess trends in incidence rates of hip and distal femoral fractures and in the use of anti-osteoporosis drugs in Italy between 2007 and 2017. Patients with hip and distal femoral fractures (ICD-9-CM codes 820.x and 821.x) were identified in the Italian National Hospital Discharge Database while anti-osteoporosis medication data were retrieved from the National Observatory on the Use of Medicines Database. A joinpoint regression analysis was performed to identify the years where the trends in incidence rates of hip and distal femoral fractures changed significantly; the average annual percentage change for the period of observation was estimated. Hospitalizations for femoral fractures were 991,059, of which 91.4% were hip fractures and 76.5% occurred in women. Age-standardized hip fractures rate per 100,000 person-years decreased both in women (-8.7%; from 789.9 in 2007 to 721.5 in 2017) and in men (-4.3%; from 423.9 to 405.6), while the rate of distal femoral fractures increased by 23.9% in women (from 67.78 to 83.95) and 22.7% in men (from 27.76 to 34.06). These changes were associated with an increment in the use of anti-osteoporosis drugs from 2007 to 2011 (from 9.1 to 12.4 DDD/1000 inhabitants/day), followed by a plateau in the period 2012-2017. The use of bisphosphonates increased progressively from 2007 to 2010 (from 8.2 to 10.5 DDD/1000 inhabitants/day), followed by a plateau and then decreased from 2015 onwards. The decreasing trend of hip fractures could be related to a major intake of anti-osteoporosis medications while the increment of distal femoral fractures might be due to population aging and to the use of bisphosphonates and denosumab. Further research is needed to identify and implement interventions to prevent hip and distal femoral fractures.

Ethnic Differences in Bone Microarchitecture

PURPOSE OF THE REVIEW

The aim of this review is to briefly introduce updates in global fracture epidemiology and then to highlight recent contributions to understanding ethnic differences in bone density, geometry and microarchitecture and consider how these might contribute to differences in fracture risk. The review focuses on studies using peripheral quantitative computed tomography techniques.

RECENT FINDINGS

Recent studies have contributed to our understanding of the differences in fracture incidence both between countries, as well as between ethnic groups living within the same country. In terms of understanding the reasons for ethnic differences in fracture incidence, advanced imaging techniques continue to increase our understanding, though there remain relatively few studies. It is a priority to continue to understand the epidemiology, and changes in the patterns of, fracture, as well as the underlying phenotypic and biological reasons for the ethnic differences which are observed.

Bone mineral density reference values in Singaporean adults and comparisons for osteoporosis establishment - The Yishun Study

Background

While there have been studies in Singapore on the prevalence and economic burden of osteoporotic hip fracture, there is a severe lack of reference data on bone mineral density and prevalence of osteoporosis. The purpose of this study is to establish the reference values for BMD and compare prevalence of osteoporotic conditions using other available reference values so as to better understand the status of bone health in Singaporean adults.

Methods

We carried out a population-based cross-sectional study using dual-energy x-ray absorptiometry (Hologic Discovery Wi) to measure the bone mineral density of Singaporean adults aged ≥21 years. A total of 542 participants were recruited from the large north-eastern residential town of Yishun. We computed T- scores (denoted by T_SG) for each individual in the study. Similar diagnoses were also done based on T-scores provided by the densitometer (T_DXA), NHANES database (T_NHANES), and China (T_CHN), and the differences in prevalence compared. We then compared the concordance between T_SG and T_DXA in the classification of osteoporosis. Osteoporosis was defined according to criteria by the World Health Organization (WHO).

Results

Peak lumbar spine BMD was 1.093 ± 0.168 g/cm² in women, and 1.041 ± 0.098 g/cm² for men. Peak whole-body BMD was 1.193 ± 0.93 g/cm² in women at, and 1.224 ± 0.112 g/cm² for men. Prevalence of osteoporosis based on lumbar spine was 9.3% in postmenopausal women, and 0.7% in men after 50 years of age. The percentage difference in prevalence range from 60.5–163.6%, when using reference values from T_DXA, T_NHANES, and T_CHN. Comparing diagnosis using T_DXA and T_SG cut-off values, 28 versus 15 women were diagnosed as osteoporotic respectively.  The kappa statistics was 0.81 for women and 0.85 for men.

Conclusion: Our study shows that T-scores provided by DXA manufacturer over-diagnosed osteoporosis in Singaporeans, and the prevalence of osteoporotic conditions is not accurately represented. This over-diagnosis may result in unnecessary treatment in some individuals.

Incidence of and trends in hip fracture among adults in urban China: A nationwide retrospective cohort study

BACKGROUND

Hip fracture is a public health concern because of its considerable morbidity, excess mortality, great risk of disability, and high societal healthcare costs. China has the largest population of older people in the world and is experiencing rapid population aging and facing great challenges from an increasing number of hip fractures. However, few studies reported the epidemiology, especially at a national level. We aimed to evaluate trends in hip fracture incidence and associated costs for hospitalization in China.

METHODS AND FINDINGS

We conducted a population-based study using data between 2012 and 2016 from the national databases of Urban Employee Basic Medical Insurance and Urban Resident Basic Medical Insurance in China, covering about 480 million residents. Data from around 102.56 million participants aged 55 years and older during the study period were analyzed. A total of 190,560 incident hip fracture patients (mean age 77.05 years, standard deviation 8.94; 63.99% female) were identified. Primary outcomes included the age- and sex-specific incidences of hip fracture. Associated annual costs for hospitalization were also calculated. Incidence was described as per 100,000 person-years at risk, and 95% confidence intervals were computed assuming a Poisson distribution. Hip fracture incidence overall in China did not increase during the study period despite rapid population aging. Incidence per 100,000 was 180.72 (95% CI 137.16, 224.28; P < 0.001) in 2012 and 177.13 (95% CI 139.93, 214.33; P < 0.001) in 2016 for females, and 121.86 (95% CI 97.30, 146.42; P < 0.001) in 2012 and 99.15 (95% CI 81.31, 116.99; P < 0.001) in 2016 for males. For both sexes, declines in hip fracture incidence were observed in patients aged 65 years and older, although incidence was relatively stable in younger patients. However, the total absolute number of hip fractures in those 55 years and older increased about 4-fold. The total costs for hospitalization showed a steep rise from US$60 million to US$380 million over the study period. Costs for hospitalization per patient increased about 1.59-fold, from US$4,300 in 2012 to US$6,840 in 2016. The main limitation of the study was the unavailability of data on imaging information to adjudicate cases of hip fracture.

CONCLUSIONS

Our results show that hip fracture incidence among patients aged 55 and over in China reached a plateau between 2012 and 2016. However, the absolute number of hip fractures and associated medical costs for hospitalization increased rapidly because of population aging.

Comparison of the Osteoporosis Self-Assessment Tool for Asians and the fracture risk assessment tool - FRAX to identify densitometric defined osteoporosis: A discriminatory value analysis in a multi-ethnic female population in Southeast Asia

Objectives

The accuracy of FRAX® as a screening tool to identify osteoporosis and how it compares with tools such as Osteoporosis Self-Assessment Tool for Asians (OSTA), in Southeast Asian women has so far been unexplored. We aimed to determine the FRAX® thresholds that accurately identify densitometric osteoporosis and to compare its performance with that of OSTA for this purpose.

Methods

Singaporean postmenopausal women (n = 1056) were evaluated. FRAX® Major Osteoporotic Fracture Probability (MOFP), Hip Fracture Probability (HFP) scores, and OSTA indices were calculated. Receiver operating characteristic (ROC) curves were constructed and via the Youden index, the optimal cut-off points of balanced sensitivity and specificity for dual energy X-ray absorptiometry (DXA)-defined osteoporosis were identified and the performance characteristics were compared.

Results

A FRAX® MOFP threshold of ≥3.7% had sensitivity, specificity, positive predictive value and negative predictive value of 0.78 (0.73–0.83), 0.63 (0.59–0.66), 0.4 (0.36–0.44), and 0.9 (0.87–0.92), respectively in identifying osteoporosis. The corresponding values for a HFP threshold of ≥0.6% were 0.85 (0.80–0.89), 0.58 (0.55–0.62), 0.39 (0.35–0.43), and 0.92 (0.9–0.94) and that for an OSTA index cut-off of ≤ −1.2 were 0.76 (0.70–0.81), 0.74 (0.71–0.77), 0.48 (0.43–0.54), and 0.91 (0.88–0.93). The area under the ROC curves were 82.8% (79.9%–85.6%), 77.6% (74.2%–81%), and 79.6% (76.5%–82.8%) for OSTA, MOFP, and HFP thresholds respectively.

Conclusions

FRAX® and OSTA perform comparably in identifying osteoporosis in our population. OSTA has only 2 parameters and may be simpler to use. However, FRAX® may also have a role in primary screening to identify the postmenopausal woman to be referred for DXA scanning and may help facilitate fracture risk reduction discussions with the patient.

Risk Factors and Trends Associated With Mortality Among Adults With Hip Fracture in Singapore

IMPORTANCE

Examining trends in mortality following hip fracture and its associated factors is important for population health surveillance and for developing preventive interventions.

OBJECTIVE

To examine temporal trends in, and risk factors associated with, mortality following hip fracture over 18 years in Singapore.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, population-based cohort study included men and women aged 50 years and older admitted to Singapore hospitals for first hip fracture identified and followed up from 2000 to 2017. Demographic information, fracture type, and Charlson Comorbidity Index (CCI) score were retrieved from nationwide claims data, and mortality data were from the National Death Registry. Data were analyzed from August 2018 to December 2019.

MAIN OUTCOMES AND MEASURES

Adjusted hazard ratios (aHRs) and their 95% confidence intervals were estimated using Cox proportional hazards regression. Kaplan-Meier life table methods were used to calculate survival following the hip fracture on a cohort basis. The crude survival over time since fracture was compared by sex, age group, ethnicity, CCI, and fracture type. Standardized mortality ratios (SMRs) were calculated using all-cause mortality obtained from Singapore population life tables.

RESULTS

Among 36 082 first inpatient admissions for hip fractures (mean [SD] patient age, 78.2 [10.1] years; 24 902 [69.0%] female; 30 348 [84.1%] Chinese, 2863 [7.9%] Malay, 1778 [4.9%] Indian, and 1093 [3.0%] other ethnicity), elevated rates of mortality were observed for male sex (aHR, 1.46; 95% CI, 1.41-1.52), Malay ethnicity (aHR, 1.23; 95% CI, 1.15-1.30 vs Chinese ethnicity), older age (aHR, 5.20; 95% CI, 4.27-6.34 for age ≥85 years vs 50-54 years), high CCI score (aHR, 3.62; 95% CI, 3.42-3.84 for CCI ≥6 vs CCI of 0), trochanteric fractures (aHR, 1.11; 95% CI, 1.06-1.16 vs cervical fractures), and earlier cohorts (aHR, 0.59; 95% CI, 0.56-0.62 for 2012-2017 vs 2000-2005). Absolute mortality decreased significantly over time: by 21% in 2006 to 2011 and by 40% in 2012 to 2017, compared with 2000 to 2005. On long-term follow-up, differences in survival associated with sex and ethnicity tended to diminish, whereas differences associated with older age, higher CCI score, and trochanteric fractures increased. In the first year after fracture, reductions in SMR were observed comparing the periods 2013 to 2016 with 2003 to 2007 in women (SMR, 2.05; 95% CI, 1.91-2.20 vs SMR, 2.54; 95% CI, 2.39-2.70, respectively) but not among men (SMR, 3.28; 95% CI, 3.04-3.54 vs SMR, 3.42; 95% CI, 3.18-3.68, respectively).

CONCLUSIONS AND RELEVANCE

Malay ethnicity, older age, male sex, prefracture comorbidity, and trochanteric fractures were independently associated with increased risk of death, identifying population groups that could be targeted for intervention strategies. The improvement in relative mortality for women but not men suggests the need to develop interventions that improve mortality outcomes for men.

Secular Trends of Hip Fractures in Lebanon, 2006 to 2017: Implications for Clinical Practice and Public Health Policy in the Middle East Region

Country-specific hip fracture incidence rates (IRs) and longevity allow the Fracture Risk Assessment Tool (FRAX) to be adapted to individual countries. Secular trends can affect tool calibration. Data on hip fracture IRs in the Middle East is scarce, and long-term secular trend studies are nonexistent. Using the Ministry of Public Health hip fracture registry, we calculated age- and sex-specific hip fracture IRs in Lebanon, from 2006 to 2017, among individuals aged ≥50 years. We used Kendall's tau-b (τb) test to determine the correlation between time and hip fracture IRs, and calculated both the annual % change in IRs and the % change in IR compared to the baseline period (2006 to 2008). The registry recorded 6985 hip fractures, 74% at the femoral neck, 23% intertrochanteric, and 3% subtrochanteric. Men constituted 32% of the population, and were significantly younger than women (76.5 ± 11.0 years versus 77.7 ± 10.3 years; p < 0.001). Annual overall IRs, per 100,000, ranged from 126.6 in 2014 to 213.2 in 2017 in women, and 61.4 in 2015 to 111.7 in 2017 in men. The average women to men IR ratio was 1.8 (range, 1.5 to 2.1). IRs steadily increased with age, and IR ratios increased in parallel in both sexes, with a steeper and earlier rise (by 5 years) in women. Data showed a consistent decline in hip fracture IRs starting in 2006 in women, and in 2009 in men. There was a significant negative correlation between time (2006 to 2014) and hip fracture IRs in women (τb = -0.611, p = 0.022) but not in men (τb = -0.444, p = 0.095). The steady decrease in IRs reversed after 2015 in both sexes. This long-term data on secular trends in the Middle East is novel and consistent with worldwide changes in hip fracture rates. The impact of such changes on national FRAX-derived estimates is unclear, should be assessed, and may necessitate an update in the FRAX Lebanon calculator. © 2019 American Society for Bone and Mineral Research.

The health and economic burden of osteoporotic fractures in Singapore and the potential impact of increasing treatment rates through more pharmacological options

PURPOSE

This study aims to estimate the health and economic burden of osteoporosis in Singapore from 2017 to 2035, and to quantify the impact of increasing the treatment rate of osteoporosis.

METHODS

Population forecast data of women and men aged 50 and above in Singapore from 2017 to 2035 was used along with prevalence rates of osteoporosis to project the osteoporosis population over time. The population projections by sex and age group were used along with osteoporotic fracture incidence rates by fracture type (hip, vertebral, other), and average direct and indirect costs per case to forecast the number of fractures, the total direct health care costs, and the total indirect costs due to fractures in Singapore. Data on treatment rates and effects were used to model the health and economic impact of increasing treatment rate of osteoporosis, using different hypothetical levels.

RESULTS

Between 2017 and 2035, the incidence of osteoporotic fractures is projected to increase from 15,267 to 24,104 (a 57.9% increase) F 10,717 to 17,225 (a 60.7% increase) and M 4550 to 6878 (a 51.2% increase). The total economic burden (including direct costs and indirect costs to society) associated with these fractures is estimated at S$183.5 million in 2017 and is forecasted to grow to S$289.6 million by 2035. However, increasing the treatment rate for osteoporosis could avert up to 29,096 fractures over the forecast period (2017-2035), generating cumulative total cost savings of up to S$330.6 million.

CONCLUSION

Efforts to improve the detection, diagnosis, and treatment of osteoporosis are necessary to reduce the growing clinical, economic, and societal burden of fractures in Singapore.

Ethnic differences in bone mineral density among midlife women in a multi-ethnic Southeast Asian cohort

Chinese Singaporean middle-aged women have significantly lower femoral neck bone mineral density and higher lumbar spine bone mineral density than Malays and Indians, after adjustment for age, body mass index, and height.

PURPOSE

Information regarding mediators of differences in bone mineral density (BMD) among Asian ethnicities are limited. Since the majority of hip fractures are predicted to be from Asia, differences in BMD in Asian ethnicities require further exploration. We compared BMD among the Chinese, Malay, or Indian ethnicities in Singapore, aiming to identify potential mediators for the observed differences.

METHODS

BMD of 1201 women aged 45-69 years was measured by dual-energy X-ray absorptiometry. We examined the associations between ethnicity and BMD at both sites, before and after adjusting for potential mediators measured using standardized questionnaires and validated performance tests.

RESULTS

Chinese women had significantly lower femoral neck BMD than Malay and Indian women. Of the more than 20 variables examined, age, body mass index, and height accounted for almost all the observed ethnic differences in femoral neck BMD between Chinese and Malays. However, Indian women still retained 0.047 g/cm² (95% CI, 0.024, 0.071) higher femoral neck BMD after adjustment, suggesting that additional factors may contribute to the increased BMD in Indians. Although no crude ethnic differences in lumbar spine BMD were observed, adjusted regression model unmasked ethnic differences, wherein Chinese women had 0.061(95% CI, - 0.095, 0.026) and 0.065 (95% CI, - 0.091, 0.038) g/cm² higher lumbar spine BMD compared to Malay and Indian women, respectively.

CONCLUSION

BMD in middle-aged Asian women differ by ethnicity and site. Particular attention should be paid to underweight women of Chinese ethnic origin, who may be at highest risk of osteoporosis at the femoral neck and hence hip fractures.