The Problem of Osteoporotic Hip Fracture in Australia

8/4/2019 The Problem of Osteoporotic Hip Fracture in Australia

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bu

lletin

76

Bulletin 76 March 2010

Te problem of osteoporotichip fracture in Australia

Key points

eage-adjustedincidencerateofosteoporotichipfractureinAustraliadecreasedoverthe10yearsto200607,by14%amongmalesandby20%amongfemales.However,theactualnumberofcasescontinuedtoincreaseinbothsexesduetopopulationgrowthandageing.

erewereanestimated16,518osteoporotichipfracturesamongAustraliansaged40yearsoroverin200607(175per100,000persons).Almostthree-quartersoftheseoccurredinfemales,whoonaveragewereaged83years(comparedwith81yearsformales).

Around1in9peoplehospitalisedwiththeprincipaldiagnosisofosteoporotichipfracturein200607weredischargedtoaresidentialagedcareservice,wherethishadnotpreviouslybeentheirplaceofresidence.

AboriginalandTorresStraitIslanderAustraliansweremuchmorelikelythanotherAustralianstobehospitalisedforanosteoporotichipfracture.eywerealsoonaveragemuchyoungeratthetimeoftheirfracture.

Osteoporosisandosteoporoticfracturescanbepreventedthroughlifestylechangesandbytakingactiontoreducetheriskoffalls.

Malesinparticularmaybenetfromincreasedattentiontohipfractureprevention.

Contents

Key points ......................... ........................... ............................ ............................ ........................... ............................ ............................ .... 1

Introduction ......................... ............................ ............................ ........................... ............................ ............................ ........................... 2

Osteoporotic hip ractures in 200607 .......................... ............................ ........................... ............................ ........................... .............. 5

Trends .......................................................................................................................................................................................................14

Preventing osteoporotic hip ractures........................ ........................... ............................ ........................... ............................ ................ 20

Conclusions ........................... ............................ ............................ ........................... ............................ ............................ ......................... 21

Appendix 1: Methods and data sources .......................... ............................ ........................... ............................ ........................... ............ 22

Appendix 2: Data tables .......................... ........................... ............................ ........................... ............................ ............................ ....... 26

Abbreviations ....................... ............................ ............................ ........................... ............................ ............................ ......................... 27

Reerences ........................ ........................... ............................ ............................ ........................... ............................ ............................ .. 28

Acknowledgments ......................... ........................... ............................ ............................ ........................... ............................ ................ 29


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Teproblemofosteoporo

tichipfractureinAustralia

2

Introduction

Everyday,morethan40Australiansbreaktheirhip.Mostareaged65yearsorover,andmorethanhalfareaged85orover.Virtuallyallofthesepeoplewillbeadmittedtohospital,andmostwillhavesomekindofsurgery.Twopeoplewilldieinthehospital,andatleastfourwillneedtogointoaresidentialagedcarefacility,eitherwhiletheyrecoverorpermanently.Ayearlater,lessthanhalfofthoseoriginal40peoplewillbeabletowalkaswellastheydidbeforethefracture,andanothersixorsevenwillhavedied.

OsteoporotichipfracturesareaconsiderableburdenonAustraliansandtheAustralianhealthsystem.Becausetheyaremorecommoninolderpeople,theageingofthe

Australianpopulationmeansthatovertimemorepeoplewillbeatriskofhavingahipfracture.Despitethis,however,theincidencerateofosteoporotichipfractureisfalling.

isbulletinpresentsthelatestdataontheincidenceofosteoporotichipfractureinAustralia,aswellaskeyconsequencesofthefracturesuchassurgery,placementinaresidentialagedcarefacilityanddeath.Informationaboutrecenttrendsinosteoporotichipfractureincidenceandvariationacrossthepopulationisalsopresented.

What is an osteoporotic hip fracture?

Ahipfractureisabreakoccurringatthetopofthethighbone(femur),nearthehip(Figure1).Inapersonwithhealthybones,astrongforceisusuallyneededtocausea

fracture.Butsomediseasesandconditionscanmakebonesfragile,sothatafracturecanoccurwithasmallamountofforceforexample,afallfromastandingheightorless.istypeoffractureiscalledaminimaltraumafracture.

Figure 1: Bones o the hip and sites o hip racture

Osteoporosisisaconditionwherethebonesweakenandlosetheirstructuralintegrity.Itismostcommoninolderfemalesbutalsoaectsmales.Peoplewhohaveosteoporosis

areathighriskofminimaltraumafractures,whicharethereforesometimescalledosteoporoticfractures.etermosteoporotichipfractureisusedinthisreporttomeanahipfracturethathasoccurredwitharelativelysmallamountofforce.


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Althoughosteoporoticfracturescanoccuranywhereinthebody,theyoccurmorefrequentlyatcertainsites,suchasthehip,pelvis,spine,wristandforearm.Hipfracturesaregenerallymoreseriousanddebilitatingthanfracturesatothersites.eyaredividedintothreesubtypesdependingonwherethethighbonebreaks:femoralneckfracture,pertrochantericfractureandsubtrochantericfracture(Figure1).

Causes and risk factors

Mostosteoporotichipfracturesresultfromafall(Cummings&Melton2002;Kannusetal.2005;Reginsteretal.2005).Othersarecausedwhenthehipstrikes(orisstruckby)asolidobjectforexample,collidingwithatable.Sometimesthefractureoccurswithout

obvioustrauma,whenanordinaryactivitymayputstrainonabone(suchaswhengettingupfromachair).isismorelikelytohappeninpeoplewithsevereosteoporosis.

Risk actors or alls

Riskfactorsforfallsmaybeintrinsic(factorsrelatedtotheindividual)orextrinsic(factorsrelatingtoapersonsenvironment).Intrinsicriskfactorsincludeproblemswithvision,muscleweakness,poorbalance,olderage,cognitiveimpairment,ahistoryoffalling,fearoffalling,useofmedicationscausingdrowsinessorconfusionandconditionsaectingbonestructure(suchasosteoporosis)(Stevens&Olson2000).Extrinsicriskfactorsincludetrippinghazards(suchasunevenground,looserugsorclutter),wetorslipperysurfaces,

slipperyfootwear,poorlightingandlackofhandrailsonstairs(AIHW2008a;Kanisetal.2004;OsteoporosisAustralia2006;Stevens&Olson2000).

Risk actors or osteoporosis

emodiableriskfactorsforosteoporosisincludecalciumandvitaminDdeciencies,physicalinactivity,smokingandbeingsubstantiallyunderweight.Non-modiableriskfactorsincludeafamilyhistoryofthecondition,olderageandgeneticpredisposition.Certaindiseasesandconditionsalsoincreasetheriskofosteoporosis,eitherasadirectcomplicationofthediseaseorasaside-eectofthemedicationusedtomanageit(AIHW2008a).eseincluderheumatoidarthritis,chronickidneydisease,eatingdisorders,

coeliacdiseaseandasthma.

Other risk actors or hip racture

Factorsthatincreasetheriskofhipfractureindependentlyofanyeectonosteoporosisandfallsincludeahistoryofcorticosteroiduseandpreviousminimaltraumafractures.Peoplewhohavehadaminimaltraumafractureareatincreasedriskofsubsequentfractures,aneectknownasthefracturecascade.DatafromtheDubboOsteoporosisEpidemiologyStudyshowthattheincreaseinriskpersistsforupto10years,andthat40%ofwomenand60%ofmenwillexperienceasecondfracturewithinthisperiod(Centeretal.2007)


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Consequences

Hipfracturescauseconsiderablefunctionalimpairmentandnearlyalwaysrequiresurgery.eymayalsogiverisetoongoingpainanddisabilitylessthan50%ofindividualsregaintheirpre-fracturewalkingabilityoneyearaftersuchfractures(Osnesetal.2004;Sernbo&Johnell1993).Qualityoflifemaybesubstantiallyreduced,particularlyinrelationtophysicalfunction,socialfunctionandroleresponsibilities(Hallbergetal.2004;Randelletal.2000;Willigetal.2001).eabilitytoundertakeactivitiesofdailylivingmaybecompromisedand,forsome,thismaynecessitateamovefromindependentaccommodationtoaresidentialagedcarefacility,achangethatmayleadtoreducedsocialinteraction,emotionaldistress,reducedself-condenceandlossofdignity(Illinois

CouncilonLongTermCare2008;Osnesetal.2004).Anxietyabouthavinganotherfractureandfearoftheconsequencesoffracture,suchasdependenceandinstitutionalisation,maybeconsiderable(Salkeldetal.2000).Insomecases,thepersonmaydevelopafearoffallingandrestricttheiractivitiestoavoidfurtherfalls.Furthermore,theriskofdeathisraisedforseveralyearsfollowingahipfracture,particularlyinmen(Bliucetal.2009;Farahmandetal.2005;Johnelletal.2004;Piirtolaetal.2008).

Costs

Hipfracturesareexpensivetotreat,withhospitalepisodesforproceduressuchaspartialjointreplacementcostingonaverage$15,500$19,500(Table1).Hipfracturesalsoincurindirectcostsforrehabilitation,outpatientvisitsforfollow-uptreatment,temporaryresidentialagedcarefacilityplacementifrequired,andassistancewithactivitiesofdailylivingathomeduringtherecoveryperiod.Forthosewhosefractureresultsinlong-termfunctionallimitationsordisability,thecostofpermanentresidentialagedcarefacilityplacementorhelptoliveindependentlymaybeconsiderable.

NoAustraliandataontheoverallcostsofhipfracturearecurrentlyavailable.In2000,SteveParrottestimatedthatthetotalannualcosttosocietyintheUKassociatedwithhipfractureswas726million(AU$1,832million)(Parrott2000).isgurerepresentsanexpenditureof31(AU$78)perpersonaged45andover.etotalcostiscomprisedof32%indirecthospitalandambulancecosts,1%inotherhealthservicecostsand67%insocialcarecosts(includingresidentialcareandsocialsupportservicesforthoseathome).


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Table 1: Estimated cost o hospital treatment or osteoporotic hip racture, by sector, 200607Public hospitals Private hospitals

DRG(a)

Number ohip racture

separations(b)Average lengtho stay (days)(c)

Average cost orthis DRG (AU$)(d)

Number ohip racture

separations(b)Average lengtho stay (days)(c)

Average cost orthis DRG (AU$)(d)

I03B 2,775 14.4 19,472 583 16.6 19,100

I03C 1,393 8.8 15,587 480 10.7 17,719

I08A 4,486 14.4 18,743 803 17.7 14,235

I08B 2,844 8.6 11,321 705 10.8 7,128

I78A 1,386 13.9 7,244 196 16.0 6,841

I78B 3,062 4.1 2,182 270 7.7 3,068

(a) DRG = diagnosis related groupa way o classiying hospital admissions into groups with similar clinical conditions and resource usage.

(b) Number o separations or osteoporotic hip racture assigned to this DRG.

(c) Average length o stay associated with separations in previous column.

(d) Average cost or all separations assigned to this DRG.

Note:Data or the top 6 DRGs are presented, accounting or 97% o osteoporotic hip racture separations in 200607.

I03Bhip replacement with complications or uncomplicated revision hip replacement

I03Cuncomplicated hip replacement

I08Aother hip and emur procedures with complications

I08Bother uncomplicated hip and emur procedures

I78Aracture o neck o emur with complications (no procedures)

I78Buncomplicated racture o neck o emur (no procedures)

Source:

AIHW National Hospital Morbidity Database and DoHA 2008.

Osteoporotic hip fractures in 200607

Incidence

erewereanestimated16,518hospitalisationsforosteoporotichipfractureamongAustraliansaged40yearsoroverin200607,equatingto175per100,000persons.Almostthree-quartersofthese(12,006fractures)occurredinfemales.eincidencewas

higheramongfemalesthanmalesacrossallagegroupsexcept4049years,wheretherateinmaleswasaroundtwicethatinfemales(seeAppendix2,TableA2.1).

eaverageageathospitalisationwas81yearsformalesand83yearsforfemales.


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6

0

500

1,000

1,500

2,000

2,500

3,000

FemalesMales

85+808475797074656960645559505445494044

Age

Number per 100,000 population

Note: Persons aged 40 years or over.

Source: AIHW National Hospital Morbidity Database.

Figure 2: Estimated incidence o osteoporotic hip racture, 200607

Fracture site

emostcommonfracturesiterecordedwasneckoffemur,accountingforaround53%ofallcases.Pertrochantericfracturesaccountedforanother43%ofcases,withsubtrochantericfracturestheleastcommonat4%.eseproportionsdidnotvarybetweenmalesandfemales,butdidvarysomewhatbyage,withatendencyforpertrochantericfracturestobecomemorecommonwithage(Figure3).Peoplewithpertrochantericfractureswere83yearsoldonaverage,comparedwith82and81yearsforneckoffemurandsubtrochantericfractures,respectively.


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Per cent

Age

0 10 20 30 40 50 60 70 80 90 100

SubtrochantericPertrochantericNeck of femur

4049

5054

5559

6064

6569

7074

7579

8084

85+

Notes

1. Persons aged 40 years or over.

2. The age groups 4044 years and 4549 years have been combined due to the small number o cases.


Figure 3: Distribution o sites o hip racture, by age, 200607

Events causing ractures

emostcommonlyrecordedexternalcausesofosteoporotichipfracturesin200607werefallonsamelevelfromslipping,trippingandstumbling(38%ofcases),otherfallonsamelevel(21%ofcases)andunspeciedfall (30%ofcases).Fallsfromabedorchairaccountedformostoftheremainingcases(9%),withotherevents(suchascollisionwithanotherperson,ananimalorotherfurniture)makingupjust2%ofthetotal.Recordingofunspeciedfallbecameslightlymorecommonwithage.

Place o occurrence

emajorityoffracturesoccurredatthepersonsplaceofresidence,withalmosthalf(47%)happeninginprivatehomes(Figure4).Afurther32%ofcasesoccurredinresidentialcarefacilities(includingresidentialagedcarefacilitiesandretirementvillages).Inalmost600cases(3%),theplaceofoccurrencewasahealthfacility,suchasahospital,healthcentreoroutpatientclinic.


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0

10

20

30

40

50

UnspeciedOtherStreet orfootpath

Health facilityPublic ortrade area

Aged carefacility

Private home

Place

Per cent

Notes

1. Public or trade areas include shops, oces, train stations, restaur ants, sporting and recreat ional acilities, schools, librari es and places o worship. Other

places include industrial premises, construction sites, arms, prisons, beaches and bushland.



Figure 4: Place o occurrence o osteoporotic hip ractures, 200607

Population variation

Healthstatusanduseofhealthservicesvariesacrossthepopulation.InAustralia,groupswhooftenhaverelativelypoorhealthoraredisadvantagedinrelationtoaccesstohealthservicesincludepeoplelivinginremoteareas,thosewhoaresocioeconomicallydisadvantaged,overseas-bornpersonsandAboriginalandTorresStraitIslanderpeople.eincidenceofosteoporotichipfractureacrosssomeofthesepopulationgroupsisdescribedbelow.

Remoteness

Femaleslivingoutsideofthemajorcitieswereslightlymorelikelytohaveanosteoporotichipfracturecomparedwithfemalesinmajorcities(Table2).Ratesamongmalesdidnotvarysignicantlybyremoteness.oselivinginremoteAustraliatendedtobeyoungeratthetimeoftheirfracture,75yearsformalesand79yearsforfemales,comparedwith81and83yearsformalesandfemales,respectively,innon-remoteareas.


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Table 2: Incidence o osteoporotic hip racture by remoteness, 200607Observed number Expected number(a) Rate ratio(b) (95% confdence interval)

Region Males Females Males Females Males Females

Major cities 2,980 7,989 . . . . 1.00 1.00

Regional Australia 1,449 3,820 1,440 3,558 1.01 (0.96, 1.05) 1.07 (1.05, 1.10)

Remote Australia 63 149 65 132 0.97 (0.78, 1.19) 1.13 (0.98, 1.30)

. . not applicable

(a) Number o cases that would be expected i people in the area experienced the same age- and sex-specifc racture rates as those living in major cities.

(b) Ratio o the number o cases observed to the number expected.

Note:Persons aged 40 years or over.


Socioeconomic disadvantage

erewasasmallbutsignicantdierencebetweentheleastdisadvantagedandsecondmostdisadvantagedgroupsforfemales(Table3).Formales,thoseinthemostdisadvantagedgroupandthemiddlegroupweresignicantlymorelikelytohaveanosteoporotichipfracturethanthoseintheleastdisadvantagedgroup,butagainthedierencesweresmall.However,ageatfracturedidincreasewithdecreasinglevelofdisadvantage.Atthetimeoffracture,maleswereaged79yearsonaverageinthemostdisadvantagedgroupand82yearsonaverageintheleastdisadvantagedgroup.Femaleswereaged82yearsonaverageinthemostdisadvantagedgroupand84yearsonaverageintheleastdisadvantagedgroup.

Table 3: Incidence o osteoporotic hip racture by socioeconomic disadvantage, 200607

Socioeconomiccategory

Obser ved number Expec ted number(a) Rate ratio(b) (95% confdence interval)

Males Females Males Females Males Females

Least disadvantaged 960 2,854 . . . . 1.00 1.00

Second leastdisadvantaged 746 2,079 739 2,047 1.01 (0.95, 1.07) 1.02 (0.98, 1.05)

Middle group 944 2,285 826 2,253 1.14 (1.08, 1.21) 1.01 (0.98, 1.05)

Second mostdisadvantaged 920 2,460 891 2,352 1.03 (0.98, 1.09) 1.05 (1.01, 1.08)

Most disadvantaged 922 2,280 848 2,269 1.09 (1.03, 1.15) 1.01 (0.97, 1.04)

. . not applicable

(a) Number o cases that would be expected i people in each group experienced the same age- and sex-specifc racture rates as people in the least

disadvantaged group.





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Indigenous status

AboriginalandTorresStraitIslanderpeopleweremorelikelytobehospitalisedforanosteoporotichipfracturethanotherAustralians.Inthetwo-yearperiod200507,IndigenousmalesweretwiceaslikelytohaveahipfractureasotherAustralianmales,whereasIndigenousfemaleswere26%morelikelytohaveahipfracturethanotherAustralianfemales(Table4).

IndigenousAustralianswereonaveragemuchyoungerthanotherAustraliansatthetimeoftheirhipfracture,aged65years(comparedwith81years)formalesand74years(comparedwith83years)forfemales.

Table 4: Incidence o osteoporotic hip racture by Indigenous status, 200507

Observed number Expected number(a) Rate ratio(b) (95% confdence interval)

Indigenous status Males Females Males Females Males Females

Other Australians 8,492 22,761 . . . . 1.00 1.00

Indigenous Australians 73 113 35 90 2.01 (1.70, 2.54) 1.26 (1.07, 1.47)

. . not applicable

(a) Number o cases that would be expected i Indigenous people experienced the same age- and sex-specifc racture rates as other Australians.


Notes

1. Data are or New South Wales, Victori a, Queensland, South Australia, Western Australia and public hospitals in the Norther n Territory only, and may not be

representative o other jurisdictions.


3. The group other Australians includes both those indentifed as non-Indigenous and those whose Indigenous status was unknown.


Interventions and outcomes

Treatment provided in hospital

Asinglefracturecangeneratemorethanonediscreteepisodeofcareinhospital(eachknownasaseparation),astheinjuredpersonistransferredbetweenhospitalsandfrom

onetypeofcaretoanother.efulltreatmentforasinglefracturemayberecordedacrossseveralseparationsinthehospitalsdatabase.Becausethedatabasedoesnotincludeanyidentifyinginformation,itisnotpossibletolinkseparationstogethertoexaminetheoveralltreatmentforeachfracture.isanalysisthereforelooksattreatmentsprovidedasaproportionofallhipfractureseparationsandnotasaproportionofallhipfractures.

Notealsothattheanalysisinthissectionreferstohospitalseparationswiththeprincipaldiagnosisofhipfracture.Apersoninitiallyhospitalisedforosteoporotichipfracturemaygenerateanotherseparationwithadierentprincipaldiagnosis,forexample,whentheyaretransferredtoarehabilitationunit.einabilitytolinkindividualseparationstogethermeansthatitisnotpossibletoexaminetheinterventionsandoutcomesofthese

otherseparationsaspartofthisanalysis.


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e16,518osteoporotichipfracturesin200607generated19,611hospitalseparationswiththeprincipaldiagnosisofhipfracture.Surgicalprocedureswerecarriedoutinmorethanthree-quartersoftheseseparations.emostcommonwere:

xationofthefracturedbone(46%ofseparations)thisinvolvesaproceduretoholdtheendsoftheboneinplacetohelpithealcorrectly

primaryorrevisionjointreplacement(28%ofseparations)thersttimeajointreplacementoccursitiscalledaprimaryjointreplacement,andanysubsequentreplacementprocedureonthesamesiteiscalledarevisionjointreplacement.

Jointreplacementwasmostcommoninpeoplewithneckoffemurfractures.reetypesofjointreplacementsurgerycanbeperformedforahipfracture.Hemiarthroplasty

involvesthereplacementoftheheadofthefemur.Partialarthroplastyinvolvespartialreplacementorresurfacingoftheheadofthefemur.Totalarthroplastyinvolvesthereplacementoftheheadofthefemur,aswellasthehipsocket.Hemiarthroplastywasthemostcommontypeofprimaryjointreplacementperformed,accountingfor83%ofsuchprocedures.

Alliedhealthinterventionswerealsofrequentlyprovidedinseparationsforosteoporotichipfracture.Physiotherapy(in78%ofseparations),occupationaltherapy(36%),socialworkanddietetics(each20%)werethemostcommonalliedhealthinterventionsprovided.

Short-term outcomes

Attheconclusionofahospitalepisode,personsmaybetransferredtoanothertypeofcarewithinthesamehospital,movedtoanotherhospitalorhealthservice,dischargedtoaresidentialagedcareservice(asanewresident)ordischargedtotheirusualresidence(whichmayhavebeenaresidentialcarefacilityorwelfareinstitution).Someleavehospitalagainstmedicaladviceandsomedieinhospital.epatternoftheseshort-termoutcomesfortheestimated16,518incidenthipfracturecasesin200607isdescribedbelow.


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2

Discharge to usualresidence 30%

Death 6%

Transfer to otherhealth service 53%

Discharge toresidential care 11%

Notes:


2. The group discharge to usual residence includes those persons who let against medical advice.

3. Only includes separations with the principal diagnosis o hip racture.


Figure 5: Outcomes o hospitalisation or osteoporotic hip racture, 200607

Discharge

Inalmost11%(1,757)ofcases,thepatientwasdischargedtoaresidentialagedcareservicewherethishadnotpreviouslybeentheirplaceofresidence.eaverageageofthesepatientswas86years.Itwasnotpossibletodeterminewhethertheplacementwastemporaryorpermanent.

Injustover30%ofcases,thepersonwasdischargedtotheirusualplaceofresidence,orleftthehospitalagainstmedicaladvice.

In-hospital deaths

erewere1,029people(6%)withtheprincipaldiagnosisofosteoporotichipfracturein200607whodiedinhospital.Maleswerealmosttwiceaslikelytodieasfemales(9%comparedwith5%).eaverageageofthosewhodiedinhospitalwas85years,comparedwith82yearsfortheremainingcases.

Transer to other health care services

Justoverhalf(53%)ofpeoplewiththeprincipaldiagnosisofosteoporotichipfractureweretransferredtootherhealthcareservices.Almostthree-quartersoftheseweretransferredtoanotheracutehospital,andone-quarterweremovedtoanothertypeofcare

withinthesamehospital(forexample,totherehabilitationunit).Asmallproportionweremovedtonon-hospitalhealthcarefacilities.


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Althoughthemajorityofpeopletransferredbetweenorwithinhospitalsaftertheirhipfracturewouldhaveeventuallybeendischarged,theprincipaldiagnosis(thatis,theproblemchieyresponsiblefortheepisodeofcare)recordedfortheirlaterseparationswouldnotnecessarilyhavebeenhipfracture.Forexample,theymaystayinhospitalchieyforrehabilitation,ortheymaybewaitingforaplacetobecomeavailableinanappropriateoutsidecarefacility.Aspreviouslynoted,itisnotpossible,usingthesedata,todeterminetheeventualoutcomeofthesecasesbecausetheseparationscannotbelinkedtotrackindividualsthroughthehospitalsystem.

Hip fracture mortality

Accordingtothecodingrulesusedfordeathsdata,injuriescannotbelistedastheunderlying(primary)causeofdeath.Rather,theconditionoreventleadingtotheinjuryforexample,afallislistedastheunderlyingcauseandtheinjuryasanassociatedcause.Hipfracturewasrecordedasanassociatedcauseof1,448deathsamongpeopleaged40yearsoroverin2006,arateof14deathsper100,000persons.Deathratesweresimilarbetweenthesexes,thoughslightlyhigheramongfemalesintheoldestagegroup(Figure6).

evastmajorityofdeaths(98%)wereofpeopleaged65yearsorover,with63%ofdeathsinpeopleaged85yearsorover.eaverageageatdeathwas87yearsforfemalesand84yearsformales.

Commonunderlyingcausesrecordedinthesecasesincludedcardiovasculardisease(in25%ofdeaths),minimaltraumafalls(24%)andexposuretounspeciedfactor(18%).PreviousinvestigationbytheAIHWNationalInjurySurveillanceUnithasestablishedthatmostdeathsatolderageswithexposuretounspeciedfactorastheunderlyingcauseandafractureasanassociatedcauseprobablyinvolvedafall(Kreisfeld&Harrison2005).

Veryfewdeaths(lessthan0.5%)weretheresultofmajortrauma(suchastransportaccidentsorhighfalls).


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0

50

100

150

200

250

300

FemalesMales

85+808475797074656960645559505445494044

Age

Deaths per 100,000 population


Source: AIHW National Mortality Database.

Figure 6: Deaths with hip racture as an associated cause, 2006

Trends

Incidence

eestimatedincidencerateofosteoporotichipfractureinAustraliaisonthedecline.Overthe10-yearperiod199798to200607,theage-standardisedratefellby14%inmales(from133to114per100,000)andby20%infemales(from246to198)(Figure7;TableA2.2).edecreasesmainlyoccurredamongmalesaged6584yearsandfemalesaged60yearsorover;littlechangewasseeninthe4059yearsagegroup,thoughthenumberofcasesinpeopleofthisagewasrelativelysmall.eaverageageathospitalisationincreasedfrom78to81inmalesandfrom81to83infemales.


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15

0

50

100

150

200

250

300

FemalesMales

200607200506200405200304200203200102200001199900199899199798

Year

Number per 100,000 population

Notes

1. Data have been age-standardised to the Australian population at 30 June 2001.



Figure 7: Trends in osteoporotic hip racture incidence, 199798 to 200607

erateoffracturesatallthreesites(neckoffemur,pertrochantericandsubtrochanteric)

decreasedsignicantlyinfemalesovertheperiod,andtherewasasignicantdecreaseinneckoffemurfracturesinmales.

Number of cases

Althoughtheage-standardisedrateofosteoporotichipfracturehasfallenovertimeinbothsexes,theactualnumberofcaseshascontinuedtoriseasaresultofgrowthofthepopulationatrisk.Ageingofthepopulationhasincreasedthenumberofpeopleaged40yearsoroverby23%overthe10yearperiod,fromalmost7.6millionin1997toover9.3millionin2006.eincreaseamongthoseaged75yearsoroverhasbeenevengreaterat35%(from948,000toalmost1.3million).esepopulationincreaseshaveledtoa

riseinthenumberofosteoporotichipfracturecasesinbothsexesbetween199798and200607,by22%inmalesand7%infemales,or11%overall(Figure8;TableA2.2).


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6

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

FemalesMales

200607200506200405200304200203200102200001199900199899199798

Year

Number of cases



Figure 8: Trends in the number o osteoporotic hip ractures, 199798 to 200607

Interventions and outcomes

Duetochangesincodingovertime,hospitaltreatmentsandmostshort-termoutcomes

wereonlyabletobecomparedfortheperiod200001to200607.In-hospitaldeathwastheonlyoutcomeabletobecomparedforthefulldecadefrom199798to200607.

Treatment provided in hospital

Allied health interventions

Provisionofalliedhealthinterventionsinseparationswiththeprincipaldiagnosisofosteoporotichipfracturesignicantlyincreasedbetween200001and200607,from76%to81%ofseparations.Inparticular,occupationaltherapy,dieteticsandphysiotherapybecamemorecommon(Figure9).


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Year

Per cent

0

10

20

30

40

50

60

70

80

90DieteticsSocial workOccupational therapyPhysiotherapyAny AHI

200607200506200405200304200203200102200001

AHI - allied health intervention

Notes

1. Per cent o osteoporotic hip racture separations (not cases) where the procedure was perormed.



Figure 9: Trends in allied health interventions or osteoporotic hip racture, 200001 to 200607

Joint replacement

Asdescribedearlier,eachfracturecangeneratemorethanonehospitalseparation,andtreatmentmaybeprovidedinanyoftheseseparations.Sometreatments,likephysiotherapy,maybeprovidedmorethanonceforasinglefracture.Othertreatments,likejointreplacement,willonlyoccuronceperfracture,sowecanassumethateachoccurrenceofthesetreatmentscorrespondstoasinglefracture.Inthissituationitispossibletoconsidertreatmentsprovidedasaproportionofallhipfractures.


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0

5

10

15

20

25

30

35

Total arthroplastyPartial arthroplastyHemiarthroplasty

200607200506200405200304200203200102200001

Per cent

Year

Notes

1. Per cent o osteoporotic hip ractures where the procedure was perormed.



Figure 10: Trend in use o joint replacement or osteoporotic hip racture, 200001 to 200607

euseofjointreplacementincreasedslightlybetween200001and200607,from

31.0%to32.4%ofallhipfractures.Hemiarthroplastywasbyfarthemostcommontype,anditsusewasfairlyconstantataround27%ofcases(Figure10).eproportionofcaseswherepartialandtotalarthroplastywereperformedincreasedovertheperiod,from1.1%to1.9%andfrom2.2%to3.5%,respectively.

Short-term outcomes

Discharge to residential aged care services

eproportionofosteoporotichipfracturecaseswherethepatientwastransferredtoaresidentialagedcareservice(asanewresident)fellsignicantlybetween200001and

200607,from12.5%to10.6%.eaverageageofpeopletransferredtoresidentialcarerosesignicantlyovertheperiod,from84.8to85.6years.

In-hospital deaths

eproportionofosteoporotichipfracturesinwhichthepatientdiedinhospitalincreasedslightlybetween199798and200607,from5.8%to6.2%.eaverageageat in-hospitaldeathalsoincreased,from83.7to85.5years.


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Transfer to other health care services

eproportionofpersonswithosteoporotichipfracturethatweretransferredtootherhealthcareservicesincreasedfrom48.5%in200001to53.1%in200607.istrendwaslargelydrivenbyanincreaseinthenumberofpatientstransferredbetweenacutehospitals.

Hip fracture mortality

Overthe10yearsfrom1997to2006,theage-standardisedrateofdeathswithhipfractureasanassociatedcausedecreasedby20.6%amongmales,from18to14deathsper100,000population(Figure11;TableA2.3).edeathrateamongfemalesdecreasedby24.0%,from19to15per100,000.

Duringthisperiod,theproportionofthesedeathsassignedtovariousunderlyingcauseschangedconsiderably.eproportionofdeathswithanunderlyingcauseofaminimaltraumafallrosefrom4%to24%,whiletheproportionwithanunderlyingcauseofexposuretounspeciedfactorfellfrom35%to18%.eproportionofdeathsattributedtocardiovasculardiseasealsodecreased,from34%to25%.ebulkoftheseshiftsoccurredtowardtheendoftheperiod,andarelikelytoberelatedtochangesindeathcerticationpracticesinAustraliainrecentyears,aswellasincreasedawarenessamongmedicalprofessionalsofosteoporosisandassociatedhipfractures.

AccordingtotheAIHWNationalInjurySurveillanceUnit,intheearlypartofthedecade,mosthipfracturedeathswerecertiedbyamedicalpractitionerratherthanbyacoroner,whichwascontrarytotheusualpracticeforotherinjurydeaths(Kreisfeld&Newson2006).Overthepastfewyearssomejurisdictionshavechangedtheircoronialreferralrequirements;consequentlymorehipfracturedeathswouldnowbecertiedbyacoroner.ismayhaveledtomoreinformationbeingmadeavailableaboutthecircumstancesofdeath,thusreducingthenumberofdeathsbeingassignedtheunderlyingcauseofexposuretounspeciedfactor.


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Year

Deaths per 100,000 population

0

5

10

15

20

25

2006200520042003200220012000199919981997

FemalesMales

Notes

1. Rates have been age-standardised to the Australian population at 30 June 2001.



Figure 11: Hip racture as an associated cause o death, 1997 to 2006

Preventing osteoporotic hip fractures

epreventionofosteoporotichipfracturesliesintwomainstrategies:topreventthemostcommoneventresultinginfracturenamely,fallsandtodecreasetheriskofthebonebreakingifafallshouldoccur,mainlybypreventingorappropriatelymanagingosteoporosis.

Preventing falls

Aspreviouslynoted,manythingscanleadtofalls.Preventionthereforemayinclude: exercisestoimprovebalanceandposture

areviewofmedications,assomemaycausedizzinessordrowsiness

attendingafallspreventionclass

repairing/removingtriphazardsandinstallingsafetyrailsandnon-slipoorstripsasappropriate

avoidingexcessivealcoholintake.

MoreinformationaboutpreventingfallsisavailablefromtheAustralianGovernmentDepartmentofHealthandAgeing(www.health.gov.au),HealthInsite(www.healthinsite.

gov.au)orOsteoporosisAustralia(www.osteoporosis.org.auorfreecall1800242141).


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Preventing and managing osteoporosis

Preventionofosteoporosiscentresaroundlifestylefactors:ahealthydietandregularexercise.Adietthatincorporatessucientamountsofcalciumisvital,asthismineralhelpsbuildandmaintainbonedensity.Calciumisfoundindairyproducts,shwithediblebonesand,insmalleramounts,inplantfoodssuchasgreenleafyvegetables.

Judiciousexposuretosunlight(keepinginmindtheriskofskincancer)isnecessaryforproducingvitaminD,whichenablesthebodytousecalcium.DietaryintakesofcalciumandvitaminDlevelscanbeincreasedthroughsupplementationifnecessary.Regularweight-bearingexercisealsohelpstostrengthenthebonesandmusclesand,combinedwithabalanceddiet,willhelptoachieveandmaintainahealthyweight.

esefactorsareimportantthroughoutlife,butparticularlyinchildhoodandadolescence,whenlargeamountsofboneareformed.Bonemassanddensityaregenerallymaintainedataconstantlevelduringearly-tomid-adulthood,butbegintodeclinefromaroundtheageof50years.Achievingahighbonedensityearlyinlifemeansthatthisprogressivelossdoesnotrapidlyreachosteoporoticlevels.

Forthosewhohaveosteoporosis,managementstrategiesincorporateboththepositivelifestylechoicesnotedabove,aswellastheuseofmedicationsthatcanhelpmaintainorimprovebonedensity.Bisphosphonatemedications(forexample,alendronateandrisedronate)reducetherateofbonelossbyslowingthereabsorptionofmineralsfromthebones.SucientlevelsofcalciumandvitaminDarealsoneededandcombination

bisphosphonatesarenowavailablethatincorporateacalciumand/orvitaminDsupplement.Morerecently,medicationsthatdirectlypromoteboneformationhavebecomeavailable:strontiumranelateandparathyroidhormone.

Fallpreventionmeasuresarealsoanimportantaspectofmanagingosteoporosis.

Conclusions

eage-standardisedincidenceofhipfractureinAustraliaisfalling,thoughpopulation

growthmeansthattheactualnumberofcasescontinuestorise.ehipfracturedeathratehasalsodecreasedsignicantlyinbothsexessince1997.

isbulletinhighlightsseveralimportantdierencesinhipfractureincidencebetweenmalesandfemales:

ehipfractureincidencerateamongmaleshasdecreasedmoreslowlythanamongfemalesinthelastdecade.

IndigenousAustralianmalesaretwiceaslikelytohaveahipfractureasotherAustralianmales,whereasthecorrespondinggapbetweenIndigenousandotherAustralianfemalesisonly26%.

Malesinthemostdisadvantagedandmiddlesocioeconomicgroupsaremorelikely

tohaveahipfracturethanthoseintheleastdisadvantagedgroup,butnosuchsocioeconomic-relateddierencesareseenamongfemales.


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Inallpopulationgroups,malesaresignicantlyyoungerthanfemalesatthetimeoftheirhipfracture.

In-hospitalmortalityfollowinghipfractureismorecommoninmalesthaninfemales.

eseresults,inconjunctionwithotherAustraliandatashowingthatmalesarelesslikelythanfemalestoundergobonedensitometrytesting(Ewaldetal.2009)ortotakeactiontomanagediagnosedosteoporosis(AIHW2008c),suggestthatmalesshouldbeafocusfortargetedhipfracturepreventioneortsinthefuture.

Appendix 1: Methods and data sources

Methods

Virtuallyallhipfracturesrequirehospitalcare.erefore,hospitalseparationsdatacanbereliablyusedtoestimatetheincidenceofosteoporotichipfractureinAustralia.DatawereobtainedfromtheAIHWNationalHospitalMorbidityDatabase(NHMD)forthenancialyears199798to200607.Casesofosteoporotichipfracturewereidentiedbyselectingseparationsofpersonsaged40yearsoroverwheretheprincipaldiagnosiswasfractureoftheupperfemurandtheexternalcausecodeindicatedalowtraumaevent.

Apersonmayhavemorethanoneseparationdirectlyfollowingonfromtheirinitialadmissiontohospitalforagivenfractureforexample,whentheyaretransferredtoanotherhospitalforfurthertreatment.Toestimateincidence,recordswherethepatienthadbeentransferredinfromanotherhospitalwereexcludedtominimisedouble-counting.However,allrecordswereincludedinanalysisofhospitalproceduresandinterventions,asthesemayoccuratanypointduringthetimespentinhospital.ismethodisconsistentwiththatusedbytheNationalInjurySurveillanceUnit(Kreisfeld&Newson2006).

OutcomesofthestayinhospitalwerederivedfromthemodeofseparationrecordedintheNHMD.Outcomesconsideredweredeath,dischargetoaresidentialagedcarefacility(wherethepersonwasnotpreviouslyresident),transferstoothermedicalcare,andother

(includingdischargetousualresidence).RelevantICD-10-AMcodesfordiagnosesandproceduresarelistedinTableA1.1.

Simplelinearregressionswereappliedtoexaminetrendsovertime(Boyle&Parkin1991).

Comparing diferent populations

eStatisticalLocalAreacodeforeachseparationwasmappedtotheAustralianStandardGeographicClassicationRemotenessStructureandtotheIndexofDisadvantage,asdenedbytheAustralianBureauofStatistics(ABS2004;2005).ismappingallowsassignmentoftheremotenessandrelativelevelofdisadvantageofthepersonsareaofresidence.


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Foranalysisbyremoteness,Australiawasdividedintothreeregions:majorcities,regionalAustraliaandremoteAustralia.eincidenceofosteoporotichipfractureineachregionwasindirectlyage-standardisedtothemajorcitiesregionandrateratioscalculated.

Foranalysisbylevelofdisadvantage,comparisonsweremadebetweenthemostandleastdisadvantagedfthsofthepopulation.erateswereindirectlyage-standardisedtotheleastdisadvantagedfthandrateratioscalculated.

ForanalysisofvariationbyIndigenousstatus,datafortwonancialyearswerecombinedinordertoobtainasucientsamplesizeforreliableestimates.ereliabilityofIndigenousidenticationvariesacrossjurisdictions;theresultspresentedhereexcludetheAustralianCapitalTerritory,TasmaniaandprivatehospitalsintheNorthernTerritory

astheIndigenousidentierwasnotconsideredsucientlyreliableforanalysisinthesejurisdictions.

Forallthreeanalyses,95%condenceintervalsfortherateratioswerecalculatedusingthesquareroottransformmethod(AIHW2008a;Breslow&Day1987).

Counting deaths

Forthisanalysis,recordsofdeathsofpersonsaged40yearsoroverwherehipfracturewasrecordedasanassociatedcauseofdeathwereextractedfromtheAIHWNationalMortalityDatabase.eunderlyingcausesofdeathwerebroadlygroupedasminimal

traumafalls,exposuretounspeciedfactor,otherexternalcauses,cardiovasculardisease,respiratorydisease,cancerandothercauses.

Deathsregisteredinthecalendaryears1997to2006wereanalysed.Simplelinearregressionswereappliedtoexaminetrendsindeathratesandassignmentofunderlyingcausesofdeath(Boyle&Parkin1991).

Data sources

edatausedinthisstudywerederivedfromtheNHMDandtheNationalMortalityDatabase.eanalysiswasrestrictedtopeopleaged40yearsandover,aslessthan1%ofminimaltraumahipfracturesoccurinpeopleyoungerthan40years.

The National Hospital Morbidity Database

eNHMD,maintainedattheAIHW,coversalmostallpublicandprivatehospitalsinAustralia(AIHW2008b).edataaresuppliedtotheAIHWbystateandterritoryhealthauthoritiesandtheDepartmentofVeteransAairsusingstandarddenitionscontainedintheNationalHealthDataDictionary.einformationintheNHMDisnotperson-based;insteaditrelatestoepisodesofcareinahospital,knownashospitalseparations.Anindividualattendinghospitalmorethanoncewillgeneratemultiplerecordswithinthedatabase.

InformationavailablewithintheNHMDincludesdatesandmodesofadmissionandseparation,diagnoses,proceduresperformed,andpatientdemographicsincludingage,sex,


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Indigenousstatusandareaofresidence.DiagnosesandproceduresarecodedbasedontheInternationalStatisticalClassicationofDiseasesandRelatedHealthProblems,ClinicalModication,9thRevisionfrom199394to199899andAustralianModication,10thRevisionfrom199899onwards(ICD-9-CMandICD-10-AM).

The National Mortality Database

eAIHWNationalMortalityDatabasecontainsinformationaboutdeathsregisteredinAustralia.Deathsareregisteredbythestateandterritoryregistrarsofbirths,deathsandmarriages.einformationisprovidedtotheAustralianBureauofStatisticsforcodingofthecauseofdeathandcompilationintoaggregatestatistics.

Informationavailableincludessex,ageatdeath,dateofdeath,areaofusualresidence,Indigenousstatus,countryofbirthandcauseofdeath.ecauseofdeathiscertiedbythemedicalpractitionerorthecoronerandcodedusingtheInternationalClassicationofDiseases,9thRevisionfrom1979to1996and10thRevisionfrom1997(ICD-9andICD-10).Multiplecausesofdeath,includingtheunderlyingandallassociatedcausesofdeathrecordedonthedeathcerticate,areavailablefrom1997onwards.


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Table A1.1: ICD codes used or data extraction and analysisICD-10 or ICD-10-AM code ICD-9 or ICD-9-CM code Defnition

Injury

S72.0 820.0, 820.1, 820.8, 820.9 Fracture o neck o emur

S72.1 820.20, 820.21, 820.30, 820.31 Pertrochanteric racture

S72.2 820.22, 820.32 Subtrochanteric racture

External cause o injury

W00 E888(a) Fall on same level involving ice and snow

W01 E885 Fall on same level rom slipping, tripping and stumbling

W03 E886Other all on same level due to collision with, or pushing by, anotherperson

W04 E888(a) Fall while being carried or supported by other personsW05 E884.6 Fall involving wheelchair

W06 E884.4 Fall involving bed

W07 E884.2 Fall involving chair

W08 E884.9 Fall involving other urniture

W18 E884.7, E888(a) Other all on same level

W19 E888(a) Unspecifed all

W22 E917.2, E917.9(a) Striking against or struck by other objects

W50 E917.9(a) Hit, struck, kicked, twisted, bitten or scratched by another person

W51 E917.9(a) Striking against or bumped into by another person

W54.8 E906.0 Struck by dog

Procedures andinterventions

47522-00 81.52 Hemiarthroplasty o hip

49315-00 81.52 Partial arthroplasty o hip

49318-00 81.51 Total arthroplasty o hip, unilateral

49319-00 81.51 Total arthroplasty o hip, bilateral

95550-00 Not comparable Allied health intervention, dietetics

95550-01 Not comparable Allied health intervention, social work

95550-02 Not comparable Allied health intervention, occupational therapy

95550-03 Not comparable Allied health intervention, physiotherapy

(a) The ICD-10 coding system provides fner detail or alls compared with ICD-9. Separation o ICD-9 codes which span multiple ICD-10 categories is notpossible.


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Appendix 2: Data tables

Table A2.1: Estimated incidence o osteoporotic hip racture, by age, 200607

Males Females Persons

Age Number Rate(a) Number Rate(a) Number Rate(a)

4044 26 3 11 1 37 2

4549 43 6 26 3 69 5

5054 58 8 89 13 147 11

5559 92 15 155 24 247 19

6064 161 31 219 43 380 37

6569 201 51 442 110 643 817074 374 122 725 219 1,099 172

7579 689 272 1,599 535 2,288 415

8084 1,133 670 2,827 1,175 3,960 966

85+ 1,735 1,589 5,913 2,642 7,648 2,297

40+ (crude rate) 4,512 99 12,006 247 16,518 175

(a) Number o cases per 100,000 population within age group.



Table A2.2: Estimated incidence o osteoporotic hip racture, 199798 to 200607

Males Females Persons

Year Number Rate(a) Number Rate(a) Number Rate(a)

199798 3,706 133 11,186 246 14,892 204

199899 3,547 123 11,124 236 14,671 193

199900 3,906 131 11,406 234 15,312 194

200001 3,918 126 11,348 223 15,266 186

200102 3,978 122 11,714 222 15,692 184

200203 4,005 119 11,705 217 15,710 179

200304 4,113 119 11,913 216 16,026 177

200405 4,197 116 11,650 205 15,847 170

200506 4,367 116 11,755 200 16,122 167

200607 4,512 114 12,006 198 16,518 164

(a) Number o cases per 100,000 population, age-standardised to the Australian population at 30 June 2001.




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Table A2.3: Deaths with hip racture as an associated cause o death, 1997 to 2006Males Females Persons

Year Number Rate(a) Number Rate(a) Number Rate(a)

1997 445 18 880 19 1,325 19

1998 504 19 882 19 1,386 19

1999 522 19 927 19 1,449 19

2000 502 18 832 16 1,334 17

2001 507 17 904 17 1,411 17

2002 599 19 1076 19 1,675 19

2003 551 17 916 16 1,467 16

2004 528 16 941 16 1,469 16

2005 546 16 955 16 1,501 16

2006 521 14 927 15 1,448 14

(a) Number o deaths per 100,000 population, age-standardised to the Australian population at 30 June 2001.



Abbreviations

ABS AustralianBureauofStatistics

AHI alliedhealthintervention

AIHW AustralianInstituteofHealthandWelfare

DRG diagnosisrelatedgroup

ICD-9 InternationalClassicationofDiseases,9thRevision

ICD-9-CM InternationalStatisticalClassicationofDiseasesandRelatedHealthProblems,9thRevision,ClinicalModication

ICD-10 InternationalClassicationofDiseases,10thRevision

ICD-10-AM InternationalStatisticalClassicationofDiseasesandRelatedHealthProblems,10thRevision,AustralianModication

NHMD NationalHospitalMorbidityDatabase


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Acknowledgments

isbulletinwaspreparedbyTracyDixonandAliceCrispoftheAIHWNational

CentreforMonitoringArthritisandMusculoskeletalConditions.

eauthorsthankcolleaguesDrKuldeepBhatia,GeorgeBodilsen,SallyBullock,RobertvanderHoek,SusanKillion,DrPaulMagnusandDrIndraniPieris-Caldwellfortheirhelpfulcommentsondraftsofthisbulletin.MembersoftheNationalCentresSteeringCommittee/DataWorkingGroupalsoprovidedvaluableinput.

isprojectwasfundedbytheAustralianGovernmentDepartmentofHealthandAgeing.


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Australian Institute o Health and Welare 2010

This work is copyright. Apart rom any use as permitted under the Copyright Act 1968, no part may be reproduced

without prior written permission rom the Australian Institute o Health and Welare. Requests and enquiriesconcerning reproduction and rights should be directed to the Head, Media and Communications Unit, Australian

Institute o Health and Welare, GPO Box 570, Canberra ACT 2601.

This publication is part o the Australian Institute o Health and Welares Bulletin series. A complete list o the

Institutes publications is available on the Institutes website .

Cat. no. AUS 121

ISSN 1446-9820

ISBN 978 1 74024 992 8

Suggested citation

AIHW (Australian Institute o Health and Welare) 2010. The problem o osteoporotic hip racture in Australia.

Bulletin no. 76. Cat. no. AUS 121. Canberra: AIHW.

Australian Institute o Health and Welare

Board Chair Director

Hon. Peter Collins, AM, QC Penny Allbon

Any enquiries or comments on this publication should be directed to:

Australian Institute o Health and Welare

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Documents

The Problem of Osteoporotic Hip Fracture in Australia