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Fragility Fractures and Imminent Fracture Risk in Hong Kong: One of the Cities with Longest Life Expectancies

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Fragility Fractures and Imminent Fracture Risk in Hong Kong: One of the Cities with Longest Life Expectancies Archives of Osteoporosis (2019) 14:104 https://doi.org/10.1007/s11657-019-0648-4 ORIGINAL ARTICLE Fragility fractures and imminent fracture risk in Hong Kong: one of the cities with longest life expectancies Ronald Man Yeung Wong1 & Wing Tung Ho1 & Law Sheung Wai1 & Wilson Li2 & Wai Wang Chau1 & Kwoon-Ho Simon Chow1 & Wing-Hoi Cheung1 Received: 6 May 2019 /Accepted: 27 August 2019 # International Osteoporosis Foundation and National Osteoporosis Foundation 2019 Abstract Introduction Imminent fracture risk, or fractures within 2 years of an initial fracture, is a pressing issue worldwide. Hong Kong is a city with one of the longest life expectancies. The concern of fragility fractures and the imminent risk of a subsequent fracture is becoming a top priority. The objective of this study was to present the epidemiology of incident fragility fractures of all public acute hospitals and the imminent risk of a subsequent fracture in Hong Kong. Methodology This was a retrospective population-based analysis. Patient records from all acute hospitals in Hong Kong from 1 January 2004 to 31 December 2018 were retrieved for patients ≥ 50 years of age with hip, distal radius, or proximal humerus fractures. Secondary fractures and falls were identified in the subsequent 5 years. Post hoc analysis in recent 2013–2018 period was performed. Overall survival (re-fracture incidence) on age subgroups using Kaplan survival analysis and variables was compared using the log-rank test. Cox proportional hazard regressions, obtaining the hazard ratios (HR) and their respective 95% confidence intervals (CI), were used. Results There is an overall increasing trend of fragility fractures (hip, distal radius, proximal humerus) from 5596 in 2004 to 8465 in 2018. The average cumulative imminent risk of fractures from recent 5 years is 3.87% at 1 year and 6.50% at 2 years. 49.5% of the patients with a secondary fracture occurred within 2 years since the initial major fragility fracture. Post hoc analysis in recent 2013–2018 period (N = 7039) showed male patients were 1.21 times more likely to have further fractures with time (HR = 1.21 (1.02, 1.45), p = 0.03) compared with female patients. Patients over age 95 were 2.01 times higher than patients of age under 75 to have further fracture over time. Conclusions Following an initial fracture, prompt treatment strategies should be adopted to avoid imminent risk of fractures. This window of opportunity in the first 2 years is a golden period to treat osteoporosis and prevent falls. Our post hoc analysis has shown that male patients and patients older than 95 are at even higher risk. Clinicians and allied healthcare professionals should be alert on these patients. Keywords Imminent fracture risk . Osteoporotic fracture . Osteoporosis . Fragility fractures . Sarcopenia Introduction study from the Swedish database has shown that the cumula- tive subsequent fracture incidence at 12 months was 7.1% and Imminent fracture risk, or fractures within 2 years of an initial at 24 months was 12.0% [3]. Johansson et al. also showed that fracture, is a pressing issue worldwide [1, 2]. In fact, a recent at 1 year after a major osteoporotic fracture, the risk of a second fracture was 2.7-fold higher than population risk com- pared with 1.4-fold at 10 years [2]. These findings highlight * Wing-Hoi Cheung the importance of early intervention after an initial fracture [email protected] with dedicated and coordinated services. Currently, an esti- 1 mated 200 million people are affected by osteoporosis and Department of Orthopaedics and Traumatology, The Chinese the lifetime fracture risk reaches up to 40% [4, 5]. With the University of Hong Kong, 5/F, Lui Che Woo Clinical Sciences Building, Shatin, New Territories, Hong Kong SAR, China aging population, the incidence of fragility fractures is expect- ed to increase yearly, posing a significant healthcare burden to 2 Department of Orthopaedics & Traumatology, Queen Elizabeth Hospital, Yau Ma Tei, Hong Kong SAR, China our society. In fact, 9 million osteoporotic fractures occurred 104 Page 2 of 11 Arch Osteoporos (2019) 14:104 worldwide in year 2000 [6], but a large healthcare gap still Methods exists leading to imminent risk of further fractures. In a previ- ous study of 905 women and 337 men with an initial fracture, Study design it was shown that 41% of women and 52% of men had an imminent fracture within 2 years [7]. It has also been reported This was a retrospective population-based analysis. Patient re- that secondary fractures cost 1.6–6.2 times higher with costs cords from all acute hospitals in Hong Kong from 1 January ranging from USD 3844 to USD 27,730 compared with those 2004 to 31 December 2018 were retrieved from the Hospital without a prior fracture [8]. This implies the healthcare costs Authority Clinical Data Analysis and Reporting System of a secondary fracture are mainly concentrated during this (CDARS, Hospital Authority, Hong Kong) [15, 16]. Patients window period. It is therefore important to increase awareness ≥ 50 years of age with hip, distal radius, or proximal humerus and enhance international network alliances to further im- fractures (major osteoporotic fractures) were identified using the prove current public and health policies. International Classification of Diseases, Ninth Revision, Clinical Hong Kong is a city with one of the longest life expec- Modification (ICD-9-CM) codes for hip fracture (820.02, 820.3, tancies worldwide. In 2017, the life expectancy for males 820.8, 820.9, 820.12, 820.20, 820.22, 820.32), proximal humer- is 81.9 years of age and for females 87.6 years of age, us fracture (812.02, 812.03, 812.09, 812.12, 812.13, 812.19), increasing steadily [9]. The concern of fragility fractures and distal radius fracture (13.41, 813.42, 813.44, 813.52, and the imminent risk of a subsequent fracture is becom- 813.54). Patients with motor vehicle accident or pathological ing a top priority. The current cost of a single hip fracture fractures were excluded. In Hong Kong, hip, distal radius, and in Hong Kong is USD 8831.9, with projected direct cost proximal humerus fractures are well captured in the database. of USD 84.7 million in total in 2018 [10]. It is well The public hospital system in Hong Kong uses the Clinical established that the single most predictive factor of a sec- Management System (CMS) and the diagnosis is entered. This ondary fracture is a previous one [1]. Apart from osteo- allows retrieval of all records through the CDARS regardless of porosis, evidence has also shown that patients with fragil- in-patient or out-patient [15, 16], and more than 90% of the ity fractures often have low muscle mass and function as Hong Kong population is captured [17]. The positive predictive well, which has been postulated as a cause of further falls value (PPV) in using ICD-9 does for CDARS database search [11]. Major pitfalls in the healthcare system include low has also been shown to be 100% for fracture hip, wrist, and rates of bone mineral density (BMD) testing, low drug humerus [17]. However, although 98% of hip fractures are ad- initiation, poor drug compliance, and low follow-up rates mitted to public hospitals instead of private hospitals and cap- leading to falls and fractures. Therefore, establishment of tured [10], there is currently no available data on the sensitivity Fracture Liaison Services (FLS) to improve patient out- and completeness in capturing all distal radius and proximal comes has been adopted in many countries [12], but is humerus fractures in Hong Kong. still not yet available in many hospitals. Thus, the rate Vertebral fractures were not retrieved initially because it is of imminent fractures remains high currently. In a recent well documented that approximately two-thirds are not diag- study in the USA, it was shown that among 337,561 nosed and therefore, diagnostic coding would strongly under- women, cumulative risk of subsequent fractures was estimate the prevalence and thereby be inaccurate [18, 19]. 10% and 18% at 1 and 2 years, respectively [13]. Incident fracture, mean age, gender, and length of stay in acute The risk of a secondary fracture decreases over time [2], hospital were recorded for 15 years (2004 to 2018). Secondary and therefore capturing imminent fractures in the first 2 years fractures and falls and deaths of patients were further identi- provides a window of opportunity in preventing a large num- fied from each year from 2004 to 2013 (follow-up of 5 years ber of secondary fractures. It is well known that osteoporotic each year) projecting up to 5 years using the Hospital fractures lead to high morbidity and mortality [14] and there- Authority CDARS. A 5-year follow-up is used as it is a com- fore a call-to-action worldwide is needed to stop further risk. mon time-point in fracture studies [20]. Imminent fractures Currently, there is a lack of published data in Asian cities on were defined as the first 2 years. To eliminate risk of double imminent risk of fractures. Presenting the imminent fracture counting, secondary fracture was excluded if it was at the risk in regions with long life expectancies and in Asia would same site as the initial fracture [2]. The Strengthening the prove to be important in strengthening the knowledge of this Reporting of Observational Studies in Epidemiology global threat. It is also crucial for representative parties inter- (STROBE) guidelines were used in preparation of this nationally to share and provide treatment goals and strategies manuscript. for our patients. The objective of this study was to present the epidemiology Data analysis of incident fractures and the imminent risk of a subsequent fracture in Hong Kong.
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