Osteoporos Int DOI 10.1007/s00198-015-3162-6

ORIGINAL ARTICLE

A survey of outcomes and management of patients post fragility fractures in China O. Wang 1 & Y. Hu 2 & S. Gong 3 & Q. Xue 4 & Z. Deng 5 & L. Wang 6 & H. Liu 7 & H. Tang 8 & X. Guo 9 & J. Chen 10 & X. Jia 11 & Y. Xu 12 & L. Lan 13 & C. Lei 14 & H. Dong 15 & G. Yuan 16 & Q. Fu 17 & Y. Wei 18 & W. Xia 1 & L. Xu 19

Received: 26 February 2015 / Accepted: 30 April 2015 # International Osteoporosis Foundation and National Osteoporosis Foundation 2015

Abstract Summary We found that the fragility hip and vertebral fractures caused excess mortality rates in this Chinese female population, which was unexpectedly lower than those in western countries and other Asian countries. This was the first nationwide survey relating to postfracture outcomes conducted among Chinese population in Mainland China. Introduction This study aimed to investigate the mortality, self-care ability, diagnosis, and medication treatment of osteoporosis following fragility hip and vertebral fractures through a nationwide survey among female patients aged over 50 in Mainland China.

Methods This was a multicenter, retrospective cohort study based on medical chart review and patient questionnaire. Female patients aged 50 or older admitted for low-trauma hip or vertebral fractures and discharged from Jan 1, 2008 to Dec 31, 2012 were followed. Results Total of 1151 subjects of hip fracture and 842 subjects of vertebral fracture were included. The mean age was 73.4± 10.0, and the median of duration from index fracture to interview was 2.6 years. The overall 1-year, 2-year, 3-year, 4-year, and 5-year cumulative mortality rates were 3.5, 7.0, 11.2, 13.1, and 16.9 %, respectively. The first year mortality rates in hip (3.8 %, 95% CI 3.3–4.4 %) and vertebral fracture (3.1 %, 95% CI 2.5–3.7 %) were significantly higher than that

* W. Xia [email protected]

9

Union Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China

* L. Xu [email protected]

10

People’s Hospital of Zhejiang, Hangzhou, Zhejiang, China

11

Wuyi First People’s Hospital, Wuyi, Zhejiang, China

12

The Second Hospital Affiliated to Suzhou University, Suzhou, Jiangsu, China

13

Wuzhong People’s Hospital of Suzhou, Wuzhong, Jiangsu, China

14

General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China

15

Shijingshan Teaching Hospital of Capital Medical University, Beijing Shijingshan Hospital, Beijing, China

16

Xinzhou District People’s Hospital of Wuhan, Wuhan, Hubei, China

17

Shengjing Hospital of China Medical University, Shenyang, Liaoning, China

1

Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Beijing, China

2

Banan People’s Hospital of Chongqing, Chongqing, China

3

Shenyang Orthopedics Hospital, Shenyang, Liaoning, China

4

Beijing Hospital, Beijing, China

5

The Second Hospital Affiliated to Chongqing Medical University, Chongqing, China

6

The 309th Hospital of PLA, Beijing, China

18

Yanchi Hospital, Yanchi, Ningxia, China

7

Beijing Jishuitan Hospital, Beijing, China

19

8

Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China

Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing 100730, China

Osteoporos Int

in the general population (1.6 %). Impaired self-care ability was observed in 33.2, 40.6, and 23.8 % of overall, hip fracture, and vertebral fracture group, respectively. The overall diagnosis rate of osteoporosis was 56.8 %, and bone mineral density (BMD) measurement had never been conducted in 42.0 % among these women. After the index fracture, 69.6 % of them received supplements and/or anti-osteoporotic medications, among which 39.6 % only received calcium with/without vitamin D supplementation. Conclusions The osteoporotic hip and vertebral fractures caused excess mortality rates in this population of Mainland China. The current diagnosis and medical treatment following the fragility fractures is still insufficient in Mainland China. Keywords China . Diagnosis . Fragility fracture . Mortality . Self-care ability . Treatment

Introduction There has been a rapid increase in the average age of the world’s population, especially in the developing countries [1]. Osteoporosis, as well as osteoporotic fractures, has become a significant public health problem since the prevalence of osteoporosis increases markedly with aging. Substantial variations have been noted in the prevalence or incidence of osteoporosis and fragility fractures. For example, Cooper C et al. had reported increasing rate in Asia in contrast to stabilizing or even decreasing rates in other regions [2]. The annual age- and sex-adjusted hip fracture incidence had been stable in the UK since 1992 and even decreased by 2.5 % in 1996– 2005 according to data from the USA. It has been estimated that at least 50 % of hip fractures worldwide will occur in Asia by 2050. In Mainland China, the average overall prevalence of osteoporosis based on nationwide surveys was 13.0 % (6.6– 19.3 %) according to the review published in 2009 [3]. Xia et al. had reported that the age-adjusted rates of hip fracture over 50-year-old increased 2.76-fold in women and 1.61-fold in men from 2002 to 2006 compared to 1990–1992 in Beijing, China [4]. It has been confirmed that the osteoporotic fractures cause excess mortality and disability in daily living. The one-year excess mortality rates after hip fractures ranged from 8.4 to 36.0 %, and those after vertebral fractures ranged from 1.9 to 42.0 %, with notable geographic and ethnic variations [5–14]. Disability after hip fractures has been well established in previous studies. Thwaites et al. from New Zealand reported that only 7.2 % of the patients were independent in walking at discharge and less than 50 % regained their pre-fracture level of mobility at 1 year [15]. More than 60 % of the patients needed help with activities of showering, dressing, and toileting at discharge, while still more than 30 % of them needed help at 12 months. Case-control study also confirmed

excess disability in daily living associated with hip fracture, with an expectation of 26 additional cases with more disability per 100 persons during a 2-year follow-up compared with controls of community-dwelling aging people matched on age, sex, and walking ability at baseline [16]. Vertebral fractures are also associated with decreased quality of life, increasing rates of back pain and kyphosis [17–19]. However, most of the data come from western countries, and there were only two nationwide studies focusing on the mortality after hip fractures in Chinese populations (one from Singapore [20] and one from Taiwan [21]). No data from nationwide survey of mortality and disability after osteoporotic fractures in Mainland China are available. The present study aimed (1) to investigate the mortality and functional outcomes following osteoporotic hip and vertebral fractures and (2) to evaluate the diagnosis and medical treatment of osteoporosis after hospitalization for fragility hip and vertebral fractures through a nationwide survey among female patients aged ≥50 years in Mainland China.

Methods Study population This was a retrospective patient survey carried out in 18 hospitals of seven provinces/cities from northeast (Shenyang), north (Beijing), northwest (Ningxia), southwest (Chongqing), south (Wuhan), and east (Suzhou and Hangzhou) China. One tertiary-level hospital and one secondary-level hospital in each city were included except for five tertiary-level and one secondary-level hospitals in Beijing since there are much more tertiary-level hospitals in Beijing than in other areas. The 10th Revision of the International Classification of Diseases (ICD-10) system was used in 17 municipal hospitals, and the 9th revision (ICD-9) was used in one military hospital for coding discharge diagnoses. The inclusion criteria were as follows: (1) female patients aged 50 years or older; (2) hospitalization for low-trauma hip fracture or vertebroplasty for fragility vertebral fractures; (3) the index fracture (the fracture qualifying the subject for enrollment) was identified by the first discharge diagnosis coded as 820.0, 820.2, and 820.8 for hip fractures and 805.2–805.5 and 806.2–806.5 for vertebral fractures in ICD-9; or S72.002, S72.0051, S72.101, and S72.1051 for hip fractures and S22.001, S22.002, S22.011, S22.1051, S32.001, S32.00, and S32.0151 for vertebral fractures in ICD-10, respectively; and (4) discharged from January 1, 2008 to December 31, 2012. A convenience sampling was used in this study with 50 % of the subjects consecutively selected forwardly from January 1, 2008 and 50 % subjects consecutively selected backwardly from December 31, 2012. The female patient would be excluded if she had both a hip fracture and vertebral fracture at the same time. Each patient

Osteoporos Int

would be included only once for the index fracture which happened earlier during the sampling period. If she was hospitalized for the second or more times for re-fracture during that sampling period, the data would be only recorded as her follow-up data. Complete data of up to 120 subjects were provided from each hospital. Approval was obtained from participating hospital IRB committees. The patients or their first-degree relatives were informed about the study protocol and enrolled in the study with their agreement.

judged by the interview physicians. The death occurred after discharge would be judged as directly related to the fracture only if it was caused by infection and cardiac or pulmonary failure due to fracture-induced long-term bedridden status. Otherwise, it would be judged as Bnot associated^ or Bunknown,^ especially in those with relative past history before the index fracture.

Data collection

The annual mortality and follow-up mortality were calculated by Kaplan-Meier curves, and Cox proportional hazards regression was used for analyzing the effects of risk factors including age, duration of hospitalization, prior fracture history, level of hospital, diagnosis of osteoporosis, medication treatment for osteoporosis before and after index fracture, refracture after index fracture for overall survival, survival in hip fracture group, and survival in vertebral fracture group. The type of index fracture was also included in the model for overall survival. Chi-square test or Fisher’s exact test was used for categorical variables. Non-paired t test was used for normally distributed numerical variables, and nonparametric test was used for non-normal numerical variables. Other outcome variables including self-care ability (independent self-care and self-care disability), re-fracture after the index fracture (yes/ no), and medication treatment for osteoporosis after index fracture were transformed to binary variables. Logistic regression analyses were applied to identify independent risk factors associated with them. To evaluate the impact of establishment of guidelines on primary osteoporosis in 2011 by Chinese Society of Osteoporosis and Bone Mineral Research (CSOBMR) [22], the time of index fracture (before 2011 and after 2011) was added as one of the covariates in the logistic analyses for diagnosis of osteoporosis, BMD measurement, and medical treatment. A two-sided p value less than 0.05 (p

A survey of outcomes and management of patients post fragility fractures in China.

We found that the fragility hip and vertebral fractures caused excess mortality rates in this Chinese female population, which was unexpectedly lower ...
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