Article

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

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Abstract

Despite an increase in absolute numbers, the age-standardized incidence of hip fractures in Singapore declined in the period 2000 to 2017. Among the three major ethnic groups, Chinese women had the highest fracture rates but were the only group to show a temporal decline. Introduction A study published in 2001 predicted a 30–50% increase in Singapore hip fracture incidence rates over the ensuing 30 years. To test that prediction, we examined the incidence of hip fracture in Singapore from 2000 to 2017. Methods We carried out a population-based study of hip fractures among Singapore residents aged ≥ 50 years. National medical insurance claims data were used to identify admissions with a primary discharge diagnosis of hip fracture. Age-adjusted rates, based on the age distribution of the Singapore population of 2000, were analyzed separately by sex and ethnicity (Chinese, Malay, or Indian). Results Over the 18-year study period, 36,082 first hip fractures were recorded. Total hip fracture admissions increased from 1487 to 2729 fractures/year in the years 2000 to 2017. Despite this absolute increase, age-adjusted fracture rates declined, with an average annual change of − 4.3 (95% CI − 5.0, − 3.5) and − 1.1 (95% CI − 1.7, − 0.5) fractures/100,000/year for women and men respectively. Chinese women had 1.4- and 1.9-fold higher age-adjusted rates than Malay and Indian women: 264 (95% CI 260, 267) versus 185 (95% CI 176, 193) and 141 (95% CI 132, 150) fractures/100,000/year, respectively. Despite their higher fracture rates, Chinese women were the only ethnic group exhibiting a decline, most evident in those ≥ 85 years, in age-adjusted fracture rate of − 5.3 (95% CI − 6.0, − 4.5) fractures/100,000/year. Conclusion Although the absolute number of fractures increased, steep drops in elderly Chinese women drove a reduction in overall age-adjusted hip fracture rates. Increases in the older population will lead to a rise in total number of hip fractures, requiring budgetary planning and new preventive strategies.

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... Rates are two-to threefold higher for every additional five years of age. (6) For Singapore women, absolute fracture numbers have increased by 3.3% (95% confidence interval [CI] 3.0-3.6) annually, leading to an absolute average increase of 46.3 (95% CI [41][42][43][44][45][46][47][48][49][50][51][52] fractures/ year (Fig. 1a). ...
... annually, leading to an absolute average increase of 46.3 (95% CI [41][42][43][44][45][46][47][48][49][50][51][52] fractures/ year (Fig. 1a). (6) However, a decreasing trend was observed when fractures rates were age-adjusted and expressed per 100,000 population (Fig. 1b), indicating the influence of ageing on the increase in absolute numbers. Following a hip fracture in Singapore, the risk of death is double (standardised mortality ratio 2.05) that of the age-matched general population in the first year, and this excess death risk was still present more than a decade later. ...
... In Singapore, approximately 8% of midlife women have osteoporosis (10) and two-thirds of all hip fractures occur in women ( Fig. 1). (6) screening, with many guidelines recommending DEXA scanning for women aged above 65 years. (3,11) Opportunistic screening of midlife women for osteoporosis For women aged below 65 years, most countries screen for osteoporosis based on an opportunistic case-finding strategy, (14) wherein a formal clinical risk assessment tool is used to identify those at high risk of osteoporosis. ...
Article
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.
... Osteoporotic hip fracture incidence rates have risen 1.5-fold for men and 5-fold for women since the 1960s (8). Between 2000 to 2017, there is a 3.5% increase in hip-fracture related hospitalization, translating to an average of 72 additional hip fractures related hospitalisation per 100,000 per year (9). In 2017, the estimated incidence of osteoporotic fracture was 15,267 case, (25.5% hip fracture, 29.1% vertebral fracture, and 45.4% other fractures), and it is estimated to increase by 58% by 2035 (10). ...
... While there have been studies in Singapore on the prevalence and economic burden of osteoporotic hip fracture (8,9,11), there is a severe lack of reference data on BMD and prevalence of osteoporosis. A study published in 2002, found Singapore men had 10% and 5% lower bone mineral density in the lumbar spine (LS) and femoral neck, respectively when compared to mean BMD peak of Caucasian reference database (8). ...
... Additionally, there are also ethnic variations within Singapore. Singaporean Chinese women have a 40% higher hip fracture rates compared to local Malay and 90% higher than Indian women (9). Post-hoc secondary analysis of covariance our data showed that there were no signi cant differences in LS BMD among the three major ethnic group for both men (p=0.692) and women (p=0.802). ...
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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 TSG) for each individual in the study. Similar diagnoses were also done based on T-scores provided by the densitometer (TDXA), NHANES database (TNHANES), and China (TCHN), and the differences in prevalence compared. We then compared the concordance between TSG and TDXA 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±0.168g/cm2 in women, and 1.041±0.098g/cm2 for men. Peak whole-body BMD was 1.193±0.93g/cm2 in women at, and 1.224±0.112g/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 TDXA, TNHANES, and TCHN. Comparing diagnosis using TDXA and TSG 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.
... Osteoporotic hip fracture incidence rates have risen 1.5-fold for men and 5-fold for women since the 1960s (8). Between 2000 to 2017, there is a 3.5% increase in hip-fracture related hospitalization, translating to an average of 72 additional hip fractures related hospitalisation per 100,000 per year (9). In 2017, the estimated incidence of osteoporotic fracture was 15,267 case, (25.5% hip fracture, 29.1% vertebral fracture, and 45.4% other fractures), and it is estimated to increase by 58% by 2035 (10). ...
... While there have been studies in Singapore on the prevalence and economic burden of osteoporotic hip fracture (8,9,11), there is a severe lack of reference data on BMD and prevalence of osteoporosis. A study published in 2002, found Singapore men had 10% and 5% lower bone mineral density in the lumbar spine (LS) and femoral neck, respectively when compared to mean BMD peak of Caucasian reference database (8). ...
... Additionally, there are also ethnic variations within Singapore. Singaporean Chinese women have a 40% higher hip fracture rates compared to local Malay and 90% higher than Indian women (9). Post-hoc secondary analysis of covariance our data showed that there were no signi cant differences in LS BMD among the three major ethnic group for both men (p=0.692) and women (p=0.802). ...
Preprint
Full-text available
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 ³ 21 years. A total of 542 participants were recruited from the large north-eastern residential town of Yishun. We computed T- scores (denoted by TSG) for each individual in the study. Similar diagnoses were also done based on T-scores provided by the densitometer (TDXA), NHANES database (TNHANES), and China (TCHN), and the differences in prevalence compared. We then compared the concordance between TSG and TDXA 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±0.168g/cm² in women, and 1.041±0.098g/cm² for men. Peak whole-body BMD was 1.193±0.93g/cm2 in women at, and 1.224±0.112g/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 TDXA, TNHANES, and TCHN. Comparing diagnosis using TDXA and TSG 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.
... Osteoporotic hip fracture incidence rates have risen 1.5-fold for men and 5-fold for women since the 1960s [8]. Between 2000 to 2017, there is a 3.5% increase in hipfracture related hospitalization, translating to an average of 72 additional hip fractures related hospitalisation per 100,000 per year [9]. In 2017, the estimated incidence of osteoporotic fracture was 15,267 case, (25.5% hip fracture, 29.1% vertebral fracture, and 45.4% other fractures), and it is estimated to increase by 58% by 2035 [10]. ...
... While there have been studies in Singapore on the prevalence and economic burden of osteoporotic hip fracture [8,9,11], there is a severe lack of reference data on BMD and prevalence of osteoporosis. A study published in 2002, found Singapore men had 10 and 5% lower bone mineral density in the lumbar spine (LS) and femoral neck, respectively when compared to mean BMD peak of Caucasian reference database [8]. ...
... Additionally, there are also ethnic variations within Singapore. Singaporean Chinese women have a 40% higher hip fracture rates compared to local Malay and 90% higher than Indian women [9]. Post-hoc secondary analysis of covariance our data showed that there were no significant differences in LS BMD among the three major ethnic group for both men (p = 0.692) and women (p = 0.802). ...
Article
Full-text available
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 TSG) for each individual in the study. Similar diagnoses were also done based on T-scores provided by the densitometer (TDXA), NHANES database (TNHANES), and China (TCHN), and the differences in prevalence compared. We then compared the concordance between TSG and TDXA 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 TDXA, TNHANES, and TCHN. Comparing diagnosis using TDXA and TSG 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.
... Osteoporotic hip fracture incidence rates have risen 1.5-fold for men and 5-fold for women since the 1960s (8). Between 2000 to 2017, there is a 3.5% increase in hip-fracture related hospitalization, translating to an average of 72 additional hip fractures related hospitalisation per 100,000 per year (9). In 2017, the estimated incidence of osteoporotic fracture was 15,267 case, (25.5% hip fracture, 29.1% vertebral fracture, and 45.4% other fractures), and it is estimated to increase by 58% by 2035 (10). ...
... While there have been studies in Singapore on the prevalence and economic burden of osteoporotic hip fracture (8,9,11), there is a severe lack of reference data on BMD and prevalence of osteoporosis. A study published in 2002, found Singapore men had 10% and 5% lower bone mineral density in the lumbar spine (LS) and femoral neck, respectively when compared to mean BMD peak of Caucasian reference database (8). ...
... Additionally, there are also ethnic variations within Singapore. Singaporean Chinese women have a 40% higher hip fracture rates compared to local Malay and 90% higher than Indian women (9). Post-hoc secondary analysis of covariance our data showed that there were no signi cant differences in LS BMD among the three major ethnic group for both men (p=0.692) and women (p=0.802). ...
Preprint
Full-text available
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 [[EQUATION]] 21 years. 314 women and 223 men 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±0.168g/cm 2 in women, and 1.041±0.098g/cm 2 for men. Peak whole-body BMD was 1.193±0.93g/cm 2 in women at, and 1.224±0.112g/cm 2 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.
... Osteoporotic hip fracture incidence rates have risen 1.5-fold for men and 5fold for women since the 1960s (8). Between 2000 to 2017, there is a 3.5% increase in hip-fracture related hospitalization, translating to an average of 72 additional hip fractures related hospitalisation per 100,000 per year (2). In 2017, the estimated incidence of osteoporotic fracture was 15,267 case, (25.5% hip fracture, 29.1% vertebral fracture, and 45.4% other fractures), and it is estimated to increase by 58% by 2035 (9). ...
... While there have been studies in Singapore on the prevalence and economic burden of osteoporotic hip fracture (2,8,10), there is a severe lack of reference data on BMD and prevalence of osteoporosis. A study published in 2002, found Singapore men had 10% and 5% lower bone mineral density in the lumbar spine (LS) and femoral neck, respectively, when compared to mean BMD peak of Caucasian reference database (8). ...
... However, signi cant differences was reported in femoral neck BMD among Singapore women (12).Though the BMD differences between different ethnicity in Singapore has not been investigated, various in uencing risk factors for low BMD, such as obesity, vitamin D de ciency, smoking, alcohol consumption and genetic heterogeneity, have been studied. Ethnic-speci c genetic variants and risk factors associated with low BMD warrant future research (2). ...
Preprint
Full-text available
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 ³ 21 years. 314 women and 223 men were recruited from the large north-eastern residential town of Yishun. We computed T- scores (denoted by TSG) for each individual in the study. Similar diagnoses were also done based on T-scores provided by the densitometer (TDXA), NHANES database (TNHANES), and China (TCHN), and the differences in prevalence compared. We then compared the concordance between TSG and TDXA in the classification of osteoporosis. Osteoporosis was defined according to criteria by the World Health Organization (WHO). Results: Peak lumbar spine BMD was 1.090±0.168g.cm⁻² in women, and 1.041±0.098g.cm⁻² for men. Peak whole body BMD was 1.193±0.93g.cm-2 in women at, and 1.224±0.112g.cm⁻² 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 TDXA, TNHANES, and TCHN. Comparing diagnosis using TDXA and TSG 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.
... Osteoporosis is characterised by a systemic loss of bone mineral and micro-architectural deterioration of bone tissue, resulting in increased risk of fracture (1). Osteoporotic fractures result in increased morbidity, disability, and mortality risk, reducing quality of life (2). Common fracture sites include the spine, hip, distal forearm, and proximal humerus. ...
... Osteoporotic hip fracture incidence rates have risen 1.5-fold for men and 5-fold for women since the 1960s (8). Between 2000 to 2017, there is a 3.5% increase in hip-fracture related hospitalization, translating to an average of 72 additional hip fractures related hospitalisation per 100,000 per year (2). In 2017, the estimated incidence of osteoporotic fracture was 15,267 case, (25.5% hip fracture, 29.1% vertebral fracture, and 45.4% other fractures), and it is estimated to increase by 58% by 2035 (9). ...
... While there have been studies in Singapore on the prevalence and economic burden of osteoporotic hip fracture (2,8,10), there is a severe lack of reference data on BMD and prevalence of osteoporosis. A study published in 2002, found Singapore men had 10% and 5% lower bone mineral density in the lumbar spine (LS) and femoral neck, respectively, when compared to mean BMD peak of Caucasian reference database (8). ...
Preprint
Full-text available
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 ³ 21 years. 314 women and 223 men were recruited from the large north-eastern residential town of Yishun. We computed T- scores (denoted by TSG) for each individual in the study. Similar diagnoses were also done based on T-scores provided by the densitometer (TDXA), NHANES database (TNHANES), and China (TCHN), and the differences in prevalence compared. We then compared the concordance between TSG and TDXA in the classification of osteoporosis. Osteoporosis was defined according to criteria by the World Health Organization (WHO). Results: Peak lumbar spine BMD was 1.090±0.168g.cm⁻² in women, and 1.041±0.098g.cm⁻² for men. Peak whole body BMD was 1.193±0.93g.cm-2 in women at, and 1.224±0.112g.cm⁻² for men. Prevalence of osteoporosis based on lumbar spine was 9.3% in women, and 0.7% in men. The percentage difference in prevalence range from 60.5 - 163.6%, when using reference values from TDXA, TNHANES, and TCHN. Among the 28 women who were diagnosed as osteoporotic by TDXA, 16.5% only had osteopenia according to TSG. 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.
... The incidence of hip fractures in Singapore has increased by 1.5 times in men and 5 times in women since the 1960s. These rates are projected to increase with Singapore's ageing population [4,5]. ...
... A before-and-after study on the implementation of clinical guidelines for other chronic diseases has previously shown improved clinical outcomes in primary care [30]. Furthermore, an epidemiological study in Singapore has postulated that the publication of clinical practice guidelines helped to raise awareness of osteoporosis and was one of the factors accounting for the recent decline in age-standardised incidence of hip fractures rates [5]. ...
Article
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Unlabelled: 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.
... Table 2 shows the incidence of hip fracture in the oldest old in Asian countries or regions. In general, the incidence of hip fracture in oldest-old women exceeded 1,000 per 100,000 person-years in Japan [10] and Singapore [12]. Interestingly, studies [10,12] tended to report the incidence in women only, although they studied both women and men. ...
... In general, the incidence of hip fracture in oldest-old women exceeded 1,000 per 100,000 person-years in Japan [10] and Singapore [12]. Interestingly, studies [10,12] tended to report the incidence in women only, although they studied both women and men. Although it is expected that the incidence of hip fracture is higher in women than in men, men had a higher incidence of hip fracture than women (Table 2) among the oldest old in India. ...
Article
Osteoporosis is a prevalent disease globally, with fragility fracture being the clinical outcome. Hip fracture is mostly associated with morbidity, immobility, and mortality among all fragility fractures. Although earlier studies in the 1990s projected that half of the hip fractures in the world will occur in Asia by 2050, epidemiology studies in Asia are inadequate. On the other hand, although the stabilizing or reducing trend of hip fracture incidence was reported in some countries or regions, the total number of hip fractures may still increase due to the rapid increase of the oldest old population. The oldest old usually have the highest fracture incidence, while the available treatment and management of osteoporosis for them are suboptimal. The undertreatment could be due to the “unfavorable” risk–benefit profile, lack of fracture prediction tool for the oldest old, and the presence of multiple comorbidities. A strategic management plan for osteoporosis in the oldest old can help cope with the coming “fracture tsunami” and achieve the “healthy aging” goal among the oldest old. Here, we reviewed the recent Asian epidemiology studies on hip fracture, focusing on the current treatment, fracture prediction, and comorbidities of the oldest old.
... For instance, in the UK, notable ethnic differences in hip fracture were recently shown using data from the Clinical Practice Research Datalink (CPRD); fragility fracture rates (radius/ulna, spine and femur/hip fractures) were the highest in White, and the lowest in Black, men and women aged 50 years and above [6]. In Singapore, age-standardised hip fracture incidence rates decreased between 2000 and 2017 [7]. Hip fracture incidence rates were higher in women than men and ethnic differences, examined in women only, existed; Chinese women had the highest fracture rates, compared to Malay and Indian women, yet were also the only ethnic group in which a decline in rate was during seen during the followup period [7]. ...
... In Singapore, age-standardised hip fracture incidence rates decreased between 2000 and 2017 [7]. Hip fracture incidence rates were higher in women than men and ethnic differences, examined in women only, existed; Chinese women had the highest fracture rates, compared to Malay and Indian women, yet were also the only ethnic group in which a decline in rate was during seen during the followup period [7]. ...
Article
Full-text available
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. Summary 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.
... A similar pattern of age-adjusted incidence lagging about 1 decade behind that of high-income countries was also found in Taiwan [35] and Hong Kong [36], 2 other economically advanced regions in China. The Hong Kong study additionally suggested that the decline may continue to occur a few years later in other Asian countries [36], and the speculation was recently confirmed in Singapore using national medical insurance claims data covering up to 5.6 million population [37]. In fact, Singapore and China were predicted to have a rapid rise in hip fracture incidence in the studies by Xia et al. and Koh et al. [16,38], but the latest data from both countries (Yong et al.'s study for Singapore [37] and our study for China) do not present that anticipated rising tendency. ...
... The Hong Kong study additionally suggested that the decline may continue to occur a few years later in other Asian countries [36], and the speculation was recently confirmed in Singapore using national medical insurance claims data covering up to 5.6 million population [37]. In fact, Singapore and China were predicted to have a rapid rise in hip fracture incidence in the studies by Xia et al. and Koh et al. [16,38], but the latest data from both countries (Yong et al.'s study for Singapore [37] and our study for China) do not present that anticipated rising tendency. Additionally, a recent study reported that the hip fracture incidence decreased slightly in males and slowly increased in females in Tangshan city in China [22]. ...
Article
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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 US60milliontoUS60 million to US380 million over the study period. Costs for hospitalization per patient increased about 1.59-fold, from US4,300in2012toUS4,300 in 2012 to US6,840 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.
... A fall in the agestandardized incidence rates of hip fractures have been observed in Singapore in the years 2000e2016 compared to 20 years ago. Hip fracture rates in Singapore are declining in women !70 years and in men between the ages of 75e85 [12]. However, despite these reduced incidence rates over time, steep increases in the aging population are driving a rise in the absolute number of hip fractures and the health economic burden of osteoporosis and osteoporotic fractures remain huge and is projected to increase exponentially over the next several years. ...
... It could be argued that using uniform thresholds be it OSTA or FRAX®, for all 3 races is inappropriate given that the risk of osteoporosis and osteoporotic fractures is likely to be different in Chinese, Malays and Indians [12]. Indeed, when we analysed the Chinese, Malay and Indian women in our study sample separately, different OSTA and FRAX® score thresholds with varying sensitivities and specificities were obtained (data not shown). ...
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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.
... [9][10][11] Although the age-adjusted rate of hip fracture has decreased 1.4% annually in Singapore, an increase of 72 additional fractures per 100 000 per year for the past 18 years reflects the aging of its population. 12 The only previous Singapore study of hip fracture mortality was restricted to Chinese patients and limited to 5 years of follow-up. 13 Individuals of Chinese, Indian, and Malay ethnicities make up more than 40% of the global population. ...
... The study population comprised patients aged 50 years or older admitted to Singapore hospitals for first hip fracture during the 18-year period from 2000 to 2017, as described in a previous study. 12 The administrative data sets from the Ministry of Health include all records of all inpatient episodes that are submitted for Medisave and MediShield claim purposes. Claims are based on a unique National Registration Identification Number issued at birth (or, for persons born outside of Singapore, at the time of obtaining residency status) and also include the ethnicity of patients. ...
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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.
... These incidents are exacerbated by agerelated factors, such as impaired balance and mobility, medication, muscle weakness, the use of walking aids, and cognitive impairment [2,3]. Notably, falls lead to severe injuries, with hip fractures being the most common and having the most debilitating consequences in older individuals [4,5], such as increased morbidity, disability, and mortality [6]. ...
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The EXO+ hip protector was developed to minimize the risk of hip fractures in seniors following falls. This study evaluated its usability in a Singapore nursing home from the perspective of the staff, focusing on learnability, efficiency, and satisfaction. A mixed-method design was employed, with nursing home residents wearing the EXO+ daily for eight weeks. Quantitative data on wear time were collected alongside qualitative insights from four repeated focus group discussions with care staff. In total, 15 residents (including 8 residents with cognitive impairments) and 9 staff participated. The analysis revealed six themes and fourteen subthemes related to EXO+’s usability. The residents wore the device for an average of 1.54 h per day, with those having cognitive impairments showing increased wear times, especially in the mornings and on weekdays. The findings indicated that the EXO+ was learnable and satisfactory for nursing home use, provided there are adequate supporting features. The efficiency of the EXO+ was not fully measured since no falls were reported during the study period. The study offers valuable insights for potential design modifications and workflow adaptations to enhance the implementation of hip protectors in healthcare settings, highlighting facilitators and barriers to support device uptake.
... These incidents are exacerbated by age-related factors, such as impaired balance and mobility, medication, muscle weakness, the use of walking aids, and cognitive impairment (Montero-Odasso et al., 2022; Tyrovolas et al., 2016). Notably, falls lead to severe injuries, with hip fractures being the most common and having the most debilitating consequences in older individuals (Stevens et al., 2006;Rau et al., 2014), such as increased morbidity, disability, and mortality (Yong et al., 2019). ...
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The EXO+ hip protector was developed to minimize the risk of hip fractures in seniors following falls. This study evaluated its usability in a Singapore nursing home from the perspective of staff, focusing on Learnability, Efficiency, and Satisfaction. A mixed-method design was employed, with nursing home residents wearing the EXO+ daily for 8 weeks. Quantitative data on wear time was collected alongside qualitative insights from four repeated focus group discussions with care staff. In total, 15 residents (including 8 residents with cognitive impairments) and 9 staff participated. The analysis revealed six themes and fourteen subthemes related to EXO+’s usability. Residents wore the device for an average of 1.54 hours per day, with those having cognitive impairments showing increased wear times, especially in the mornings and on weekdays. Findings indicated that the EXO+ was learnable and satisfactory for nursing home use, provided there are adequate supporting features. The efficiency of the EXO+ was not fully measured since no falls were reported during the study period. The study offers valuable insights for potential design modifications and workflow adaptations to enhance the implementation of hip protectors in healthcare settings, highlighting facilitators and barriers to support device uptake.
... Studies from Hong Kong show increases in hip fracture incidences between 1966 and 1985 (1.7-fold in men and 2.5-fold in women), followed by a plateau between 1985 and 1995. A Singapore study showed that hip fracture rates trended higher by 0.7% annually in men and 1.2% annually in women between 1991 and 1998 (Koh et al. 2001), followed by a subsequent study that showed declines in the fracture rates between 2000 and 2017 (Yong et al. 2019). In Japan, a study showed increases in hip fracture rate between 1986 and 2001 (Hagino et al. 2005), and a follow-up study showed that these trends continue through 2006 (Hagino et al. 2009). ...
... Although a few studies have been conducted on CTX1 in post-menopausal women, a direct comparison cannot be made because different ethnicities may have influenced the variability of the results. For instance, Chinese women have been reported to have suboptimal bone health or higher hip fractures than Malay and Indian women in Malaysia (74,75) and Singapore (76). Moreover, different units of CTX1 were used in different studies, making comparisons impossible. ...
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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.
... Falls are associated with increased morbidity, mortality and health related costs. Based on the latest world guidelines for falls prevention and management for older adults (29), clinicians are strongly recommended to ask about falls in older adults as these are often not spontaneously reported (30). The high prevalence of fear of falling picked up during our community frailty screening programme shows the need for proactive interventions into falls and geriatric syndromes in the community and not relying on persons to self-report or actively ask for multi-disciplinary and multi-component interventions. ...
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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.ResultsA 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 Comorbidity 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.
... On the other hand, in the US, it has been reported that the degree of decrease in the fracture rate has slowed since 2013 [28]. Some reports in Asia have shown an increase [29], while others have shown a plateau to a decreasing trend [30,31]. In Japan, the number and incidence of new hip fractures are steadily increasing [7,9,32]. ...
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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.
... In Singapore, recent estimates range from 9.3 to 19.4% [124,125] for the prevalence of osteoporosis among postmenopausal women and 0.7% among men aged 50 + [124]. One large Singaporean fracture database study reported that 7% of women ages 50 + had a history of fragility fracture [126], and a study examining hip fracture incidence in adults ages 50 + reported age-adjusted incidence of 253 per 100,000 among women and 125 among men [127]. Another study from Singapore reported estimated vertebral fracture rates of 300 and 130 per 100,000 for women and men, respectively, and other osteoporotic fracture rates of 465 and 205 per 100,000 for women and men, respectively [128]. ...
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Unlabelled: 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.
... A recent study using the UK Clinical Practice Research Datalink with a 20-year follow-up revealed stable overall sex-specific fracture incidence, with radius-ulna fractures decreasing in women and hip fractures rising in men [38]. Recent data revealed an increase in hip fracture rates in Singapore (2000-2017) [39] and Lebanon (2006Lebanon ( -2017 [40]. ...
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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.PurposeWe 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.ResultsMean (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.
... Worldwide, with a trend of increased life expectancy, the incidence of hip fractures is projected to increase from 1.66m in 1990 to 6.26m by 2050. 1 Hip fractures have significant consequences: with mortality rates of up to 10% at 1 month and 30% at 1 year, as well as morbidity, with only approximately half returning to their previous mobility and 10-20% requiring discharge to nursing or residential care. 1 Due to the growing and rapidly ageing population, the absolute number of patients with hip fractures admitted to Singaporean hospitals per year increased from 1487 in 2000 to 2729 in 2017. 2 Ideally, hip fractures should be operated on within 48 h of admission, contingent on the surgery being able to proceed safely once patients are optimised, as this would allow patients to return to ambulation earlier and minimise complications of prolonged immobility. 3 Intra-capsular neck of femur (NOF) fractures make up almost half of proximal femur fractures in the elderly and patients usually undergo joint sacrificing surgery such as hemiarthroplasty (HA) or a total hip arthroplasty (THA). ...
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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.
... (1) The incidence of hip fractures in Singapore has also increased because of its ageing population. (2) Hip fractures in the elderly are often fragility fractures secondary to undiagnosed osteoporosis. Bone remodelling is affected by the activity of bone formation by osteoblasts and bone resorption by osteoclasts. ...
Article
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.
... Yet, vitamin D supplements might not be effective in primary prevention of osteoporosis and fractures in women without vitamin D deficiency [45]. We have previously reported that Indian and Malay women in the IWHP cohort have lower risks of osteoporosis and low bone mineral density than Chinese women [20] and lower risk of hip fractures nationwide [46]. These associations are opposite to those we observed for hypovitaminosis D in the current study. ...
Article
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.
... Although validation studies of the Italian HDRs considering femoral fractures are lacking, the main diagnosis is used to assess the value of diagnosis-related groups (DRGs) [28], which are used to identify hospital reimbursements. Therefore, the main diagnosis is considered to be an accurate choice for the identification of femoral fractures from HDRs and has been used in similar studies [45][46][47]. Conversely, the identification of chronic conditions (including osteoporosis chronic conditions) and associated medications using Italian automated pharmacy data has been validated in 2005 [48]. The study demonstrated that use of pharmacy data is a valuable strategy to estimate the extent to which large populations are affected by chronic conditions, the associated pharmaceutical utilization and cost. ...
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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.
... For hip fractures, data on inpatient admissions of Singapore residents with a discharge diagnosis of fracture involving the neck or the intracapsular, upper epiphyseal, subcapital, cervical, trochanteric, or subtrochanteric areas were used. This data which had been retrieved using the following diagnostic codes from the International Classification of Disease, Tenth revision, Australian version (ICD-10-AM): S7200, S7201-S7211, S722-S723, was published in 2018 [25]. ...
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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.
... is coupled with an ageing population will lead to an increase in the burden of osteoporotic fractures. [2][3] A recent study by Yong et al 4 showed that while age-adjusted fractures rates have decreased from 2000 to 2017, the total number of hip fractures standard for diagnosing osteoporosis. ...
Article
Background Our institution implemented a multi-disciplinary protocolised care for surgically managed hip fractures in 2017, initiating measures pre-operatively to provide early access to surgery, and post-operatively to ensure early mobilisation and smooth transition to step down care. Objectives Key performance indicators (time to admission and time to surgery) and acute outcomes (length of stay, discharge disposition and inpatient mortality) were evaluated to determine the impact of multi-disciplinary protocolised care on surgically managed hip fracture patients. Methods 935 patients in the POST-PROTOCOL group (between February 2017 to January 2020) were compared with 701 patients in the PRE-PROTOCOL group (between January 2015 to January 2017) in terms of key performance indicators and acute outcomes. Results In the POST-PROTOCOL group, a higher proportion were of ASA class III and IV ( p = .026). More patients in the POST-PROTOCOL group were admitted to the ward within 4 hours (97.2% vs 86.0%; p < .001) and operated on within 48 hours (56.4% vs 36.8%; p < .001). Mean length of stay was shorter in the POST-PROTOCOL group (11.2 ± 9.0 vs 14.8 ± 13.0 days; 95% CI, 2.5 to 4.7; p < .001), with more patients discharged within 9 days (55.6% vs 43.2%; p < .001). Inpatient mortality rate was similar ( p = .213). Conclusion Despite having a higher proportion of patients with poorer physiological status, time to admission, time to surgery and length of stay improved in the POST-PROTOCOL group.
Article
A cost-effectiveness analysis of FRAX® intervention thresholds (ITs) in Indian women over 50 years indicated that generic alendronate was cost-effective for age-dependent major osteoporotic fracture (MOF) ITs and hip fracture (HF) ITs starting at ages 60 and 65 years for full and real-world adherence, respectively. Alendronate was cost-effective at fixed MOF IT of 14% and HF IT of 3.5%, regardless of age. Osteoporosis represents a significant public health challenge in India, with an increasing economic burden due to the aging population. This study evaluated the cost-effectiveness of using fracture risk assessment tool (FRAX®)–based intervention thresholds (ITs) for managing osteoporosis with generic alendronate in Indian women. A Markov microsimulation model, adapted to the Indian healthcare context, was used to simulate the costs and quality-adjusted life years (QALYs) associated with different treatment strategies. The one-time gross domestic product (GDP) per capita (estimated at INR 1,97,468/QALY gained) was used as the cost-effectiveness threshold. The model revealed that generic alendronate is cost-effective for major osteoporotic fracture (MOF) ITs beginning at age 60 years with full adherence—incremental cost-effectiveness ratio (ICER) of INR 102,151 per QALY gained, and age 65 with real-world adherence—ICER of INR 28,203 per QALY gained (conversion rate used is 1 US dollar (USD) = INR 83.97 and 1 EURO = INR 92.70). Hip fracture (HF) ITs showed similar cost-effectiveness at ages 60 (ICER of INR 67,144) and was the dominant strategy (i.e., more QALYs for lower costs) at ≥ 65 years. Fixed ITs of 14% for MOF and 3.5% for HF proved cost-effective across all age groups (dominant strategy for ages ≥ 65 years). Limitations of our study include the reliance on fracture incidence data from Singaporean Indians and variability in fracture prevalence across India. The results support the integration of FRAX®-based fixed ITs from the age of 50 years and age-based ones from the age of 65 years in India to optimize resource allocation and improve osteoporosis management.
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Hip fractures are a significant cause of morbidity and mortality among the elderly population, often requiring surgical intervention to restore mobility and independence. Following hip fracture surgery, the assessment of self-care abilities becomes crucial as it directly impacts the overall recovery of these patients. Objective: To assess the self-care abilities and associated factors among elderly patients after hip fracture surgery. Methods: A descriptive cross-sectional study was conducted at Mayo Hospital Lahore to assess self-care abilities among elderly patients who had undergone hip fracture surgery. 150 patients were selected using a simple random sampling technique. A self-developed questionnaire with a content validity of 0.88 and reliability of 0.674 was used for data collection. Results: Most of the participants were female 53.3%, almost 45.3%, within the age of 61 to 65 years and 38% had received education up to middle school level. Furthermore, 65.3% of the participants were married. In terms of self-care ability, 58.7% of the participants demonstrated a moderately adequate level of self-care. The findings of this study indicate that increasing age, lack of formal education, and being married are factors associated with a decrease in self-care ability, with a significance level of p<0.05. Conclusions: The findings indicate that the participants have moderate adequacy in terms of their self-care abilities. These results emphasize the significance of addressing self-care needs not only during the surgery period but also in the post-operative phase, particularly when individuals experience self-care deficit.
Article
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.
Article
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.
Article
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.PurposeTo 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).ResultsCompared to no bone densitometry, SBD using the OSTA would cost between 40,679and40,679 and 73,909 per QALY gained for men aged 75–80 and 22,386to22,386 to 58,185 per QALY gained for post-menopausal women aged 70–80. Universal bone densitometry would cost 157,955to157,955 to 177,127 per QALY gained for men aged 75–80 and 40,179to40,179 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.
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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’.PurposeThis 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.ResultsEpidemiological 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’.
Article
Objectives: To study the impact of bundled payments for surgically managed hip fractures on care access, care quality, healthcare resource utilisation, clinical impact and acute care cost. Design: An observational retrospective cohort study using a quasi-experimental design comparing pre- and post- bundled payments through an interrupted time series analysis. Setting: A public acute care general hospital. Patients: Patients ≥60 years, with surgery for an isolated, unilateral, non-pathological hip fracture during 2014-first quarter of2019 (diagnosis-related group [DRG] 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, healthcare resource utilisation, clinical impact and cost. Results: Of 1477 patients, 811 were assigned to pre-, and 666 to post- bundled payments. Although there was an improving trend of ward admission waiting times during post- bundled payments (OR=1.14; 95%CI: 1.02 - 1.28), ward admission waiting times were longer when compared to pre-bundled 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 post- bundled payments. Acute care cost for complex cases were higher (OR=0.49; 95%CI: 0.26-0.92) during bundled payments, compared to pre- bundled 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.
Article
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.
Article
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.IntroductionAs 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.ResultsA 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.
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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.
Article
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 Cmax and AUC0→∞ 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.
Article
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.IntroductionHip 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.ResultsTwenty-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.
Article
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.
Article
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.IntroductionTo 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.ResultsThe 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.
Article
Objectives: Due to demographic changes, aging is a health priority. We aimed to identify midlife women’s perceived health information needs and the preferred method(s) of information delivery. Methods: A questionnaire was offered to women, aged 45–69 years, attending gynecological clinics during April/May 2016, collecting age and ethnicity data. Participants were asked to indicate important midlife health topics out of 26 topics, including ‘other’. For each topic, six delivery options were offered. Age was stratified by 5-year intervals. Associations with age and ethnicity were examined using Pearson’s chi-square tests (p < 0.05); analyses were performed with SPSS version 22.0. Results: The top health topics chosen were gynecological cancer (66.0%), joint/muscle aches and pain (64.4%), bone health (63.2%), breast screening (55.9%), and heart health (55.3%). Adjusted results from the logistic regression model found that the odds of choosing the topics gynecological cancer, cervical screening, and complementary and alternative medicine for menopausal symptoms were significantly lower in age groups 55–59, 60–64 and 65–69 years compared to age group 45–49 years. Both Malay and Indian women were less likely to report bone health as important (odds ratio = 0.59, 95% confidence interval = 0.41–0.86) and (odds ratio = 0.64, 95% confidence interval = 0.42–0.98), respectively. Written leaflets were chosen by the majority (84.7%). Conclusion: This study of over 1000 midlife Asian women found that holistic health information is desired and requires tailoring by age, not ethnicity. Written information was preferred over support groups. These findings will guide clinical health services in delivering patient-centered information resources for midlife women.
Article
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 S183.5millionin2017andisforecastedtogrowtoS183.5 million in 2017 and is forecasted to grow to S289.6 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.
Article
Country‐specific hip fracture incidence rates (IRs) and longevity allow 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 non‐existent. Using the Ministry of Public Health hip fracture registry, we calculated age and sex‐specific hip fracture IRs in Lebanon, from 2006–2017, 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 (2006–2008). The registry recorded 6,985 hip fractures, 74% at the femoral neck, 23% inter‐trochanteric, and 3% sub‐trochanteric. Men constituted 32% of the population, and were significantly younger than women (76.5 ± 11.0 years vs. 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 1.5–2.1). 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 (2006–2014) 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. This article is protected by copyright. All rights reserved.
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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/cm²higher 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.
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We aimed to report the first genome‐wide association study (GWAS) meta‐analysis of dual‐energy X‐ray absorptiometry (DXA)‐derived hip shape, which is thought to be related to the risk of both hip osteoarthritis and hip fracture. Ten hip shape modes (HSMs) were derived by statistical shape modelling using SHAPE software, from hip DXA scans in the Avon Longitudinal Study of Parents and Children (ALSPAC; adult females), TwinsUK (mixed‐sex), Framingham Osteoporosis Study (FOS; mixed), Osteoporotic Fractures in Men study (MrOS) and Study of Osteoporotic Fractures (SOF; females) (total n = 15,934). Associations were adjusted for age, sex, and ancestry. Five genome‐wide significant (P < 5 × 10−9, adjusted for 10 independent outcomes) single nucleotide polymorphisms (SNPs) were associated with HSM1, and three SNPs with HSM2. One SNP, in high linkage disequilibrium with rs2158915 associated with HSM1, was associated with HSM5 at genome‐wide significance. In a look‐up of previous GWASs, three of the identified SNPs were associated with hip osteoarthritis, one with hip fracture, and five with height. Seven SNPs were within 200 kb of genes involved in endochondral bone formation, namely SOX9, PTHrP, RUNX1, NKX3‐2, FGFR4, DICER1 and HHIP. The SNP adjacent to DICER1 also showed osteoblast cis‐regulatory activity of GSC, in which mutations have previously been reported to cause hip dysplasia. For three of the lead SNPs, SNPs in high LD (r2 > 0.5) were identified which intersected with open chromatin sites as detected by ATAC‐seq performed on embryonic mouse proximal femora. In conclusion, we identified eight SNPs independently associated with hip shape, most of which were associated with height and/or mapped close to endochondral bone formation genes, consistent with a contribution of processes involved in limb growth to hip shape and pathological sequelae. These findings raise the possibility that genetic studies of hip shape might help in understanding potential pathways involved in hip osteoarthritis and hip fracture. This article is protected by copyright. All rights reserved
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Osteoporosis remains undertreated in Japan, and bone fractures are the most frequent complications imposing heavy burden on individuals and the community. This paper investigates the clinical and economic burden of fractures among osteoporosis patients in Japan. The Japan National Health and Wellness Survey 2012–2014 database was used for analysis. Respondents aged ≥ 50 years and indicated a physician diagnosis of osteoporosis (N = 1107) were categorized into three subgroups: no prior fracture (N = 693), single fracture (N = 242), and multiple (≥ 2) fractures (N = 172). Health-related quality of life (HRQoL), work productivity and activity impairment, healthcare resource utilization and associated direct and indirect costs were compared across three fracture subgroups adjusting for respondents’ sociodemographic and clinical characteristics using generalized linear regression models. The estimated fracture prevalence among respondents with osteoporosis who were ≥ 50 years was 37.4%, of whom 41.5% had multiple fractures. Relative to osteoporosis respondents with no fracture and with single fracture, those with multiple fractures reported significant higher disability in HRQoL, more healthcare resource utilization, and were associated with higher direct costs. Improved treatment of fractures among osteoporosis patients is necessary and may help reduce the clinical and economic burden in this osteoporosis population.
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Osteoporosis is a major, growing healthcare issue. This is especially of concern in an ageing population like that of Singapore. Osteoporotic patients are at risk of fractures, which can result in increased morbidity and mortality. The use of antiresorptive therapy with bisphosphonates or denosumab has been proven to reduce fracture risk. However, the use of these medications has rarely been associated with the development of osteonecrosis of the jaw, a potentially debilitating condition affecting one or both jaws. Appropriate understanding of the patient’s antiresorptive therapy regime, as well as early institution of preventive dental measures, can play an important role in preventing medication-related osteonecrosis of the jaw (MRONJ). Regular monitoring and prompt referral to specialist care is warranted for patients with established MRONJ.
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Osteoporosis is an important health issue for older adults, and has been relatively understudied in older men. This study aimed to examine ethnic differences in bone mineral density (BMD), and elucidate the role of bone turnover markers (BTMs), fat and fat biomarkers on these ethnic differences. BMD at the lumbar spine and femoral neck, marrow fat at femoral neck, visceral adipose tissue (VAT) and subcutaneous adipose tissue, bone and fat biomarkers were evaluated in 120 healthy men aged ≥ 60 years. Indians had higher BMD values compared to Chinese at the lumbar spine (β = 20.336, SE = 4.749, p < 0.001) and the femoral neck (eβ = 1.105, SE = 0.032, p < 0.001), after adjusting for BTMs, fat composition and lifestyle choices. Marrow fat, VAT and adiponectin were independent predictors of BMD. However, these factors did not explain the lower BMD observed in older Chinese men. Our findings suggest that older Chinese men are at significant risk of osteoporotic fractures due to lower BMD. Fat appears to be a key factor associated with lower BMD, and warrants further longitudinal studies to elucidate the complex interactions between adipose tissue and bone strength. Electronic supplementary material The online version of this article (doi:10.1007/s00223-017-0342-8) contains supplementary material, which is available to authorized users.
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The Singapore Integrative Omics Study provides valuable insights on establishing population reference measurement in 364 Chinese, Malay, and Indian individuals. These measurements include > 2.5 millions genetic variants, 21,649 transcripts expression, 282 lipid species quantification, and 284 clinical, lifestyle, and dietary variables. This concept paper introduces the depth of the data resource, and investigates the extent of ethnic variation at these omics and non-omics biomarkers. It is evident that there are specific biomarkers in each of these platforms to differentiate between the ethnicities, and intra-population analyses suggest that Chinese and Indians are the most biologically homogeneous and heterogeneous, respectively, of the three groups. Consistent patterns of correlations between lipid species also suggest the possibility of lipid tagging to simplify future lipidomics assays. The Singapore Integrative Omics Study is expected to allow the characterization of intra-omic and inter-omic correlations within and across all three ethnic groups through a systems biology approach.
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Background: Hip fracture is a common cause of disability and mortality among the elderly. Declining incidence trends have been observed in Sweden. Still, this condition remains a significant public health problem since Sweden has one of the highest incidences worldwide. Yet, no Swedish lifetime risk or survival trends have been presented. By examining how hip fracture incidence, post-fracture survival, as well as lifetime risk have developed between 1995 and 2010 in Sweden, this study aims to establish how the burden hip fractures pose on the elderly changed over time, in order to inform initiatives for improvements of their health. Material and methods: The entire Swedish population 60 years-old and above was followed between 1987 and 2010 in the National Patient Register and the Cause of Death Register. Annual age-specific hip fracture cumulative incidence was estimated using hospital admissions for hip fractures. Three-month and one-year survival after the first hip fracture were also estimated. Period life table was used to assess lifetime risk of hip fractures occurring from age 60 and above, and the expected mean age of the first hip fracture. Results: The age-specific hip fracture incidence decreased between 1995 and 2010 in all ages up to 94 years, on average by 1% per year. The lifetime risk remained almost stable, between 9% and 11% for men, and between 18% and 20% for women. The expected mean age of a first hip fracture increased by 2.5 years for men and by 2.2 years for women. No improvements over time were observed for the 3-month survival for men, while for women a 1% decrease per year was observed. The 1-year survival slightly increased over time for men (0.4% per year) while no improvement was observed for women. Conclusions: The age-specific hip fracture incidence has decreased over time. Yet the lifetime risk of a hip fracture has not decreased because life expectancy in the population has increased in parallel. Overall, survival after hip fracture has not improved.
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The objective is to analyse the evolution of the incidence of hip fracture in the female population of Spain from 2000 to 2012 and to establish the possible changes which may have been seen over this period of time, including the trends in the different regions of the country. Fragility-related hip fractures are considered to be the fractures of greatest significance to public health due to their high degree of morbidity and mortality. The change in their incidence, both in absolute values and when adjusted for age, is the subject of debate. The objective of this article is to describe the changes in the rates of hip fracture in Spain by autonomous community between the years 2000 and 2012. Using the data from the Spanish Minimum Basic Data Set, in which are all the recorded cases of women with a principal diagnosis of hip fracture, the incidence rates by age group and by autonomous community were obtained. Poisson distribution or negative binomial regressions were carried out to estimate the average annual change over the time period analysed. There have been statistically significant changes in the trends of rates of incidence for all age groups of women over 65 years of age. The annual reduction was 2.2 % for women of 65-74 years of age and less for those between 75 and 84. The rates of incidence for those over 85 increased annually by 0.58 %. Hip fractures continue to increase in absolute numbers, although if the rates are adjusted for age, a downward trend is seen in certain age groups. These findings have various origins, although in the absence of great changes in population structure, we believe that drug treatments for osteoporosis may play a role. There is variability in the change in incidence of hip fractures in different parts of the country. Further studies are required to be able to identify the causes.
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Background: Vitamin D deficiency is common in older adults in Western countries with seasonal winters, when the amount of sunlight is much reduced. There is a paucity of data on the prevalence of vitamin D deficiency in patients with hip fracture in countries such as Singapore where the climate is predominantly tropical. Objectives: In this study, our aims were to ascertain the prevalence of vitamin D deficiency and risk factors associated with vitamin D deficiency in hospitalized elderly patients with hip fracture in Singapore. Methods: We prospectively studied 485 patients with hip fracture admitted to the orthopedic department over a 1-year period. Nonfragility fractures and younger patients (patients <60 years and those with high-impact injuries) were excluded. Data on patient demographics, comorbidities, functional status, and serum 25-hydroxyvitamin D3 levels were collected. Vitamin D deficiency was defined using Holick classification. Results: Vitamin D levels were available for 412 patients. Vitamin D deficiency was present in 57.5% (n = 237). Prevalence of vitamin D insufficiency was 34.5%, with only 8% of patients having normal vitamin D levels. Univariate analyses showed Malay race and functional factors (being housebound, requiring bathing and dressing assistance) to be associated with vitamin D deficiency. However, only ethnicity and housebound patients were significant in the multivariate model. Conclusions: Vitamin D deficiency and insufficiency are common in patients with hip fracture in Singapore. Vitamin D deficiency was associated with being housebound and those of Malay ethnicity. Clothing habits resulting in reduced sunlight exposure may increase the risk of vitamin D deficiency.
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A significant care gap exists in the management of osteoporotic fractures. Osteoporosis Patient Targeted and Integrated Management for Active Living (OPTIMAL) is a secondary fracture prevention program instituted in the public hospitals of Singapore. We aim to describe the operational characteristics of OPTIMAL and initial audit data of patients who were recruited into the program at Singapore General Hospital. Introduction Fractures often represent the first opportunity for care of osteoporosis. However, a significant care gap still exists in the management of these sentinel events and underdiagnosis and undertreatment of osteoporotic fractures are prevalent worldwide. Fracture liaison services run by care coordinators have been shown to reduce the fracture care gap. OPTIMAL is a clinician champion-driven, case manager-run secondary fracture prevention program set up in the public hospitals of Singapore in 2008. Methods We present the operational characteristics and initial audit data of OPTIMAL from the largest tertiary teaching hospital in Singapore. Results One thousand and fourteen patients have been recruited into OPTIMAL at our hospital since 2008, and 476 patients are currently in active follow-up. Two hundred and eighty-seven patients had completed a 2-year follow-up at the hospital as of August 2012 and were evaluated; 97.5 % of these patients had DXA evaluation upon enrollment into the program, and 62 % of the patients reported compliance with an exercise program over the 2-year follow-up. Compliance to osteoporosis medications as estimated by the medication possession ratio (MPR) was 72.8 ± 34.5 % at 2 years with patients maintaining good compliance (MPR ≥ 80 %) for an average of 20.2 months (95 % CI 19.3–21.1). Conclusion Our report provides the first compelling evidence of the potential success of a secondary fracture prevention program from an Asian country. The ultimate success of the program will be determined by fracture outcomes and cost effectiveness, but in the interim, clear evidence of enhanced assessment and treatment rates has been demonstrated.
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Background: there is a suggestion that while the age-adjusted incidence of hip fracture in the West may be declining, the incidence may be rising in Asia. Objective: this study examines the incidence and post-fracture mortality from 2001 to 2009 among the population aged 65 years and over. Methods: hip fracture incidence rates and case-fatality rates among Hong Kong population aged 65 and over for the period 2001-09 were obtained from the Hong Kong Hospital Authority (HA) database. Rates were adjusted for age. Poisson and logistic regressions were used to examine trends in incidence and post-fracture mortality, respectively. Results: the age-adjusted incidence rate of hip fracture among the population aged 65 and over in Hong Kong (per 100,000 population) decreased from 381.6 for men and 853.3 for women in 2001 to 341.7 and 703.1, respectively, in 2009. There were no significant changes in post-fracture mortality trends. Conclusions: there is a downward trend in age-specific hip fracture incidence rates since 2001 among Hong Kong Chinese, but no change in post-fracture mortality trends.
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Bone mineral density (BMD) is the most widely used predictor of fracture risk. We performed the largest meta-analysis to date on lumbar spine and femoral neck BMD, including 17 genome-wide association studies and 32,961 individuals of European and east Asian ancestry. We tested the top BMD-associated markers for replication in 50,933 independent subjects and for association with risk of low-trauma fracture in 31,016 individuals with a history of fracture (cases) and 102,444 controls. We identified 56 loci (32 new) associated with BMD at genome-wide significance (P < 5 × 10(-8)). Several of these factors cluster within the RANK-RANKL-OPG, mesenchymal stem cell differentiation, endochondral ossification and Wnt signaling pathways. However, we also discovered loci that were localized to genes not known to have a role in bone biology. Fourteen BMD-associated loci were also associated with fracture risk (P < 5 × 10(-4), Bonferroni corrected), of which six reached P < 5 × 10(-8), including at 18p11.21 (FAM210A), 7q21.3 (SLC25A13), 11q13.2 (LRP5), 4q22.1 (MEPE), 2p16.2 (SPTBN1) and 10q21.1 (DKK1). These findings shed light on the genetic architecture and pathophysiological mechanisms underlying BMD variation and fracture susceptibility.
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The country-specific risk of hip fracture and the 10-year probability of a major osteoporotic fracture were determined on a worldwide basis from a systematic review of literature. There was a greater than 10-fold variation in hip fracture risk and fracture probability between countries. The present study aimed to update the available information base available on the heterogeneity in the risk of hip fracture on a worldwide basis. An additional aim was to document variations in major fracture probability as determined from the available FRAX models. Studies on hip fracture risk were identified from 1950 to November 2011 by a Medline OVID search. Evaluable studies in each country were reviewed for quality and representativeness and a study (studies) chosen to represent that country. Age-specific incidence rates were age-standardised to the world population in 2010 in men, women and both sexes combined. The 10-year probability of a major osteoporotic fracture for a specific clinical scenario was computed in those countries for which a FRAX model was available. Following quality evaluation, age-standardised rates of hip fracture were available for 63 countries and 45 FRAX models available in 40 countries to determine fracture probability. There was a greater than 10-fold variation in hip fracture risk and fracture probability between countries. Worldwide, there are marked variations in hip fracture rates and in the 10-year probability of major osteoporotic fractures. The variation is sufficiently large that these cannot be explained by the often multiple sources of error in the ascertainment of cases or the catchment population. Understanding the reasons for this heterogeneity may lead to global strategies for the prevention of fractures.
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Osteoporosis constitutes a major public health problem through its association with age-related fractures, most notably those of the proximal femur. Substantial geographic variation has been noted in the incidence of hip fracture throughout the world, and estimates of recent incidence trends have varied widely. Studies in the published literature have reported an increase, plateau, and decrease in age-adjusted incidence rates for hip fracture among both men and women. Accurate characterisation of these temporal trends is important in predicting the health care burden attributable to hip fracture in future decades. We therefore conducted a review of studies worldwide, addressing secular trends in the incidence of hip and other fractures. Studies in western populations, whether in North America, Europe or Oceania, have generally reported increases in hip fracture incidence through the second half of the last century, but those continuing to follow trends over the last two decades have found that rates stabilise with age-adjusted decreases being observed in certain centres. In contrast, some studies suggest that the rate is rising in Asia. This synthesis of temporal trends in the published literature will provide an important resource for preventing fractures. Understanding the reasons for the recent declines in rates of hip fracture may help understand ways to reduce rates of hip fracture worldwide.
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The relationship between serum 25-hydroxyvitamin D [25(OH) vitamin D] concentration and hip fractures is unclear. To see whether low serum 25(OH) vitamin D concentrations are associated with hip fractures in community-dwelling women. Nested case-control study. 40 clinical centers in the United States. 400 case-patients with incident hip fracture and 400 control participants matched on the basis of age, race or ethnicity, and date of blood draw. Both groups were selected from 39 795 postmenopausal women who were not using estrogens or other bone-active therapies and who had not had a previous hip fracture. Serum 25(OH) vitamin D was measured and patients were followed for a median of 7.1 years (range, 0.7 to 9.3 years) to assess fractures. Mean serum 25(OH) vitamin D concentrations were lower in case-patients than in control participants (55.95 nmol/L [SD, 20.28] vs. 59.60 nmol/L [SD, 18.05]; P = 0.007), and lower serum 25(OH) vitamin D concentrations increased hip fracture risk (adjusted odds ratio for each 25-nmol/L decrease, 1.33 [95% CI, 1.06 to 1.68]). Women with the lowest 25(OH) vitamin D concentrations (< or =47.5 nmol/L) had a higher fracture risk than did those with the highest concentrations (> or =70.7 nmol/L) (adjusted odds ratio, 1.71 [CI, 1.05 to 2.79]), and the risk increased statistically significantly across quartiles of serum 25(OH) vitamin D concentration (P for trend = 0.016). This association was independent of number of falls, physical function, frailty, renal function, and sex-steroid hormone levels and seemed to be partially mediated by bone resorption. Few case-patients were nonwhite women. Bone mineral density and parathyroid hormone levels were not accounted for in the analysis. Low serum 25(OH) vitamin D concentrations are associated with a higher risk for hip fracture.
Article
Introduction: Whether burden of inpatient care, problems after admission, and mortality rates differ between diabetics and non-diabetics undergoing surgery for osteoporotic hip fractures has not been explored in Asian populations. Method: Three hundred eighty-nine multi-ethnic diabetic and non-diabetic patients recruited into a FLS at a large Asian hospital with new osteoporotic hip fractures requiring operative repair were analyzed. Results: 87.9% were Chinese, 6.4% Malay, and 3.6% Indians. BMI and age did not significantly differ between diabetics and non-diabetics. Median (IQR) length of hospitalization (LOHS) in days was 12 (9, 17) in diabetics and 11 (8, 14) in non-diabetics (p = 0.011). Median time from admission to operation (TTO) was 3 (2, 5) in diabetics versus 2 (1, 4.5) in the non-diabetics (p = 0.003). Occurrence of aggregate post-operative complications did not differ between diabetics and non-diabetics. No in-hospital mortalities occurred in either group. Thirty-day and 1-year mortality rates did not differ between the two groups. One-year mortality was 2.8% in the entire cohort. On multivariate regression analysis adjusted for age and race, only TTO (β; 1.8, 95% CI 1.5-2.0, p < 0.001) and occurrence of post-operative complications (β; 6.3, 95% CI 3.7-7.9, p < 0.001) correlated with LOHS. TTO and age-adjusted Charlson's Comorbidity Index (CCI) correlated significantly with the development of post-operative complications. Conclusions: Diabetes was not independently associated with LOHS in patients undergoing hip fracture surgery. Aggregate post-operative complications did not differ between diabetics and non-diabetics. TTO and occurrence of post-operative complications significantly affected LOHS. TTO correlated with post-complications development. Surgery should be expeditiously done in both diabetics and non-diabetics to avoid the development of post-operative complications and to prevent prolonged hospital stay.
Article
Introduction: Hip fractures are a major public health concern due to high morbidity, mortality, and healthcare expenses. Previous studies have reported a decrease in the annual incidence of hip fractures in the US beginning in 1995, coincident with the introduction of modern diagnostic tools and therapeutic agents for osteoporosis. In recent years, there has been less bone density testing and fewer prescriptions for osteoporosis treatments. The large osteoporosis treatment gap raises concern of possible adverse effects on hip fracture rates. Methods: We assessed hip fracture incidence in the US to determine if the previous decline in hip fracture incidence continued. Using 2002 to 2015 Medicare Part A and Part B claims for women ≥ 65 years old, we calculated age-adjusted hip fracture rates, weighting to the 2014 population. Results: We found that hip fracture rates declined each year from 2002 to 2012 and then plateaued at levels higher than projected for years 2013, 2014, and 2015. Conclusions: The plateau in age-adjusted hip fracture incidence rate resulted in more than 11,000 additional estimated hip fractures over the time periods 2013, 2014, and 2015. We recommend further study to assess all factors contributing to this remarkable change in hip fracture rate and to develop strategies to reduce the osteoporosis treatment gap.
Article
Introduction: In order to identify novel correlates associated with low spinal bone mineral density (BMD) in mid-life women, we examined a large number of lifestyle and medical and performance measurements and developed a prediction model for triage to BMD scanning. Methods: Women (n = 512) aged 45-69 years (mean 57.0 ± 6.3) attending gynecology clinics for "well woman" visits were recruited for this cross-sectional study from 2014 to 2015. We assessed symptoms, medical history, anthropometry, and physical performance. Stepwise multinomial logistic regressions were performed to examine significant associated covariates for pre-specified outcomes (normal [T-score ≥ -1.0], low bone mass [T-score between -1 and -2.5], and OP [T-score ≤ -2.5] at the lumbar spine). A new screening model was developed, and its performance was compared with the OP Screening Tool for Asians (OSTA) and Fracture Risk Assessment Tool (FRAX®). Results: Spinal OP was found in 6.8%. Multivariate analysis indicated that chronic joint pain, the most common symptom reported by 37.5% of the women, was significantly associated with OP. Only age (Relative Risk Ratio [RRR] 1.63; 95%CI, 1.03-2.60), weight (RRR 0.14; 95% CI, 0.07-0.27), postmenopausal status (RRR 11.59, 95%CI, 1.15-116.73), chronic joint pain (RRR, 4.12; 95% CI, 1.53-11.07), and right handgrip strength (RRR 0.50; 95% CI, 0.31-0.80) were independently associated with spinal OP. Combining these five variables, our final model's area under curve (AUC) was significantly higher at 84% than both the OSTA [AUC; 79% (p value < 0.0231 'c' statistics)] and FRAX® [AUC 58% (p value < 0.0001 'c' statistic)]. Conclusion: A novel screening tool that combines age, weight, and menopausal status with chronic joint pain and right handgrip strength more reliably predicts spinal OP in mid-life Singaporean women.
Article
A growing elderly population is expected worldwide, and the burden of hip fractures on health care system will continue to increase. By 2035, there will be a 2.7-fold increase in the number of hip fractures in Taiwan. The study provides quantitative basis for the future distribution of medical resources. Introduction: Hip fractures have long been recognized as a major public health concern. The study aimed to determine time trends in the incidence of hip fractures and to forecast the number of hip fractures expected in Taiwan up to 2035. Methods: A nationwide survey was conducted using data from the Taiwan National Health Insurance Research Database from 2004 to 2011. A total of 141,397 hip fractures were identified, with a mean of 17,675 fractures/year. Annual incidences of hip fractures were calculated and tested for trends. Projections of the incidence rates of hip fractures and bed days associated with hip fractures were calculated using Poisson regression on the historical incidence rates in combination with population projections from 2012 to 2035. Results: The incidence rates of hip fracture during 2004-2011 were 317 and 211 per 100,000 person-years among women and men, respectively. Over this 8-year period, the age-standardized incidence of hip fracture decreased by 13.4% among women and 12.2% among men. Despite the decline in the age-standardized incidence, the absolute number of hip fractures increased owing to the aging population. The number of hip fractures is expected to increase from 18,338 in 2010 to 50,421 in 2035-a 2.7-fold increase. The number of bed days for 2010 and 2035 was estimated at 161,248 and 501,995, respectively, representing a 3.1-fold increase. Conclusions: The socioeconomic impact of hip fractures will be high in the near future. This study provides a quantitative basis for future policy decisions to serve this need.
Article
Despite wide variations in hip rates fractures worldwide, reasons for such differences are not clear. Furthermore, secular trends in the age-specific hip fracture rates are changing the world map of this devastating disease, with the highest rise projected to occur in developing countries. The aim of our investigation is to systematically characterize secular trends in hip fractures worldwide, examine new data for various ethnic groups in the United States, evidence for divergent temporal patterns, and investigate potential contributing factors for the observed change in their epidemiology. All studies retrieved through a complex Medline Ovid search between 1966 and 2013 were examined. For each selected study, we calculated the percent annual change in age-standardized hip fracture rates de-novo. Although occurring at different time points, trend breaks in hip fracture incidence occurred in most Western countries and Oceania. After a steep rise in age-adjusted rates in these regions, a decrease became evident sometimes between the mid seventies and nineties, depending on the country. Conversely, the data is scarce in Asia and South America, with evidence for a continuous rise in hip fracture rates, with the exception of Hong-Kong and Taiwan that seem to follow Western trends. The etiologies of these secular patterns in both the developed and the developing countries have not been fully elucidated, but the impact of urbanization is at least one plausible explanation. Data presented here show close parallels between rising rates of urbanization and hip fractures across disparate geographic locations and cultures. Once the proportion of the urban population stabilized, hip fracture rates also stabilize or begin to decrease due to the influence of other factors such as birth cohort effects, changes in bone mineral density and body mass index, osteoporosis medication use and/or lifestyle interventions such as smoking cessation, improvement in nutritional status and fall prevention. © 2014 American Society for Bone and Mineral Research
Article
We determined the number and incidence of hip fractures in Tangshan, China, in 2010. Compared with data we reported in Tangshan from 1994, the crude and age-specific incidence increased significantly for both sexes, especially in women. Strategies are needed for effective fracture prevention in the future. The aims of the study were to determine the incidence of cervical and trochanteric fractures of the proximal femur in Tangshan, China, in 2010 and to compare the incidence with data from 1994. The orthopedic departments of 15 hospitals in Tangshan were visited in 2010; the medical records and radiographs of patients who had sustained cervical and trochanteric fractures were reviewed. The absolute number of admissions was collated and the incidence rate per 100,000 person years was calculated, adjusted by different age ranges, and gender. We then calculated the age-standardized incidence in 2010 as compared with those from 1994. The population of Tangshan in 2010 was determined to be 3,075,382 (1,558,173 males; 1,517,209 females); there were 1,509 cervical and trochanteric fractures (in 745 males and 764 females). The overall incidence was 47.8 and 50.4 fractures per 100,000 per year for men and women, respectively. Females showed a higher fracture incidence than males in those aged 55 years and over. Comparing the 2010 data with the 1994 findings, the incidence increased by 85 % in men and by 306 % in women; age-specific increases were observed in all female and male groups (except the 55-59 years age group). Compared with the results in 1994, the incidence of hip fracture has markedly increased in 2010 in Tangshan, China. It is necessary to implement a comprehensive policy for hip fracture prevention in our communities.
Article
Unlabelled: The prevalence of secondary contributors to osteoporosis in our population of SE Asian patients is high. Though various low thresholds Z score values have been proposed as suggestive of a high likelihood of secondary osteoporosis, they appear to have only limited discriminatory value in identifying a secondary cause. Introduction: Many patients with osteoporosis have significant secondary contributors towards their bone loss. The sensitivity and diagnostic utility of using Z score thresholds to screen for secondary osteoporosis have not yet been convincingly demonstrated nor has there been any previous attempt to estimate the prevalence of secondary osteoporosis in South East Asia. We aimed to study the prevalence of commonly recognized contributors and to determine the discriminatory ability of Z score thresholds in screening for them in Singaporean men and post-menopausal women with osteoporosis. Method: Three hundred thirty-two consecutive patients seen at the osteoporosis clinic of the largest hospital in Singapore were evaluated. The frequencies of the different contributors were determined and sensitivities, specificities, and positive and negative predictive values (PPV and NPV) of pre-specified Z score cut-off values calculated. Results: Vitamin D deficiency was present in 18.5% of the patients, hyperthyroidism in 10.11%, primary hyperparathyroidism in 1%, secondary hyperparathyroidism in 6%, hypercalciuria in 21.63%, glucocorticoid use in 8.43%, and hypogonadism in 9.4% of males. A Z score value of <-1 had a sensitivity of 71.7 % and NPV of 66.2 % in identifying the presence of a secondary contributor in post-menopausal women. The sensitivity and NPV of a similar threshold in men was 59.1 and 40 %, respectively. ROC curves used to investigate various Z score diagnostic thresholds for sensitivity and specificity showed that they provided poor predictive value for the presence of secondary osteoporosis. Conclusion: Secondary contributors are common in our patients with osteoporosis. Z score diagnostic thresholds have only limited value in discriminating between primary and secondary osteoporosis.
Article
The age-specific rates of hip fractures have been declining in most countries in the West but a few studies suggest that the rates might be increasing in areas of Asia that are undergoing urbanization.(1) We previously conducted a population-based study of hip fracture rates in Beijing, China in 1990-92 that included validation of hip fracture cases. Using a similar approach to validate cases, we estimated the age-specific hip fracture rates in Beijing, China for 2002-2006. Specifically, we obtained hospital discharge data for hip fractures were reported to the Beijing Bureau of Public Health. To confirm the diagnoses, Beijing residence, and find cases missed by the public records we checked individual cases in the public health records against medical records in a random sample of Beijing hospitals. The rates from public health data were adjusted for these under- and overestimations. We found that between 1990-92 and 2002-2006, the adjusted age-specific rates of hip fracture over age 50 years increased 2.76-fold (95% CI, 2.68 to 2.84) in women and 1.61-fold (95% CI, 1.56 to 1.66) in men. Over age 70 years, the age-specific rates increased 3.37-fold (95% CI, 3.28 to 3.47) in women and 2.01-fold (95% CI, 1.95 to 2.07) in men. From 2002 to 2006, the rates over age 50 years increased 58% in women and 49% in men. We conclude that the rate of hip fracture has been rising very rapidly in Beijing, China. Therefore, the burden of hip fractures may be shifting rapidly from the West to urbanizing areas of the East. © 2011 American Society for Bone and Mineral Research.
Article
Compliance and persistence to bisphosphonates amongst Singaporean patients with osteoporosis were estimated. Mean medication possession ratio (MPR) ± standard deviation (SD) was 78.9 ± 27.5%, and 69.0% was persistent at 1 year. In contrast to US and Europe where poor adherence is noted, our study suggests higher adherence rates to bisphosphonate therapy amongst patients. Adherence to bisphosphonate therapy during treatment of osteoporosis has been reported to be poor. We aimed to estimate the compliance and persistence to prescribed bisphosphonate therapy amongst patients at the largest public restructured hospital in Singapore. This is a retrospective analysis of records of patients who were prescribed the two most commonly used oral bisphosphonates-alendronate and risedronate. The study was conducted between January 2007 and December 2008. Prescription and pharmacy refill records of all patients were extracted and matched. Compliance was calculated using the MPR, while persistence, a dichotomous variable, was defined as continuous refill of bisphosphonates for at least 12 months with a permissible gap of 30 days. Seven hundred ninety-eight patients were included in the study. Mean MPR ± SD was 78.9 ± 27.5%, and 69.0% of the patients were persistent with bisphosphonate therapy at 1 year. The proportion of patients with MPR ≥ 80% at 6, 12 and 18 months was 90%, 72% and 62%, respectively. Age <69 years was associated with better compliance (OR, 1.34; 95% CI, 0.99-1.82; P = 0.043), and history of fractures was associated with better compliance (OR, 1.38; 95% CI, 1.02-1.87; P = 0.038) and persistence (OR, 1.33; 95% CI, 0.97-1.82; P = 0.046). In contrast to studies conducted in the US and Europe that show poor adherence, our study suggests higher adherence rates to bisphosphonate therapy amongst Singaporean patients.
Article
We examined trends in fracture rates over 20 years in the Province of Manitoba, Canada. Hip fractures, major low-trauma fractures, and high-trauma fractures declined significantly from 1986 to 2006. Secular decreases in hip fracture rates have been reported in some countries. Whether this phenomenon applies to other fracture sites is not well described. We used 20 years of data from the Population Health Research Data Repository for the Province of Manitoba, Canada. Age-adjusted fracture rates were calculated for men and women age 50 years and older 1986-2006 according to fracture site and mechanism (presence/absence of external injury codes). Generalized linear models with generalized estimating equations were used to derive adjusted annual rates and test for linear change in men and women. Major low-trauma fractures (hip, forearm, spine, and humerus) showed a significant annual linear decline in women (-1.2% [95% CI, -0.7% to -1.8%]) and in men (-0.4% [95% CI, -0.7% to -0.2%]). Hip fracture showed a significant annual decline for both sexes, while forearm and humerus fractures showed a significant decline only in women. The only fracture category that did not show a significant annual decline in either sex was the spine. The observed annual reduction in high-trauma fractures was even larger and did not show a sex difference (-1.8% [95% CI, -2.8% to -0.7%]). We observed a decrease in both low-trauma and high-trauma fracture rates over the study period. This decline was apparent in years prior to widespread osteoporosis testing or availability of modern pharmacotherapy.
Article
Controversies exist about the change in hip fracture incidence among countries. In France, over the last 6 years, the incidence in people aged 40 years and over of hip fractures decreased in women over 39 years and increased in men; a decrease in the incidence was observed in both genders in the elderly. Controversies exist about the change in hip fracture incidence among countries. The aim of this study was to assess the incidence of hip fractures in men and women aged 40 years and over between 2002 and 2008 in France. Data were drawn from the French Hospital National Database. The absolute number of admissions was described and the incidence rates per 1,000,000 adjusted on age (40-59, 60-74; 74-84, and ≥ 85 years), and gender was calculated using the data of the French population. The number of hip fractures increased in men (+13%; from 14,736 in 2002 to 16,611 in 2008) and remained stable in women (+0.2%, 50,910 in 2008). Between 2002 and 2008, the French population increased by 9% in both genders. Incidence over 39 years decreased by 8% in women (3,356 and 3,093 per million in 2002 and 2008, respectively) and increased by 4% in men (1,131 and 1,172 per millions in 2002 and 2008, respectively). An age-specific incidence decrease was found, in particular, in the elderly in both genders (74-84 and ≥ 85 years), most importantly in women. Over the last 6 years, the incidence of hip fractures decreased in women aged over 39 years and increased in men aged over 39 years; a decrease in the incidence of these fractures was observed in both genders in the elderly. Such epidemiological data may help policy making, planning resource allocation, and setting up complementary health decisions for the management of osteoporosis.
Article
In this population-based study, we determined the incidence rates of hip fracture among Singapore residents aged 50 years and above. Information was obtained from a centralized database system which captured admissions with the primary diagnosis of a closed hip fracture (ICD-9 codes 820, 820.0, 820.2 and 820.8, n = 12,927) from all health care establishments in the country from 1991 to 1998 inclusive. After removing duplicates, hospital transfers, readmissions and non-acute care admissions, the total number of hip fractures was 9406. Based on the national population census 1990 (n = 464,100) and yearly population estimates, the age-adjusted hip fracture rates for 1991-1998 (per 100,000) were 152 in men and 402 in women. This was 1.5 and over 5 times higher than corresponding rates in the 1960s. From 1991 to 1998, these hip fracture rates tended to increase by 0.7% annually in men and by 1.2% annually in women. Among the three major racial groups, in men, the Chinese had significantly higher age-adjusted hip fracture rates (per 100,000): 168 (95% confidence interval (CI) 158-178) compared with 128 (95% CI 105-152) for Indians and 71 (95% CI 54-88) for Malays. A similar pattern occurred in women: 410 (95% CI 395-425), for Chinese compared with 361 (95% CI 290-432) for Indians and 264 (95% CI 225-303) for Malays. Since the 1960s, the main increases in hip fracture rates have been seen in the Chinese and Malays, with the rates in Indians appearing to decrease. Hip fracture incidence rates in Singapore have risen rapidly over the past 30-40 years, particularly in women, and are now among the highest in Asia. Significant racial differences in hip fracture rates occur within the same community. Time trends in hip fracture rates differed between races.
Article
Many drugs are now available for the prevention and treatment of osteoporosis. They have differing levels of evidence of efficacy and each may be used according to clinical indications. A Medline search of clinical drug trials using various therapeutic agents used for osteoporosis was carried out. Several randomised controlled trials have been carried out using many agents. The agents with the best data to date with regards to the prevention of spine as well as hip fractures in patients with prevalent fractures belong to alendronate and risedronate. Parathyroid hormone has been shown in one trial to reduce the risk of non-vertebral fractures. For reduction of spine fractures, in addition to the above two bisphosphonates, many agents, in particular raloxifene, have been shown to be clearly beneficial. Weaker data exist for hormone replacement, calcitonin, cyclical etidronate and the vitamin D analogues calcitriol and alfacalcidol. There are many therapeutic agents shown to be clearly effective in the treatment of osteoporosis.
Article
Osteoporosis twenty years ago was a very different disease from what we know of it today. At that time a diagnosis of osteoporosis was made at the point of sustaining a fracture as there was no routine method of pre-fracture diagnosis such as bone mineral density measurement.
Article
A population-based survey was conducted to determine the awareness, knowledge of risk factors, and attitudes toward osteoporosis in middle-aged and elderly women in Singapore. Chinese women aged 45 years and above ( n=1,376) living in Teban Gardens (community on the western side of Singapore) were randomly sampled. Household interviews were conducted and questions on socioeconomic status, knowledge of osteoporosis, identification of risk factors for osteoporosis, and health beliefs were assessed. There were 946 (68.8%) women who were postmenopausal and 430 (31.2%) who were not. Fifty-eight percent of the sample had heard of osteoporosis. Women who were younger, better educated, who exercised regularly, or who were single were more likely to have heard of osteoporosis. The main sources of information about osteoporosis were the mass media and friends. The identification of risk factors ranged from fair to good: 85.7% of women identified low calcium intake, 43.7% identified lack of exercise, and 30.5% identified family history of osteoporosis as risk factors for osteoporosis. Most women (79.1%) were concerned about developing osteoporosis but only 15.2% thought that osteoporosis was more serious than cancer. Community-based health education programs on osteoporosis that target a wide audience including the less well educated, could be implemented. Increasing the awareness of osteoporosis and its risk factors may be essential in efforts to decrease the incidence of this disease.