Ching-Lung Cheung, PhD, on the Health Burden of Osteoporotic Fractures Among the Aging Population

In this Q&A session from the Rheumatology and Arthritis Learning Network, Ching-Lung Cheung, PhD, associate professor in the department of pharmacology and pharmacy, at the Li Ka Shing Faculty of Medicine, University of Hong Kong, spoke to us about his study of trends in incidence rates of treatment following hip fracture. Through a series of questions, Dr Cheung sheds light on actions that could help to reduce the projected public health burden of osteoporotic fractures among the aging population.

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RALN: What prompted you to conduct this research into studying the trends in hip fractures?

Dr Cheung: Hip fracture is a public health issue. Estimating the incidence of hip fracture is vital for clinical management and policy development. However, the existing data were collected using heterogeneous methodologies, so it is not easy to directly compare the incidence across countries and regions. In addition, some data needed to be updated. Thus, it is important to have an update on the incidence and the secular trend of hip fractures using a standardized method across different countries and regions.

RALN: Would you describe the general outline of your study?

Dr Cheung: In total, we analyzed 4,115,046 hip fractures data in 20 databases from 19 countries and regions across Oceania (State of Victoria in Australia, New Zealand), Asia (Hong Kong, Japan, Singapore, South Korea, Taiwan, Thailand), Northern and Western Europe (Denmark, Finland, the United Kingdom, France, Germany, Italy, the Netherlands, Spain), and North and South America (Canada, the United States, Brazil).

We sought to clarify:

The incidence rate of hip fracture,
The rates of post-hip fracture treatment within 1 year following hip fracture, 
The all-cause mortality rate within 1 year following hip fracture, and
The projection of the number of hip fracture in 2050.

RALN: What did you find?

Dr Cheung: The reported age- and sex-standardized incidence rates of hip fractures ranged from 95.1 (95% confidence interval [CI] 94.8–95.4) in Brazil to 315.9 (95% CI 314.0–317.7) in Denmark per 100,000 population. Incidence rates decreased over the study period in most countries; however, the estimated total annual number of hip fractures nearly doubled from 2018 to 2050. Within 1 year following a hip fracture, post-hip fracture treatment ranged from 11.5% (95% CI 11.1% to 11.9%) in Germany to 50.3% (95% CI 50.0% to 50.7%) in the United Kingdom.

RALN: During your research, did you identify any trends in the prevalence of hip fractures across various demographic differences such as age, gender, race, socio-economic factors and smoking habits?

Dr Cheung: Since we performed an age-standardized analysis, differences in age across various countries and regions should not affect the observed overall incidence rate. However, differences in the secular trend of hip fracture exist in various age groups and genders. Notably, although a decreasing trend of hip fracture was observed in many countries, such a decreasing trend was mainly driven by the data from women.

RALN: One of the objectives of the study was to understand the trends in the number of patients receiving antiosteoporosis medications postfracture. What specifically did you find? Did you identify any trends among men and women, young and old?

Dr Cheung: We were pretty surprised that almost all countries and regions studied had a suboptimal prescription of antiosteoporosis medications postfracture.

Most, if not all, international guidelines recommend using antiosteoporosis medications after hip fracture. However, more than 90% of the studied sites had a prescription rate of less than 50% within 1 year following hip fracture.

Our data clearly showed that men used antiosteoporosis medication less than women. This could be because osteoporosis is commonly seen as a “woman’s disease”. Together with the secular trend observed in men, these findings highlight the gender inequalities in the clinical management of osteoporosis.

RALN: What does that signify? Is there a subcategory of patients that physicians need to pay more attention to?

Dr Cheung: This suggests that physicians and patients do not see osteoporosis as a severe disease. Indeed, previous studies showed that primary care physicians and nurses see osteoporosis as a low-priority condition. Majority of the primary care physicians have a poor knowledge of osteoporosis. Physicians should understand that osteoporosis is not a woman’s disease. Treatment of osteoporosis in men is also important, especially when the mortality rate after hip fracture is much higher in men than in women.

RALN: Are there any alternatives to medication postfractures?

Dr Cheung: Medication remains the key component in the fracture management since it is the most effective way to reduce the fracture risk. In addition to medication, we should also pay attention to nonpharmacological interventions, like dietary advice, fall prevention, and exercise, which are also important.

RALN: The final aim of the study was to determine the all-cause mortality rates after an initial hip fracture. What did you find?

Dr Cheung: We found that the all-cause mortality 1-year after a hip fracture was >14% in general, ranging from 14.4% in Singapore to 28.3% in the United Kingdom.

RALN: The number of hip fractures among aging patients is expected to double by 2050, according to your research. Is that projection due primarily to the aging of the population in general, or are there other factors associated with the potential for such a dramatic increase in fractures?

Dr Cheung: Although a few countries showed an increasing trend in the incidence of hip fracture, the dramatic increase in the number of fractures by 2050 is primarily due to the expanding aging population and prolonged life expectancy.

RALN: What do you think rheumatologists can do – or do better – that might help to reduce that projection?

Dr Cheung: Rheumatologists are indeed very important in the management of osteoporosis. Osteoporosis in rheumatic diseases is a well-known complication, especially among patients with rheumatoid arthritis and receiving steroid treatment. Patients with rheumatic disease are at particularly high risk of fracture. Thus, timely management is required to reduce their fracture risk. Rheumatologists should evaluate patients’ fracture risk and prescripe antiosteporosis medication if appropriate.

RALN: Did anything about the results surprise you?

Dr Cheung: The prescription of antiosteoporosis medication after hip fracture is known to be low in Hong Kong. Regarding prescription rates, other countries should be much better than in Hong Kong. The data showed that I was wrong! Most countries have a low prescription rate, as bad as Hong Kong’s. This is something we need to pay attention to.

On the other hand, many people believe that fall prevention is important to prevent fractures; some even believe that fall prevention is more important than pharmacological intervention. In Hong Kong, we recently showed an increasing incidence of hospitalized falls. (https://www.thelancet.com/pdfs/journals/lanwpc/PIIS2666-6065(21)00092-4.pdf).

However, we also observed a decreasing trend in the incidence of hip fracture at the same time. This suggests that bone health has been improving in Hong Kong, leading to a decreasing trend of hip fractures despite an increasing trend of hospitalized falls.

RALN: Do you have any plans to expand this to a broader study?

Dr Cheung: The plan includes evaluating the impact of hip fracture in the high-risk group, such as patients with various comorbidities and receiving steroids. Our study shows that hip fracture remains a key public health issue, and the burden will increase even more in the coming years. Developing strategies to identify osteoporosis patients and provide timely management is important. For example, community screening for osteoporosis could be an effective way to reduce the burden of hip fractures.

Reference:

Sing CW, Lin TC, Bartholomew S et al. Global epidemiology of hip fractures: Secular trends in incidence rate, post-fracture treatment, and all-cause mortality. J Bone Miner Res. 2023; 38: 1064-1075. DOI: https://doi.org/10.1002/jbmr.4821