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Excess mortality after hip fracture: fracture or pre-fall comorbidity?

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Abstract

Summary

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.

Introduction

Hip 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.

Results

Twenty-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.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Singapore

    M.H.L. Liow, J.D.Y. Chen, J.S.B. Koh & T.S. Howe

  2. Division of Policy, Research and Evaluation, Ministry of Health, Singapore, Singapore

    G. Ganesan & K.B. Tan

  3. Department of Obstetrics and Gynecology, National University Hospital, National University of Singapore, Singapore, Singapore

    E.-L. Yong & M.S. Kramer

  4. Departments of Epidemiology, Biostatistics and Occupational Health and of Pediatrics, McGill University Faculty of Medicine, Quebec, Montreal, H3G 1Y6, Canada

    M.S. Kramer

  5. Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore

    K.B. Tan

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  1. M.H.L. Liow
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  2. G. Ganesan
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  3. J.D.Y. Chen
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  4. J.S.B. Koh
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  5. T.S. Howe
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  6. E.-L. Yong
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  7. M.S. Kramer
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  8. K.B. Tan
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Correspondence to M.H.L. Liow.

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MHL and GG are joint first authors.

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Liow, M., Ganesan, G., Chen, J. et al. Excess mortality after hip fracture: fracture or pre-fall comorbidity?. Osteoporos Int 32, 2485–2492 (2021). https://doi.org/10.1007/s00198-021-06023-0

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  • DOI: https://doi.org/10.1007/s00198-021-06023-0

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