Act now to reduce the burden of fragility fracture in Hong Kong
Hong Kong is facing a rising burden of osteoporosis and fragility fracture due to its aging population. Life expectancy in the territory is high, at 81.9 years for men and 87.6 years for women (based on 2017 data),1,2 and over 30% of the population will be 65 years or older by 2065 (Figure 1A).3 Prevalence of osteoporosis in men and women over 50 years of age is estimated to be as high as 37% in some studies, and a cohort analysis found that 7% of men and 11% of women older than 65 years had sustained one or more major osteoporotic fractures (MOFs) over 9.9 years and 8.9 years of follow up, respectively.4 Hospital Authority data show the annual number of hip fracture surgeries almost doubled from 3,678 in 2000 to 6,300 in 2020, and estimates suggest this will rise further to more than 14,500 by the year 2040 (Figure 1B).5
For patients who suffer a fragility fracture, followup care is suboptimal; a 2012 study of patients admitted for fragility hip fractures across six large Hong Kong hospitals found that only 35.1% attended out-patient followup in the following year and a mortality rate of 17.3% was observed (compared with 1.6% in an age-matched population).6 The same study found that 1 year after fracture mobility had deteriorated in 70% of patients, 6% had fracture complications and 4% had secondary fractures.6 Fragility fractures also impose a high economic burden: the direct cost of a single hip fracture surgery was HKD 81,120,4 and 23% of formerly community-dwelling patients were discharged into an old-age home after a hip fracture, imposing further costs on families.6
Fortunately, many of the studies that provide alarming data on the burden of osteoporosis in Hong Kong also clearly identify gaps in care that can be closed, preventing many fractures from occurring. The locally-recommended diagnostic for osteoporosis is dual-energy x-ray absorptiometry (DXA), but barriers to access exist in both the private and public sector, and in 2013 waiting times in the public sector as long as 9 months were noted.7 A 2007 survey of postmenopausal women in several Asian countries found that in Hong Kong, less than 50% of patients who suffered a fragility fracture were diagnosed with osteoporosis in the following 6 months, and fewer than 20% underwent bone mineral density (BMD) measurement.8 Bone strengthening medications are underused in Hong Kong; even in patients who have experienced a hip fracture, fewer than 10% are prescribed antiosteoporosis medication in the following year.9 Overall, there is substantial room for improvement in the diagnosis and treatment of osteoporosis in Hong Kong.
Encouraging examples of what can be done to improve diagnosis, treatment and fall prevention can be found in studies both local and abroad. Screening programmes that use DXA to identify patients, followed by treatment with antiresorptive drugs, can be a cost effective approach to reduce the burden of fragility fractures.10,11 A screening programme in the UK used the Fracture Risk Assessment (FRAX) questionnaire and DXA measurements to identify older women at risk of fracture and encourage them to seek treatment with their general practitioner.12 Compared with controls, women in the screening programme had higher use of antiosteoporosis medications (15% vs 4% at the end of year 1), and, over 5 years, a 28% relative reduction in hip fractures was observed.12 A local study found risk assessments and modifications to the homes of community-dwelling older persons can be effective in reducing the prevalence of falls,13 and such assessments are recommended in international guidelines.14
While an aging population may be unavoidable, an ever-increasing burden of fragility fracture need not be inevitable. A group of local osteoporosis experts is formulating a set of locally-adapted, evidence-based practical recommendations to reduce the burden of fragility fracture in Hong Kong. The recommendations will include proposals for population screening, treatment with antiresorptive drugs and structured assessment of fracture risk. These proposals, their economic costs and benefits and the supporting evidence will be discussed in detail in a forthcoming publication in the Hong Kong Medical Journal. This publication will be an important first step in reducing the burden of osteoporosis, and ensuring that older people in Hong Kong can look forward to a healthier future.