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Original Investigation
June 17, 2019

Association of Disease Definition, Comorbidity Burden, and Prognosis With Hip Fracture Probability Among Late-Life Women

Author Affiliations
  • 1Department of Medicine, University of Minnesota, Minneapolis
  • 2Division of Epidemiology & Community Health, University of Minnesota, Minneapolis
  • 3Center for Chronic Disease Outcomes Research, VA Health Care System, Minneapolis, Minnesota
  • 4Department of Medicine, Johns Hopkins University, Baltimore, Maryland
  • 5Department of Medicine, VA Health Care System, Minneapolis, Minnesota
  • 6HealthPartners Institute, Bloomington, Minnesota
  • 7Division of Health Policy & Management, University of Minnesota, Minneapolis
  • 8Department of Medicine, University of California, San Francisco
  • 9California Pacific Medical Center Research Institute, San Francisco
JAMA Intern Med. 2019;179(8):1095-1103. doi:10.1001/jamainternmed.2019.0682
Key Points

Question  What is the association of disease definition, comorbidity burden, and prognosis with 5-year hip fracture probabilities among women 80 years and older?

Findings  This prospective cohort study found that the 5-year hip fracture probability, taking into account the competing risk of death, was over 3-fold higher among women with osteoporosis compared with women without osteoporosis but at high fracture risk. The difference between groups in hip fracture probabilities was even more pronounced in women with a greater number of comorbidities or poorer prognosis.

Meaning  Women 80 years and older with osteoporosis, including those with more comorbidities or poorer prognosis, have a high hip fracture probability despite accounting for competing mortality risk and may be the group most likely to be candidates for drug treatment to prevent hip fractures.

Abstract

Importance  Advanced age is associated with lower use of drug treatment to prevent fractures, but concerns about comorbidities and prognosis increase the complexity of managing osteoporosis in this age group.

Objective  To determine the association of disease definition, number of comorbidities, and prognosis with 5-year hip fracture probabilities among women who are 80 years and older.

Design, Setting, and Participants  This prospective cohort study (4 US sites) included 1528 community-dwelling women identified as potential candidates for initiation of osteoporosis drug treatment.

Main Outcomes and Measures  Women were contacted every 4 months to ascertain vital status and hip fracture. Five-year hip fracture probability was calculated accounting for competing mortality risk. Participants were classified into 2 distinct groups based on disease definition criteria proposed by the National Bone Health Alliance: with osteoporosis (n = 761) and without osteoporosis but at high fracture risk (n = 767). Comorbid conditions were assessed by self-report. Prognosis was estimated using a mortality prediction index. All analysis was performed between March 2018 and January 2019.

Results  The study had 1528 participants, all of whom were women, with a mean (SD) age of 84.1 (3.4) years. During follow-up, 125 (8.0%) women experienced a hip fracture and 287 (18.8%) died before experiencing this event. Five-year mortality probability was 24.9% (95% CI, 21.8-28.1) among women with osteoporosis and 19.4% (95% CI, 16.6-22.3) among women without osteoporosis but at high fracture risk. In both groups, mortality probability similarly increased with more comorbidities and poorer prognosis. In contrast, 5-year hip fracture probability was 13.0% (95% CI, 10.7-15.5) among women with osteoporosis and 4.0% (95% CI, 2.8-5.6) among women without osteoporosis but at high fracture risk. The difference was most pronounced among women with more comorbidities or worse prognosis. For example, among women with 3 or more comorbid conditions, hip fracture probability was 18.1% (95% CI, 12.3-24.9) among women with osteoporosis vs 2.5% (95% CI, 1.3-4.2) among women without osteoporosis but at high fracture risk.

Conclusions and Relevance  Women 80 years and older who have osteoporosis, including those with more comorbidities or poorer prognosis, have a high 5-year probability of hip fracture despite accounting for competing mortality risk. In contrast, among women without osteoporosis but at high fracture risk, competing mortality risk far outweighs hip fracture probability, especially among those with more comorbidities or worse prognosis.

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