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The potential effect on hip fracture incidence of mass screening for osteoporosis
Nicholas A Pocock, Nicole L Culton and Neil D Harris
MJA 1999; 170: 486-488
For editorial comment, see Morris et al; see also Sanders et al.
With ageing of the Australian population, treatment of osteoporosis-related hip fractures will impose an increasing burden on the healthcare system. Based on current age-adjusted hip fracture incidence and population projections for New South Wales, we estimated a 90% increase in hip fractures by the year 2021. Contributing significantly to this increase will be the number of men reaching the high risk age group for osteoporotic hip fractures. A suggested solution -- screening and appropriate therapy for individuals at high risk of osteoporosis -- may have only a modest impact. Our calculations show that, even with optimistic screening and therapy compliance rates, hip fractures could still increase by over 50%. Other approaches need to be further explored.
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| Introduction |
Osteoporosis-related hip fractures are a high-cost item in the
Australian healthcare budget, and place considerable demands upon
the limited resources of the public health system. This burden will
increase in the first quarter of the next century as the projected
Australian population over 65 years of age increases from the current
level of 2.25 million to between 4.02 and 4.05 million by
2021.1 To avoid this impending
healthcare crisis, several reports have suggested a screening
program to identify individuals at high risk of osteoporosis,
followed by appropriate intervention to reduce the number of hip
fractures.2-6
The possible introduction of a mass-screening program for osteoporosis raises a number of issues. Cost effectiveness is of major importance, and there are reports to indicate that screening for osteoporosis may well be cost effective.3,5,6 However, few data exist on the impact of a screening program on the healthcare system, and, in particular, on the demand for acute-care hospital beds, which has important implications for healthcare planning. To assess the impact of screening on the demand for hospital beds for hip fracture treatment, we have used available population projections for New South Wales (NSW) to calculate the likely number of hip fractures in people aged 65 years or older by the year 2021. We then assessed the potential of a screening program, coupled with effective therapy, to reduce hip fracture incidence using available data on population capture rates of current large screening programs, and data on therapy compliance and drug-efficacy rates. Our methods and the results we obtained are shown in the Box. | ||||||
| Discussion |
Current costs of osteoporotic hip fractures in Australia exceed $400
million annually,15 and hip fracture
treatment is making great demands on an already overstretched
hospital infrastructure.2,7,16,17
In 1994-95, there were 52017 admissions to NSW hospitals of patients over 65 years of age with major hip fractures. Without further intervention, our calculations show that, even with a low population growth model, this figure may rise by the year 2021 to 9800 hip fracture admissions annually in this age group, an increase of about 89%. A major cause will be the increase in the number of men reaching the high risk age group for osteoporotic hip fractures. In 1997, the population of men in NSW over 80 years of age numbered about 60 300.1 This is projected to increase to about 123 900 by 2021,1 an increase of 106%. A 65% increase in the number of women over 80 years of age is expected in the same interval. Our calculations show the limited preventive effect on increasing hip fracture incidence of an active interventional screening and therapy program for osteoporosis. Even with a relatively optimistic 60% screening and therapy compliance rate, hip fractures may still increase by about 55% compared with 1994-95. In view of the age of the target population (the average age of hip fracture patients in NSW is 82 years7), 40% capture and therapy compliance rates may be more realistic, suggesting that hip fractures may increase by 74% compared with 1994-95. It is also possible that capture and therapy compliance rates in the target population might not even achieve these levels. We also used the lowest of a number of population growth models.1 If faster population growth occurs, the increase in hip fractures will exceed our predictions, with correspondingly more serious implications for the healthcare system. We assumed the screening technique would identify all patients at increased risk of hip fracture and all would be offered therapy. This optimistic assumption is almost certainly incorrect and thus our calculations overestimate the benefits of a screening program. On the other hand, compared with current drug regimens, advances in therapy may decrease fracture risk. Moreover, therapies with minimal toxicity and which have demonstrated benefit, such as vitamin D and calcium, could be applied widely to high risk patients in nursing homes and other institutions.2,13 However, the potential benefit of such an approach is limited, as, at present, only 29% of hip fracture patients are admitted from nursing homes and an additional 9% from hostels.7 Our analysis does not address the cost efficacy of a screening program for osteoporosis. Nor does it address the possible role of population education in preventing osteoporosis. Recent raised community awareness of osteoporosis may translate in the future into consumer-driven demand for preventive action from healthcare providers and more self- initiated prevention. The recent increased demand for acute-care hospital beds in NSW has been partly met by reducing the average length of stay in hospital and increasing the number of day-only procedures. However, there is a limit to how much of the demand for hospital services can be met by these means. The average length of stay for hip fracture treatment in NSW has already been reduced from 31.5 days in 198018 to 11 days in 1995,7 and there is likely to be only limited additional gain from future efforts to reduce hospital stay for these patients.7 The increased number of hip fractures by 2021 will require considerable additional hospital resources, and, in view of the seasonal variation in hip fracture incidence,18 may impose an extreme burden on hospital services at certain times of the year. To cope with this, health service providers need to address the issue of future hospital bed availability for hip fractures. Failure to plan adequately may result in delay in treating other, less urgent, patients. In conclusion, Australia, like other Western countries, must cope with the health problems of an ageing population in the early part of the next century, with osteoporotic hip fractures likely to be a major component of the expected increased demand for acute-care hospital services. A preventive program based on mass screening for osteoporosis and treatment of high risk individuals may have only a limited impact. While potentially of benefit, this approach would be insufficient by itself, and additional or alternative approaches to this problem, such as education of the community, need to be further explored. | ||||||
| References |
(Received 13 Nov 1998, accepted 13 Mar 1999) | ||||||
| Authors' details |
Department of Nuclear Medicine and Bone Densitometry, St Vincent's
Hospital, Sydney, NSW.
Nicholas A Pocock, MD, FRACP, Senior Staff Specialist. Nicole L Culton, BAppSc, Research Officer. Neil D Harris, BA(Comm), RN, Research Officer.
Reprints will not be available from the authors. ©MJA 1999 | ||||||
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