Why hip fractures are the development health challenge we need to discuss

CANBERRA — At the 68th session of the World Health Organization Regional Committee for the Western Pacific, held in Brisbane last month, health priorities under discussion included infectious diseases, childhood obesity, nutrition, mother-to-child disease transmission, and the cost of health delivery.

But a new report from the Economist Intelligence Unit and biotechnology company Amgen highlights a new health risk for the region — hip fractures and osteoporosis.

Why do we need to discuss hip and fragility fractures?

The risks of hip fractures and osteoporosis are known to increase with age. For the sufferers, they can lead to loss of mobility, independence, and — in some instances — death. And once someone has suffered a fracture, they are greatly at risk of another.

According to the new report, hip fractures are already a significant public health challenge across the Asia-Pacific region, where ageing populations, increased urbanization, and low vitamin D levels are combining to increasing the risks of osteoporosis and subsequent fractures — with impacts beyond the individual sufferer. In many societies within the Asia-Pacific, where older members of society support their families as caregivers and are in turn financially supported, fractures impact household structures and incomes.

“What we’re trying to do is highlight the problem of osteoporosis,” Professor Peter Ebeling, medical director for Osteoporosis Australia, explained to Devex. “And we want to demystify the effects of ageing on increasing the risk of osteoporosis. So what we are doing is looking at the economic impact on countries, and it is very high.”

While the study investigated risks in developed countries, experts contributing to the research explained to Devex that the key lessons are no less important for developing nations, whose health systems are already stressed.

“In Australia alone this year, the cost of treating hip fractures due to osteoporosis is over $3 billion [Australian dollars], so that is going to increase to over $5 billion [Australian dollars] unless something is done about it soon,” Ebeling said. “It is a huge amount of money. But all countries in the region are going to be affected, with China and India among those that will have the largest economic impact.”

What are the lessons for developing countries in the Pacific?

Research into hip fractures and osteoporosis is in its relative infancy, but the research conducted highlights the hidden medical burden it plays in societies.

For sufferers, ineffective diagnosis or lack of treatment means some patients need to live with the fracture. “We know in Australia about 20 percent of women and 35 percent of men die in the first 12 months after a hip fracture,” Ebeling said. In other countries in the Asia-Pacific region, especially developing countries, he said the risk of death is greater.

According to Professor Kerrie Sanders, from the Institute for Health & Ageing at the Australian Catholic University, developing countries could do well to learn from the missteps of nations like Australia.  

“Population projections show us that the number of elderly in developing country populations is skyrocketing and it’s a much greater increase than even Australia and the U.K. because they are starting from such a small number of very elderly,” Sanders explained to Devex. “Previously their life expectancy wasn’t great, but as their life expectancy grows so too do the health risks.”

While Australia and many other countries have had to go through research to document that only 15 to 20 percent of people who suffer fractures are investigated for a risk of osteoporosis and subsequent fractures, developing countries should consider this fact and go straight to intervention policies. “We know people who have had a fracture are double — if not more — at risk of a secondary fracture,” Sanders said.

Second, she said, is being aware of the numbers associated with the population at risk, as this is important in projecting the number of hospital beds required to support hospital treatment due to hip fractures.

“Even if countries decrease the risk of subsequent fractures, the explosion in the number of people likely to fracture means governments really need to be looking at the capacity for hospital beds for their older population,” Sanders said. “And it’s good to be setting up protocols for how you treat hip fracture patients. Good protocols can minimize length of stay while maximizing the return of difficult function and quality of life.”

Is the risk increased in developing countries?

The WHO regional meeting underscored how high health service costs among Pacific island countries impacted their ability to serve the needs of their communities. Given the pressures health systems already face, their ability to respond to the burden of hip fractures and osteoporosis is low, said Ebeling and Sanders.

For people living in poor or remote communities, meanwhile, the risk of death from fractures was likely to be higher.

“Without the support systems set up, it can be a downward spiral of physical functions and mental health,” Sanders said.

And there is concern that the growing inactivity of children, poor diets, and obesity among children in developing countries will lead to a higher likelihood of osteoporosis in future elderly populations.

“The most important time for the development of bones is before puberty and around the time of puberty,” Ebeling explained. “So you need to have adequate calcium intake and good vitamin D to optimize that. But the most important thing, around that time, is to exercise. That has a major effect in increasing bone density.”

What strategies can assist?

Both Ebeling and Sanders identified a service and strategy that is working in supporting sufferers of fractures — the fracture liaison services.

“This is where somebody is employed in the health care system to track patients who come into a hospital or emergency department with a broken bone,” Ebeling explained. “If they are over the age of 50 it is most likely due to osteoporosis, so the patient is investigated and treated. But without that, less than 20 percent of people get investigated and treated. With a good fracture liaison service, we get the level of investigation and treatment to somewhere between 75 to 80 percent. And this has been shown to reduce subsequent fractures, and they become cost effective by reducing the cost of treating fractures.”

Sanders agreed. “It is a cost-effective model that has been shown over and over again to save money and work,” she said.

But it takes strong policy and governmental leadership to implement the program successfully.

“Even in Australia, we’re working hard to highlight to policy makers and the public that just because you are getting old you shouldn’t assume you will have a fracture,” Sanders said. “It can be prevented, and don’t take it as a normal part of ageing that you fracture. Changing policy is driven from what the people want. If the public are aware, it will drive change.”

Calls for regional and WHO leadership on hip fractures

The report called for better awareness of hip fractures, osteoporosis, and the prevention of death for the public, health care providers, and governments. It also calls for a multistakeholder response to effectively deal with the coming health burden.

But Ebeling said the recent WHO regional meeting showed that hip fractures and osteoporosis were still being underestimated by the WHO. “There tends to be lack of integration and interest in osteoporosis and broken bones,” he said.

“We’ve got an Australian researcher working with the WHO to include hip fractures and osteoporosis in the global burden of disease, which might improve the messaging of the WHO. But at the moment it is still missed. And that is why we think this report into the state of bone health in the Asia-Pacific region is important.”

Sanders explained that the backing and identification of fractures and osteoporosis as a health burden by the WHO is extremely powerful; it can lead to government policy focus but also increase the likelihood of financial support for research. “It certainly gives extra weight to grant applications,” she said. “Their policy and recommendations around this space will make a big impact.”

For leaders in the region, including the WHO, the key message from the report is to act now.

“It is really a crisis that is approaching,” Ebeling said. “We don’t want the Asia-Pacific region to be the epicenter of hip fractures in 2050. The time to act is now and we really need to approach the individual governments in the region with this data.”

Read more Devex coverage on global health.