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Racial and Ethnic Differences in Hip Fracture Outcomes in Men
Lucy H. Liu, MD, MPH; Malini Chandra, MS, MBA; Joel R. Gonzalez, MPH, MPP; and Joan C. Lo, MD
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Racial and Ethnic Differences in Hip Fracture Outcomes in Men

Lucy H. Liu, MD, MPH; Malini Chandra, MS, MBA; Joel R. Gonzalez, MPH, MPP; and Joan C. Lo, MD
Racial and ethnic differences in hip fracture incidence and mortality outcome were observed within a diverse population of older men, with lower rates of both among Asians.
Although men contribute a much smaller subset of the hip fracture population than women, they suffer greater morbidity and mortality compared with women. In our study, 1-year mortality following hip fracture was 32.9% in men—substantially higher than women (22.8%) within the same healthcare setting.23 National and regional data also demonstrate higher mortality rates up to 1 year post hip fracture in men compared with women.2,34 Because men may be less prone to falls, those who do experience hip fracture may have increased frailty, greater comorbidity, higher susceptibility to medical complications (eg, pneumonia), and potentially lower rates of subsequent bisphosphonate therapy compared with women.18,32,43 Whether the observed gender differences in mortality risk following hip fracture relate to pre- or postfracture health, including a potentially greater contribution of infection-related complications in men,15 is unclear.

Our study contributes to the growing recognition of racial/ethnic differences in postfracture mortality. Similar to women, 1-year mortality rates following hip fracture were lower in Asian men, but mortality rates were comparable for white, black, and Hispanic men. A recent study examining nonfederal hospital admissions for hip fracture–related procedures in California reported more than one-third lower postfracture mortality risk for Asian men and somewhat lower mortality risk among black and Hispanic compared with white men.34 Whether hospital readmission or other postfracture complications,44 as well as ethnic differences in family structure, social support, and use of rehabilitation services,45-48 contribute to these findings is unclear. Contemporary data pertaining to US Asian men also remain limited. Collectively, these findings emphasize the need to further investigate factors underlying the observed ethnic differences in hip fracture outcomes among older men.

Limitations and Strengths

Our study has several limitations. First, we did not examine specific preexisting comorbidities, functional status, osteoporosis risk factors, and treatment, which may differ by race and play an important role in patient outcomes. Second, information on mobility and/or functional independence, discharge to inpatient rehabilitation, body mass index, and nutritional status were not systematically available. Lastly, we were unable to account for population trends in mortality to determine whether the observed racial differences reflect mortality patterns within our health plan population, irrespective of hip fracture. 

The strengths of our study include access to an extremely large and diverse population, with comprehensive data on mortality outcomes and hospitalized events. Asians represent one of the fastest growing ethnic subgroups within the United States, among whom a better understanding of hip fracture epidemiology and outcome has become increasingly important. These data are among the first to examine contemporary differences in both hip fracture rates and mortality outcome in men of Asian ethnicity and white race receiving care within the same healthcare delivery system.

CONCLUSIONS

We noted important racial/ethnic differences in hip fracture incidence and 1-year mortality outcome following the fracture. Compared with men of white race, Asian men had two-thirds lower hip fracture incidence and one-third lower mortality risk at 1 year following hip fracture. As the aging population becomes increasingly diverse, a greater understanding of the cultural, social, and health-related factors affecting fracture outcomes in healthcare settings will optimize the targeting of multidisciplinary efforts to reduce morbidity and mortality following hip fracture in men.

Author Affiliations: Department of Medicine, Kaiser Permanente Oakland Medical Center (LHL, JCL), Oakland, CA; Division of Research, Kaiser Permanente Northern California (MC, JRG, JCL), Oakland, CA.

Source of Funding: None.

Author Disclosures: Ms Chandra has previously received research funding from Amgen. Dr Lo has previously received research funding from Amgen and Sanofi. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

Authorship Information: Concept and design (LHL, MC, JCL); acquisition of data (MC, JCL); analysis and interpretation of data (LHL, MC, JRG, JCL); drafting of the manuscript (LHL, JCL); critical revision of the manuscript for important intellectual content (LHL, MC, JRG, JCL); statistical analysis (MC); provision of patients or study materials (JCL); administrative, technical, or logistic support (LHL, JRG, JCL); and supervision (JCL). 

Address Correspondence to: Joan C. Lo, MD, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612. E-mail: Joan.C.Lo@kp.org. 
REFERENCES

1. Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res. 2007;22(3):465-475. doi: 10.1359/jbmr.061113.

2. Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA. 2009;302(14):1573-1579. doi: 10.1001/jama.2009.1462.

3. Orces CH. In-hospital hip fracture mortality trends in older adults: the National Hospital Discharge Survey, 1988-2007. J Am Geriatr Soc. 2013;61(12):2248-2249. doi: 10.1111/jgs.12567.

4. Stevens JA, Rudd RA. The impact of decreasing U.S. hip fracture rates on future hip fracture estimates. Osteoporos Int. 2013;24(10):2725-2728. doi: 10.1007/s00198-013-2375-9.

5. Zingmond DS, Melton LJ 3rd, Silverman SL. Increasing hip fracture incidence in California Hispanics, 1983 to 2000. Osteoporos Int. 2004;15(8):603-610. doi: 10.1007/s00198-004-1592-7.

6. Jacobsen SJ, Goldberg J, Miles TP, Brody JA, Stiers W, Rimm AA. Race and sex differences in mortality following fracture of the hip. Am J Public Health. 1992;82(8):1147-1150.

7. Lo JC, Zheng P, Grimsrud CD, et al. Racial/ethnic differences in hip and diaphyseal femur fractures. Osteoporos Int. 2014;25(9):2313-2318. doi: 10.1007/s00198-014-2750-1.

8. Pothiwala P, Evans EM, Chapman-Novakofski KM. Ethnic variation in risk for osteoporosis among women: a review of biological and behavioral factors. J Womens Health (Larchmt). 2006;15(6):709-719. doi: 10.1089/jwh.2006.15.709.

9. Endo Y, Aharonoff GB, Zuckerman JD, Egol KA, Koval KJ. Gender differences in patients with hip fracture: a greater risk of morbidity and mortality in men. J Orthop Trauma. 2005;19(1):29-35.

10. Penrod JD, Litke A, Hawkes WG, et al. The association of race, gender, and comorbidity with mortality and function after hip fracture. J Gerontol A Biol Sci Med Sci. 2008;63(8):867-872.

11. Kannegaard PN, van der Mark S, Eiken P, Abrahamsen B. Excess mortality in men compared with women following a hip fracture. National analysis of comedications, comorbidity and survival. Age Ageing. 2010;39(2):203-209. doi: 10.1093/ageing/afp221.

12. Haentjens P, Magaziner J, Colón-Emeric CS, et al. Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med. 2010;152(6):380-390. doi: 10.7326/0003-4819-152-6-201003160-00008.

13. Forsén L, Sogaard AJ, Meyer HE, Edna T, Kopjar B. Survival after hip fracture: short- and long-term excess mortality according to age and gender. Osteoporos Int. 1999;10(1):73-78.

14. Sterling RS. Gender and race/ethnicity differences in hip fracture incidence, morbidity, mortality, and function. Clin Orthop Relat Res. 2011;469(7):1913-1918. doi: 10.1007/s11999-010-1736-3.

15. Wehren LE, Hawkes WG, Orwig DL, Hebel JR, Zimmerman SI, Magaziner J. Gender differences in mortality after hip fracture: the role of infection. J Bone Miner Res. 2003;18(12):2231-2237. doi: 10.1359/jbmr.2003.18.12.2231.

16. Alegre-López J, Cordero-Guevara J, Alonso-Valdivielso JL, Fernández-Melón J. Factors associated with mortality and functional disability after hip fracture: an inception cohort study. Osteoporos Int. 2005;16(7):729-736. doi: 10.1007/s00198-004-1740-0.

17. Hawkes WG, Wehren L, Orwig D, Hebel JR, Magaziner J. Gender differences in functioning after hip fracture. J Gerontol A Biol Sci Med Sci. 2006;61(5):495-499.

18. Ekström W, Samuelsson B, Ponzer S, Cederholm T, Thorngren KG, Hedström M. Sex effects on short-term complications after hip fracture: a prospective cohort study. Clin Interv Aging. 2015;10:1259-1266. doi: 10.2147/CIA.S80100.

19. Holt G, Smith R, Duncan K, Hutchison JD, Gregori A. Gender differences in epidemiology and outcome after hip fracture: evidence from the Scottish Hip Fracture Audit. J Bone Joint Surg Br. 2008;90(4):480-483. doi: 10.1302/0301-620X.90B4.20264.

20. Fransen M, Woodward M, Norton R, Robinson E, Butler M, Campbell AJ. Excess mortality or institutionalization after hip fracture: men are at greater risk than women. J Am Geriatr Soc. 2002;50(4):685-690.

21. Ebeling P. Osteoporosis in men: why change needs to happen. International Osteoporosis Foundation website. http://share.iofbonehealth.org/WOD/2014/thematic-report/WOD14-Report.pdf. Published October 2014. Accessed April 1, 2016.

22. Wright NC, Saag KG, Curtis JR, et al. Recent trends in hip fracture rates by race/ethnicity among older US adults. J Bone Miner Res. 2012;27(11):2325-2332. doi: 10.1002/jbmr.1684.

23. Lo JC, Srinivasan S, Chandra M, et al. Trends in mortality following hip fracture in older women. Am J Manag Care. 2015;21(3):e206-e214.

24. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45(6):613-619.

25. 2010 Census: United States profile. United States Census Bureau website. http://www2.census.gov/geo/maps/dc10_thematic/2010_Profile/2010_Profile_Map_United_States.pdf. Published July 15, 2011. Accessed July 22, 2011.

26. U.S. Preventive Services Task Force. Screening for osteoporosis in postmenopausal women: recommendations and rationale. Ann Intern Med. 2002;137(6):526-528.

27. U.S. Preventive Services Task Force. Screening for osteoporosis: U.S. preventive services task force recommendation statement. Ann Intern Med. 2011;154(5):356-364. doi: 10.7326/0003-4819-154-5-201103010-00307.

28. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2014;25(10):2359-2381. doi: 10.1007/s00198-014-2794-2.

29. Qaseem A, Snow V, Shekelle P, Hopkins R Jr, Forciea MA, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Screening for osteoporosis in men: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008;148(9):680-684.

30. Watts NB. Osteoporosis in men. Endocr Pract. 2013;19(5):834-838. doi: 10.4158/EP13114.RA.

31. Curtis JR, McClure LA, Delzell E, et al. Population-based fracture risk assessment and osteoporosis treatment disparities by race and gender. J Gen Intern Med. 2009;24(8):956-962. doi: 10.1007/s11606-009-1031-8.

32. Kiebzak GM, Beinart GA, Perser K, Ambrose CG, Siff SJ, Heggeness MH. Undertreatment of osteoporosis in men with hip fracture. Arch Intern Med. 2002;162(19):2217-2222.

33. Adams AL, Shi J, Takayanagi M, Dell RM, Funahashi TT, Jacobsen SJ. Ten-year hip fracture incidence rate trends in a large California population, 1997-2006. Osteoporos Int. 2013;24(1):373-376. doi: 10.1007/s00198-012-1938-5.

34. Sullivan KJ, Husak LE, Altebarmakian M, Brox WT. Demographic factors in hip fracture incidence and mortality rates in California, 2000-2011. J Orthop Surg Res. 2016;11:4. doi: 10.1186/s13018-015-0332-3.

35. Nam HS, Shin MH, Zmuda JM, et al; Osteoporotic Fractures in Men (MrOS) Research Group. Race/ethnic differences in bone mineral densities in older men. Osteoporos Int. 2010;21(12):2115-2123. doi: 10.1007/s00198-010-1188-3.

36. Nelson DA, Jacobsen G, Barondess DA, Parfitt AM. Ethnic differences in regional bone density, hip axis length, and lifestyle variables among healthy black and white men. J Bone Miner Res. 1995;10(5):782-787. doi: 10.1002/jbmr.5650100515.

37. George A, Tracy JK, Meyer WA, Flores RH, Wilson PD, Hochberg MC. Racial differences in bone mineral density in older men. J Bone Miner Res. 2003;18(12):2238-2244. doi: 10.1359/jbmr.2003.18.12.2238.

38. Shin MH, Zmuda JM, Barrett-Connor E, et al; Osteoporotic Fractures in Men (MrOS) Research Group. Race/ethnic differences in associations between bone mineral density and fracture history in older men. Osteoporos Int. 2014;25(3):837-845. doi: 10.1007/s00198-013-2503-6.

39. Marshall LM, Zmuda JM, Chan BK, et al; Osteoporotic Fractures in Men (MrOS) Research Group. Race and ethnic variation in proximal femur structure and BMD among older men. J Bone Miner Res. 2008;23(1):121-130. doi: 10.1359/jbmr.070908.

40. Travison TG, Beck TJ, Esche GR, Araujo AB, McKinlay JB. Age trends in proximal femur geometry in men: variation by race and ethnicity. Osteoporos Int. 2008;19(3):277-287. doi: 10.1007/s00198-007-0497-7.

41. Zengin A, Pye SR, Cook MJ, et al. Ethnic differences in bone geometry between white, black and South Asian men in the UK. Bone. 2016;91:180-185. doi: 10.1016/j.bone.2016.07.018.

42. Gordon NP. Sociodemographic and health-related characteristics of members aged 65 and over in Kaiser Permanente’s Northern California region, 2011. Kaiser Permanente website. https://divisionofresearch.kaiserpermanente.org/projects/memberhealthsurvey/SiteCollectionDocuments/mhs_seniors_report_%202011_regional.pdf. Published December 2012. Accessed October 7, 2015.

43. Beaupre LA, Morrish DW, Hanley DA, et al. Oral bisphosphonates are associated with reduced mortality after hip fracture. Osteoporos Int. 2011;22(3):983-991. doi: 10.1007/s00198-010-1411-2.

44. Dy CJ, Lane JM, Pan TJ, Parks ML, Lyman S. Racial and socioeconomic disparities in hip fracture care. J Bone Joint Surg Am. 2016;98(10):858-865. doi: 10.2106/JBJS.15.00676.

45. Graham JE, Chang PF, Bergés IM, Granger CV, Ottenbacher KJ. Race/ethnicity and outcomes following inpatient rehabilitation for hip fracture. J Gerontol A Biol Sci Med Sci. 2008;63(8):860-866.

46. Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: a meta-analytic review. PLoS Med. 2010;7(7):e1000316. doi: 10.1371/journal.pmed.1000316.

47. Ottenbacher KJ, Smith PM, Illig SB, et al. Disparity in health services and outcomes for persons with hip fracture and lower extremity joint replacement. Med Care. 2003;41(2):232-241. doi: 10.1097/01.MLR.0000044902.01597.54.

48. Nguyen-Oghalai TU, Ottenbacher KJ, Kuo YF, et al. Disparities in utilization of outpatient rehabilitative care following hip fracture hospitalization with respect to race and ethnicity. Arch Phys Med Rehabil. 2009;90(4):560-563. doi: 10.1016/j.apmr.2008.10.021.
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