Department of Obstetrics and Gynecology, National University Hospital, National University of Singapore, Singapore.
Division of Policy, Research and Evaluation, Ministry of Health, Singapore.
JAMA Netw Open. 2020 Feb 5;3(2):e1919706. doi: 10.1001/jamanetworkopen.2019.19706.
Examining trends in mortality following hip fracture and its associated factors is important for population health surveillance and for developing preventive interventions.
To examine temporal trends in, and risk factors associated with, mortality following hip fracture over 18 years in Singapore.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective, population-based cohort study included men and women aged 50 years and older admitted to Singapore hospitals for first hip fracture identified and followed up from 2000 to 2017. Demographic information, fracture type, and Charlson Comorbidity Index (CCI) score were retrieved from nationwide claims data, and mortality data were from the National Death Registry. Data were analyzed from August 2018 to December 2019.
Adjusted hazard ratios (aHRs) and their 95% confidence intervals were estimated using Cox proportional hazards regression. Kaplan-Meier life table methods were used to calculate survival following the hip fracture on a cohort basis. The crude survival over time since fracture was compared by sex, age group, ethnicity, CCI, and fracture type. Standardized mortality ratios (SMRs) were calculated using all-cause mortality obtained from Singapore population life tables.
Among 36 082 first inpatient admissions for hip fractures (mean [SD] patient age, 78.2 [10.1] years; 24 902 [69.0%] female; 30 348 [84.1%] Chinese, 2863 [7.9%] Malay, 1778 [4.9%] Indian, and 1093 [3.0%] other ethnicity), elevated rates of mortality were observed for male sex (aHR, 1.46; 95% CI, 1.41-1.52), Malay ethnicity (aHR, 1.23; 95% CI, 1.15-1.30 vs Chinese ethnicity), older age (aHR, 5.20; 95% CI, 4.27-6.34 for age ≥85 years vs 50-54 years), high CCI score (aHR, 3.62; 95% CI, 3.42-3.84 for CCI ≥6 vs CCI of 0), trochanteric fractures (aHR, 1.11; 95% CI, 1.06-1.16 vs cervical fractures), and earlier cohorts (aHR, 0.59; 95% CI, 0.56-0.62 for 2012-2017 vs 2000-2005). Absolute mortality decreased significantly over time: by 21% in 2006 to 2011 and by 40% in 2012 to 2017, compared with 2000 to 2005. On long-term follow-up, differences in survival associated with sex and ethnicity tended to diminish, whereas differences associated with older age, higher CCI score, and trochanteric fractures increased. In the first year after fracture, reductions in SMR were observed comparing the periods 2013 to 2016 with 2003 to 2007 in women (SMR, 2.05; 95% CI, 1.91-2.20 vs SMR, 2.54; 95% CI, 2.39-2.70, respectively) but not among men (SMR, 3.28; 95% CI, 3.04-3.54 vs SMR, 3.42; 95% CI, 3.18-3.68, respectively).
Malay ethnicity, older age, male sex, prefracture comorbidity, and trochanteric fractures were independently associated with increased risk of death, identifying population groups that could be targeted for intervention strategies. The improvement in relative mortality for women but not men suggests the need to develop interventions that improve mortality outcomes for men.
检查髋部骨折后死亡率的趋势及其相关因素对于人口健康监测和预防干预措施的制定非常重要。
在新加坡，在 18 年的时间内，检查髋部骨折后死亡率的时间趋势及其相关危险因素。
设计、地点和参与者：本回顾性、基于人群的队列研究纳入了年龄在 50 岁及以上的男性和女性，他们在 2000 年至 2017 年期间因首次髋部骨折住院，并从全国索赔数据中检索了人口统计学信息、骨折类型和 Charlson 合并症指数（CCI）评分，死亡率数据来自国家死亡登记处。数据分析于 2018 年 8 月至 2019 年 12 月进行。
使用 Cox 比例风险回归估计了调整后的风险比（aHR）及其 95%置信区间。使用 Kaplan-Meier 生命表方法按队列计算了髋部骨折后的生存情况。通过性别、年龄组、种族、CCI 和骨折类型比较了骨折后随时间推移的粗生存率。使用来自新加坡人口生命表的全因死亡率计算了标准化死亡率比（SMR）。
在 36082 例首次住院的髋部骨折患者中（平均[SD]患者年龄，78.2[10.1]岁；24902 例[69.0%]为女性；30348 例[84.1%]为华裔、2863 例[7.9%]为马来族、1778 例[4.9%]为印度裔和 1093 例[3.0%]为其他族裔），男性（aHR，1.46；95%CI，1.41-1.52）、马来族（aHR，1.23；95%CI，1.15-1.30 vs 华裔）、年龄较大（aHR，5.20；95%CI，85 岁及以上年龄组 vs 50-54 岁年龄组）、CCI 评分较高（aHR，3.62；95%CI，CCI 为 6 分 vs CCI 为 0 分）、转子间骨折（aHR，1.11；95%CI，1.06-1.16 vs 颈骨折）和早期队列（aHR，2012-2017 年 vs 2000-2005 年）与较高的死亡率相关。绝对死亡率随时间显著下降：与 2000-2005 年相比，2006-2011 年下降 21%，2012-2017 年下降 40%。在长期随访中，与性别和种族相关的生存差异趋于缩小，而与年龄较大、CCI 评分较高和转子间骨折相关的差异则增加。在骨折后的第一年，与 2003-2007 年相比，2013-2016 年期间女性的 SMR 降低（SMR，2.05；95%CI，1.91-2.20 vs SMR，2.54；95%CI，2.39-2.70），但男性 SMR 无降低（SMR，3.28；95%CI，3.04-3.54 vs SMR，3.42；95%CI，3.18-3.68）。
马来族、年龄较大、男性、骨折前合并症和转子间骨折与死亡风险增加独立相关，确定了可作为干预策略目标的人群。女性的相对死亡率有所改善，但男性没有，这表明需要制定改善男性死亡率的干预措施。
