While fracture has long been regarded as the terminal outcome of osteoporosis, we now know that almost all fractures lead to further fractures, functional decline and premature mortality. In Australia, it has been estimated that more than one in three women and one in five men aged 50+ will suffer fractures. The relationship between fracture and subsequent adverse outcomes depends on both fracture site and underlying general health.
The vast (95%) majority of people with osteoporosis have at least one and > 66% of people have at least two comorbidities. Indeed, multimorbidity associated with increased risk of subsequent fracture, even after accounting for the competing risk of mortality. Concerningly, multimorbidity was also associated with lower risk of being treated or investigated for underlying bone health after a fracture.
We have also demonstrated that underlying co-morbidities independently add to increased post fracture mortality. Furthermore, we have found that comorbidities naturally group into specific clusters that are strongly associated with post-fracture premature mortality. These clusters are based on disease severity and co-existence of related conditions. These clusters differentiated fracture patients who had uncomplicated comorbidity or were unlikely to have comorbidity from those with either multiple or/and advanced comorbidities. Indeed, the contribution of these clusters to fracture risk was at least as great, and mostly greater, than the individual comorbidities themselves.
As comorbidities both exacerbate the adverse post-fracture outcomes and lower treatment rates, there is an urgent need to identify the highest risk patients and prioritise their care. In this presentation, I will discuss the evidence surrounding the role of comorbidities and underlying health on fracture outcomes and suggest alternatives to our current model of care.