Hip fracture is a public health problem internationally and more can be anticipated with aging populations. Most clinical trials and research focus on women, given they have the highest incidence of hip fracture. However, whether there are disparities in morbidity, mortality, and function between men and women or between races/ethnicities is unclear.
There are a number of limitations of this review. This review was a nonsystematic review by a single author. The articles chosen for inclusion did not meet predetermined explicit inclusion criteria and therefore studies of higher scientific quality may have been left out while others of lesser quality included. Second, only English language articles were considered and most of the articles focused on patients from the United States, limiting the generalizability of the conclusions to populations outside of the United States. The articles chosen were from a search of only one database (PubMed) and not others (EMBASE, Google Scholar, etc.) that could have expanded the choice of articles for inclusion. The review has not addressed social, economic, or political systems that may have biased the data from individual studies due to differences in access and delivery of healthcare to the populations studied. Finally, because of the limited data available with regards to functional outcome, strong conclusions cannot be drawn that can be universally applied to individual patient populations.
Where are we now? Although the incidence of fracture has decreased for both men and women, the number of hip fractures continues to increase as the population ages and remains a major public health concern. There are substantial gender and race/ethnicity differences among patients with hip fractures. Men are younger (by 3–6 years) and sicker (more comorbidities or higher ASA score) than women who fracture, and African Americans and Hispanics are younger and sicker than whites who fracture. Mortality in men is as much as twice that of women, with excess mortality due to cardiovascular disease, pneumonia, and sepsis. Patients with hip fractures have excess mortality out to 10 years postfracture, and this excess is greater for men than for women. Blacks, Hispanics, Native Americans have higher mortality than whites, but little is understood about the influence of race/ethnicity in this difference. Functional outcomes in survivors favor whites, and men may have a slight advantage. The male advantage may be due to the elevated mortality in men, which leads to selection of the highest-functioning men available for study of function. Non-Hispanic blacks and Hispanics have lower and less FIM™ improvement than whites. Overall, there is a paucity of functional outcome studies addressing gender and race/ethnicity.
Where do we need to go? While our knowledge of gender and race/ethnicity differences and hip fracture epidemiology, mortality, and outcome has dramatically increased over the last 10 years, more research is needed. The large database analyses are from the 1980s, and hip fracture mortality has decreased since these data were captured. Reporting of race/ethnicity has only recently become incorporated into large patient databases and relatively little is known of its relationship to hip fracture. To further elucidate gender and race/ethnicity differences in hip fracture incidence, continued longitudinal study is needed, with improved collection of race/ethnicity data in the databases to better understand these relationships. There is a paucity of data on race/ethnicity, especially for Asians and Native Americans and this must be acknowledged and addressed. Outcome studies demonstrating the influence of gender and race/ethnicity are lacking in the literature and more concentrated study is needed here as well.
How do we get there? Further hip fracture research is the key need to help understand gender and racial/ethnic influence on epidemiology, mortality, and outcomes. The foundation for many of the needed studies has already been laid, but expanding the number of patients and continued longitudinal followup are needed to draw more meaningful conclusions, leading to improvements in prevention and postfracture care delivery. First, more complete inclusion of race/ethnicity data in patient databases will allow us to better understand the relationships existing between gender and race/ethnicity and hip fracture. The reporting of race/ethnicity cannot be an optional data point. Second, large cohort studies comparing patients of different gender and patients of different race/ethnicity must be undertaken with focus on both short- and long-term outcome. Within these studies, study of the biochemical changes occurring in the immediate postoperative period and beyond is needed to better understand the changes in patient physiology after hip fracture and the persistent increase in mortality after the early recovery. We need comprehensive studies of patient characteristics, demographics, biochemical markers, and function outcomes to understand the disparities that exist and to allow us to maximize patients’ outcomes. Third, we must also consider the influence of healthcare delivery system as a variable. Most of the studies in this review were based on patients in the United States; however, in other countries with different healthcare delivery systems, the influence of gender and race/ethnicity may be substantially different, and the generalization of any of these studies should be undertaken with caution due to a lack of understanding of both the patient factors and healthcare delivery system factors, which may influence patient treatment and outcomes. Finally, researchers must understand the importance of including these data when reporting on hip fractures (or any osteoporotic fracture) and journal editors should require authors to include this information or provide an explanation for its absence.