Very little data are available about the incidence and consequences of fractures in Lithuania [8-10]. Osteoporosis in Lithuania is still under-reported on hospital discharge forms as co-morbidity, even in elderly patients with hip fractures. As yet, information about the economic consequences of treating fractures that resulted from osteoporosis has not been published in Lithuania.

The comparison of our data with data of other studies is challenging due to differences in study year, size of the study region or size of population investigated, different age groups and data presentation. Several previous studies were based on the analysis of health registries, hospital databases, nationwide health insurance databases and outpatient data, and so the results are not directly comparable with our data obtained by reviewing the medical records of every patient.

Although the literature review revealed relevant differences in study methods, the incidence of fractures is the most suitable index to compare different countries. Northern European countries have a higher hip fracture incidence than southern European countries [3,6], and different incidence rates were also seen among regions in the same country [12,14-16]. We have found the hip fracture incidence in Vilnius to be lower than in Portugal, France, Austria, Switzerland and Hungary [14,15,17-19], and especially lower than in Scandinavian countries [6,20-22]. Approximately the same results as ours were reported in studies from Greece [23] and Germany [16]. Lower incidence rates were reported from Spain [24] and Poland [25], and in another study comparing East and West Germany [26]. A similar pattern was seen when the overall incidence of hip fractures among women in Vilnius was compared with figures from equivalent studies in Europe. The overall female to male ratio of hip fractures was 1.9:1, which is similar to that in Poland [25], Hungary [19], Denmark [20] and Greece [23], but is lower than in Austria [17], Germany [16] and Norway [27]. This lower ratio may be explained by the higher incidence of hip fractures in men in Vilnius compared to other countries. The overall incidence of hip fractures (per 100,000 inhabitants) among men in Vilnius (160) is higher than in Germany (110.2) [26], Portugal (129.39) [14], Poland (89) [25] and Spain (100.4) [24], and the differences between our data and that from other countries for men are not as great as for women.

The geographic differences could be due to environmental and/or socioeconomic factors. It would be interesting to compare regions similar to Vilnius with respect to these factors, but we were not able to find any data on fracture incidence in neighbouring countries (i.e. Latvia, Estonia and Belorussia) in the literature. The only available study is from Poland in 2005, which reported one of the lowest incidence rates in Europe: 165/100,000 fractures for women above 50years, and 89/100,000 for men [25]. Although these figures are lower than ours, the results are not directly comparable due to differences in the study population. The hip fracture incidence rates in Poland are based on national data whereas we analysed data only for the city of Vilnius. In 2006, Johnell and Kanis computed the incidence of hip fracture worldwide for men and women aged 50-years or more in five-year age intervals, from the year 1990 onwards [4]. Country-specific data was used for subregions within the same region of the global burden of osteoporosis. The only estimate available for the subregion in which Lithuania was included was from Hungary. The incidence of hip fractures in Vilnius, the capital of Lithuania, is lower than in Hungary, where the total incidence of hip fractures per 100,000 individuals was 343: 430 in women and 223 in men aged over 50years, although the female/male ratio was approximately the same in both studies – 1.93:1. Thus, the results of our study fill a gap in the data from Europe and also the "blank areas" in the world map where there is a lack of data regarding the incidence of fractures [6].

To the best of our knowledge, this study is the first attempt to estimate the global burden of hip fractures in Lithuania, whereas several studies estimating medical expenditures for hip fractures or other osteoporotic fractures have been conducted during the past two decades [13,15,18,28-33]. The results of our study show that the overall direct hospital costs in Vilnius were as high as 1,114,292.05 EUR in 2010. These costs included the costs of ambulance transportation and continuous hospitalisations immediately after a hip fracture, which are covered by the Lithuanian healthcare system. Analysis of our data shows that the majority of costs were incurred for acute hospital stay (53%) and stays at a long-term care hospital (35%) versus 12% for medical rehabilitation.

We calculated the mean overall hospital cost for treating a hip fracture to be 2,526.74 EUR. This cost is low compared to many other countries. The costs of inpatient acute hospital care for hip fracture varies widely and was estimated at 5,983 US dollars in Turkey [34], 4,365.50 US dollars per case in Mexico [32], 14,616 CHF per case of hospitalisation for any osteoporotic fracture in Switzerland [18] and from 8,048 to 8,727 EUR in France [15]. As a study from Belgium reported, the mean cost of acute hospital stay was 8,667 EUR and the mean one-year, hip-fracture-related post-hospitalisation extra costs were 6,636 EUR [29]. In Sweden, the mean fracture-related cost the year after fracture was estimated at 14,221 EUR [33]. The mean total cost of hip fracture per patient per year in the United States was estimated at 26,856 US dollars [30], and in Canada the mean one-year cost was estimated at 26,527 Canadian dollars [31]. It is difficult to compare our results of cost estimates with the results of studies in other countries. Differences in the costs of hip fractures between countries may be attributed to differences in the economic development level, the healthcare financing system, price levels, rehabilitation rates and the length of hospital stay. Moreover, studies have used different methodology and data collection procedures. Some studies report only the direct hospital costs; others include outpatient costs, the costs associated with rehabilitation and residency at nursing homes, or all fracture-related costs in the following year. It would be reasonable to compare the incidence and cost of hip fractures in neighbouring countries. However, to our knowledge, no studies focusing on the economic burden of hip fractures in these countries have yet been published.

In Lithuania, acute care and long-term care hospitals, as well as rehabilitation units, are public institutions, and the costs of items do not vary from institution to institution, but only from treatment to treatment. We have estimated the direct hospital costs across age groups, gender and treatment types. The results show that the greatest part of the burden of hip fractures was incurred by women, and that the costs increased with age among both genders. The greatest part of the expenditure (90% in women and 86% in men) was accounted for by people above 65-years of age, and costs for individuals aged 85 and older account for almost one-third of all direct hospital costs. Similar percentages were reported in other studies [13,18,30,32,33]. When the costs of four types of treatment provided for hip fractures were analysed, our data showed that the highest overall expenditures were for internal fixation by screw, followed by internal fixation by plate. The major factor affecting the overall expenditures was the cost of stay in a long-term care hospital. In both types of treatment, long-term care constituted a large component of overall costs (39% in fixation by screw and 41% in cases of fixation by plate), whereas long-term care accounted for only 2% of the overall cost among patients treated by arthroplasty. Another important component of the costs of internal fixation by screw was the cost of re-admission. All 12 individuals re-admitted for the same fracture underwent the arthroplasty. Moreover, ten of them were later discharged to a rehabilitation facility.

When the overall hospital costs were considered, the estimated cost of arthroplasty was low since only 13% underwent this type of treatment. Although it is evident that acute hospital stay in the case of hip replacement is the most expensive when comparing the estimated costs of the treatment types, arthroplasty did not increase the mean overall hospital costs associated with hip fracture. The mean cost (2,419.44 EUR) was lower than the cost of treatment by internal fixation by screw (2,730.30 EUR).

The primary strength of this analysis is that all the hip fractures that were managed in the hospitals in Vilnius in 2010 were counted and analysed in our study. In Lithuania, persons suffering from hip fracture almost always receive hospital care, and it is difficult to model the situation if a person could evade medical aid and admission to an orthopaedic department. No patients with hip fracture were admitted to any of the private hospitals. While it is possible that a few inhabitants of Vilnius with hip fractures could be treated outside the city, this would not significantly influence the results of our study. It is more common for people of the surrounding regions to come to Vilnius for healthcare than vice versa.

Another major strength of the present study is the accuracy of information provided. All medical records - i.e. not discharge data - were reviewed by specially trained staff using the same data collection form and eliminating the possibility of counting fractures twice. All cases of re-admission for the same fracture were excluded from fracture incidence evaluation but added when fracture costs were calculated.