Trends in osteoporotic fracture and related in-hospital complications during the COVID-19 pandemic in Alberta, Canada

Fragility fractures (FF) due to osteoporosis account for more than 80% of all fractures in Canadians over the age of 50. The risk of a major osteoporotic fracture in Canada is among the highest in the world, with an annual incidence of 211,986, more than heart attacks, strokes, and breast cancer cases combined [1]. FF occur following low-energy trauma, which is defined as a fall from standing height or less (e.g., tripping, or transitioning out of bed), as opposed to high-energy trauma fractures, which can be experienced falling from greater than standing height or from high impact forces (e.g., motor vehicle accidents) [1]. Hip fractures are the most common FF and are associated with increased morbidity and mortality [2]. Hip FF are also associated with high medical costs, particularly within the first-year post-fracture, with the largest proportion of cost dedicated to hospitalization and long-term care (mean cost 1-year post-hip fracture CA$62,793 ± CA$44,438 in 2017) [2, 3]. In Canada, with the aging demographics, the annual economic cost of hip fracture alone is projected to reach $2.4 billion by 2041 [3]. However, first-year incremental healthcare costs of other FF such as the wrist (CA$16,541 ± CA$25,687), vertebrae (CA$40,900 ± CA$47,837), and pelvis (CA$45,350 ± CA$38,572) are substantial as well, and contribute to an overall estimated cost of FF across Canada in excess of CA$1.9 billion annually [2].

FF are associated with a significant increase in mortality, comparable to other chronic diseases like cardiovascular disease [4, 5]. Individuals who experience FF have a decreased 1-year and 5-year survival rates compared to non-fracture individuals (1-year survival: fracture 85.6% vs. non-fracture 94.7%; 5-year survival: fracture: 58.5% vs. non-fracture 75.2%) [5]. Due to the significant morbidity, mortality, and cost associated with FF, the Public Health Agency of Canada has recently highlighted osteoporosis and related fractures as a major public health concern [6].

The orthopedic management of FF requires significant resources and patient care. Outpatient care requires multiple visits to a fracture clinic, while inpatient care can include surgical intervention, post-surgical care, and management of complications. Surgical complications are reportedly found in up to 30% of cases, and require increased patient care [7]. Rates of complications are higher in older patients, who are more likely to experience FF, and additionally may have one or more comorbid conditions (e.g., diabetes, stroke, osteoarthritis), thus further complicating the treatment approach [8]. Elderly individuals with FF are more likely to require hospitalization for non-operative fractures as well, such as stable pelvic and humeral fractures [3].

The pandemic has impacted many conditions requiring admission to the emergency department (ED). For example, metropolitan hospitals in Italy reported highly significant decreases in atraumatic musculoskeletal issues, sport-related injuries, and motor vehicle accidents presenting to the ED during lockdown [9]. Despite the decrease reported for musculoskeletal injuries, Italian hospitals reported an increased rate of FF in the elderly population over the same lockdown period [9]. Conversely, in France, the absolute number of hip fractures in patients 50 years of age and older decreased by 11% during the first coronavirus-19 (COVID-19) lockdown period [10]. The impact of the pandemic on the incidence of FF and associated outcomes is anticipated to vary across jurisdictions due to variations in lockdown measures and public health policies or practices. General healthcare resources and resources that support fracture care (e.g., fracture liaison services) were disrupted and/or strained globally at various timepoints during the pandemic [11]. Logistical and operational changes to hospital organization (e.g., surgical prioritization, staffing modifications, bed reallocation) and pre-surgical protocols (e.g., COVID-19 testing), in addition to orthopedic ward and rehabilitation infection practices, have all reduced capacity for FF treatment [11‐19]. It has also been hypothesized that the pandemic may have led to potential delays in timely care for certain conditions due to the fear of going to the ED. Delays in care experienced by Canadians suffering FF during the COVID-19 pandemic could have potentially exacerbated the already existing osteoporotic care gap and negatively impacted the socioeconomic burden of osteoporosis in Canada.

The purpose of this study is to characterize the extent to which osteoporosis care patterns were affected during the first 6 months of the pandemic, relative to a pre-pandemic control period, within a Canadian setting. The primary objective was to describe the overall rate of low-energy fractures occurring at several common osteoporotic fracture sites (e.g., hip, femur, vertebral) during the initial months (first wave) of the COVID-19 pandemic relative to rates in the 3 years prior. The secondary objectives were to describe time-to-surgery, and complications and deaths post-surgery in fracture patients during and 3 years prior to the pandemic.

The results of this study show that low-energy fractures remained a public health concern over the lockdown period, accounting for a large majority of overall fractures. The majority of low-energy fractures in this population often occur either spontaneously (e.g., compression fractures of the spine) or by sustaining a low-energy fall (e.g., at home or outdoors) from standing height or less [20]. Data suggest that the first state of emergency period within Alberta had a slight impact on the total number of fractures recorded (both overall and low-energy fractures), with vertebral, hip, and proximal/upper humerus fractures all experiencing slight declines in the March to June 2020 period, relative to previous years. The number of patients with fractures increased in the June to September 2020 period. Drivers of these changes may include decreased movement and activity resulting from the stay-at-home public health orders in the March to June 2020 period and fear or hesitation to seek medical attention at an in-hospital setting during this lockdown period. As the lockdown was lifted, increased activity (thus subsequent risk of falling) and health-seeking behavior may contribute to the increase in observed fractures. A depletion-of-susceptible individuals bias is not anticipated to be a driver of the reduced fractures observed in the first COVID-19 period, as the population ≥ 50 years of age including among those ≥ 80 years of age has continued to grow year over year in Alberta [21] and the excess mortality was fairly comparable between the two COVID periods [22].

Increased time to surgery following fracture is known to be associated with increased mortality, particularly for hip fractures [23, 24]. Although these results show a decrease in the absolute number of patients who received surgical intervention for fracture repair in less than 24 h, the proportion of patients who received surgery in less than 24 h, including those with a hip fracture, remained relatively stable relative to the previous year. During lockdown, elective surgeries were delayed in the first period of the pandemic to provide additional room for patients presenting to the hospital with COVID-19. These data suggest that the cancellation of elective surgeries did not influence the timing of surgery for this population. The number of hospitalized COVID cases did not exceed hospital capacity during the first wave in Alberta, likely with minimal impact to operating room access.

The results suggest that the median length of stay in-hospital for all low-energy fractures and low-energy hip fractures remained consistent. Medians for all fractures and hip fractures did not change with the exception of hip fractures from March to June of the COVID-19 period which was reduced by 1 day. Length of hospital stay results should be interpreted with caution considering the large variability of length of stay data demonstrated by the interquartile ranges for each study period. Although small, the decreased length of stay during the March to June COVID-19 period relative to the previous year may be reflective of patients being discharged early to create space for critically ill patients with COVID-19 infection. The large standard deviation observed in the length of stay data suggests that there are patients with exceptionally long length of stay, possibly awaiting an alternative level of care rather than an acute stay. The standard deviation was much smaller during the COVID-19 period possibly due to changes in care for such patients [25]. Another challenge during the pandemic was care facilities being put on outbreak status and preventing patients from being transferred back to their long-term care homes. Many nursing homes were not accepting new patients during the lockdown, which resulted in hospitals creating space on another ward for patients to await transfer, potentially increasing the time that a patient would stay in the hospital [26, 27].

Early data also suggest an overall decrease in the absolute number of complications following surgical intervention for low trauma fracture, in line with the lower total number of patients with fractures. The proportion of patients experiencing complications during the COVID-19 periods was within range of the control periods for all complications except post-surgical infections, which had a decrease during the March to June COVID-19 period relative to the 2019 control period. It is difficult to ascertain the reason for this observed decrease; however, increased sanitation practices and potential changes to exposure protocols in hospitals during lockdown may have been contributing factors.

The absolute number of deaths post-surgical fracture repair decreased over the first two periods of the COVID-19 lockdown, largely driven by hip fractures which accounted for more than half of the low-energy fractures receiving surgical repair in this population. The greatest decrease in deaths post-surgical fracture repair was observed in the June to September COVID-19 period relative to the 2019 control period. The decrease in complications observed during the March to June COVID-19 period may have contributed to a decrease in death during the June to September COVID-19 period relative to the previous year. Alternatively, the decrease in death could also be associated with the slight decrease observed in the length of stay during the COVID-19 period. Patient death was captured as occurring in-hospital, as such, death following discharge would not have been captured in this study. Of note, there was an overall increase in all-cause deaths in the province [28]. Alberta had an excess of 682 deaths from March to September of the COVID-19 period, relative to previous years [22]. Therefore, the deaths reported herein may not represent the totality of deaths associated with a high mortality fracture (e.g., hip fracture) that could have taken place following the transfer of a patient from the hospital to home, a rehabilitation facility, or a long-term care home, or among patient that did not seek care for a fracture. There were also no homecare physiotherapy, osteoporosis physiotherapy programs, or private clinics open during the first lockdown, possibly increasing the number of deaths related to fractures following interaction in a hospital setting [29].

The current results provide descriptive evidence of low-energy fracture frequency and acute low-energy fracture management in Alberta, Canada, during the onset (first wave) of the COVID-19 pandemic. Data suggest that low-energy fracture rates declined slightly but largely remained stable in the first few months of the pandemic. This is an important finding as over half of the patients ≥ 50 years of age presenting to a hospital across both the control and COVID-19 periods with suspected low-energy FF were hip fracture patients that required surgery.

Although early results suggest little to no change in the care of low-energy fractures, particularly low trauma hip fractures requiring surgical repair, this may not accurately reflect acute treatment of low-energy fractures during subsequent COVID-19 waves when the healthcare system was under severe strain. Further investigation regarding acute care and treatment patterns throughout the course of the COVID-19 pandemic is warranted.