An Observational Study of Post-hip Fracture Outcomes in Older Adults with Type 2 Diabetes

BACKGROUND: Hip fracture is a global public health concern, with over 10 million cases worldwide in 2019. Post-hip fracture outcomes, including mortality, vary by type 2 diabetes (T2D) co-diagnosis and patient demographics. OBJECTIVE: To examine post-hip fracture outcomes and identify factors modifying mortality differences in a racially and ethnically diverse population of older United States (US) adults with T2D. DESIGN: Retrospective cohort study using Medicare fee-for-service data from 2014 to 2020. PARTICIPANTS: Men and women aged > 65 years, with T2D diagnosis who had experienced a non-traumatic hip fracture. MAIN MEASURE(S): We evaluated associations between race and ethnicity and one-year mortality, dual energy x-ray absorptiometry (DXA) testing, osteoporosis treatment, and incident destitution post-hip fracture using multivariable Cox proportional hazards models. KEY RESULTS: Among 159,699 older adults with T2D, one-year post-hip fracture mortality was 30.4%. In age- and sex-adjusted models, mortality was higher in Black individuals (HR 1.26 [95% CI, 1.22-1.31) and lower in Asian and Hispanic individuals (HR 0.78 [95% CI, 0.73-0.83] and 0.91 [95% CI,0.86-0.96], respectively) compared with White individuals. Elevated mortality in Black individuals persisted across subgroups stratified by sex, age, region, BMI, and frailty, but not among those with advanced chronic kidney disease (CKD stages 4-5; HR 1.01 [0.93-1.09]) or low socioeconomic status (SES; Medicaid eligibility; HR 1.00 [0.88-1.14]). Models adjusting for important demographic and clinical covariates mitigated mortality differences between Black and White individuals. DXA testing and osteoporosis treatment initiation rates were low overall (7.3% and 5.6%, respectively). Black individuals had lower DXA testing (HR 0.51 [0.45-0.56]) and treatment (HR 0.58 [0.51-0.65]) rates, and higher incident destitution (HR 1.41 [1.29-1.55]) than White individuals in all models. CONCLUSIONS: Overall mortality was high and guideline-concordant care was low in the first year post-hip fracture in Medicare-insured older adults with T2D. Furthermore, racial and ethnic differences in post-hip fracture mortality and management exist.