Multimorbidity, fragility fractures, and out-of-pocket expenditure in older Indian adults: evidence from a national survey.

UNLABELLED: This study examines the association between multimorbidity, fragility fractures, and the subsequent financial burden among older adults in India using nationwide data of 66,066 individuals. Seventy-one percent reported multimorbidity with fractures, higher costs in private care, and infirm integrated health strategies that target fall prevention, multimorbidity, and equal access to healthcare.

BACKGROUND

Fragility fractures are a major public health concern, particularly among older adults. While osteoporosis is widely recognized as a risk factor, the cumulative impact of multiple chronic conditions on fracture risk and post-fracture outcomes remains underexplored. This study examines the multimorbidity, fragility fractures, and financial burden in older Indian adults. The current study examines the association between multimorbidity, fragility fractures, and the subsequent financial burden among older adults in India.

METHODS

We conducted a secondary analysis of 66,066 older adults (≥ 45 years) from the Longitudinal Aging Study in India (Wave 1). Fracture multimorbidity was defined as the presence of two or more chronic conditions, along with fracture, and fragility fractures were identified based on the self-reported history of fractures. The percentage of mediation was also recorded to assess the degree of mediation effect. We reported the direct, indirect, and total effects of mediation analyses.

RESULTS

The prevalence of fracture was 4.2%. Of these, 43% underwent surgery, 71% reported fracture with multimorbidity, and falls accounted for 87% of fractures. Hospitalization burden was significantly higher among fracture multimorbid individuals. Out-of-pocket expenditure was found to be more than twice in private hospitals as compared to public hospitals, which considerably vary by age, sex, place of residence, living status, education level, and wealth quintile.

CONCLUSION

Major predictors of fragility fractures in those with multimorbidity include age, sex, place of residence, living status, education level, and wealth quintile. In addition, ADL disability, cognitive impairment, and depression were also found to be significantly associated with bone or joint fractures. These findings highlight the urgent need for policy interventions, including integrating multimorbidity screening into fracture prevention programs, expanding insurance coverage for pre- and post-fracture treatment, and access to mobility assistive devices. Interpretation A shift towards multimorbidity-inclusive fracture prevention and management policies is essential to mitigate the health and economic burden of fragility fractures. Future interventions should focus on comprehensive assessment, fall prevention strategies, and equitable healthcare financing mechanisms.