Age-period-cohort effects in the incidence of hip fractures: political and economic events are coincident with changes in risk

Trends in hip and distal femoral fracture rates in Italy from 2007 to 2017

Osteoporosis-related fractures are a growing public health concern worldwide due to high societal and economic burden. The study aims to assess trends in incidence rates of hip and distal femoral fractures and in the use of anti-osteoporosis drugs in Italy between 2007 and 2017. Patients with hip and distal femoral fractures (ICD-9-CM codes 820.x and 821.x) were identified in the Italian National Hospital Discharge Database while anti-osteoporosis medication data were retrieved from the National Observatory on the Use of Medicines Database. A joinpoint regression analysis was performed to identify the years where the trends in incidence rates of hip and distal femoral fractures changed significantly; the average annual percentage change for the period of observation was estimated. Hospitalizations for femoral fractures were 991,059, of which 91.4% were hip fractures and 76.5% occurred in women. Age-standardized hip fractures rate per 100,000 person-years decreased both in women (-8.7%; from 789.9 in 2007 to 721.5 in 2017) and in men (-4.3%; from 423.9 to 405.6), while the rate of distal femoral fractures increased by 23.9% in women (from 67.78 to 83.95) and 22.7% in men (from 27.76 to 34.06). These changes were associated with an increment in the use of anti-osteoporosis drugs from 2007 to 2011 (from 9.1 to 12.4 DDD/1000 inhabitants/day), followed by a plateau in the period 2012-2017. The use of bisphosphonates increased progressively from 2007 to 2010 (from 8.2 to 10.5 DDD/1000 inhabitants/day), followed by a plateau and then decreased from 2015 onwards. The decreasing trend of hip fractures could be related to a major intake of anti-osteoporosis medications while the increment of distal femoral fractures might be due to population aging and to the use of bisphosphonates and denosumab. Further research is needed to identify and implement interventions to prevent hip and distal femoral fractures.

Regional drinking water composition effects on hip fracture risk: a spatial analysis of nationwide hospital admissions in Portugal, from 2000 to 2010

Abstract Geographical variation on hip fractures (HF) may be related to the geographical variation of drinking water composition (DWC); minerals in drinking water may contribute to its fragility. We aim to investigate the effects of DWC on HF risk in Portugal (2000-2010). From National Hospital Discharge Register we selected admissions of patients aged ≥50 years, diagnosed with HF caused by low/moderate energy traumas. Water components and characteristics were selected at the municipality level. A spatial generalized additive model with a negative binomial distribution as a link function was used to estimate the association of HF with variations in DWC. There were 96,905HF (77.3% in women). The spatial pattern of HF risk was attenuated after being adjusted for water parameters. Results show an indirect association between calcium, magnesium, and iron and HF risk but no clear relation between aluminum, cadmium, fluoride, manganese, or color and HF risk. Regarding pH, the 6.7pH and 7pH interval seems to pose a lower risk. Different dose-response relationships were identified. The increase of calcium, magnesium, and iron values in DWC seems to reduce regional HF risk. Long-term exposure to water parameters, even within the regulatory limits, might increase the regional HF risk.

A generalized additive model to disentangle age and diagnosis-specific cohort effects in psychological and behavioral outcomes in people living with HIV: the French cross-sectional ANRS-VESPA2 survey

BACKGROUND

Unlike their younger counterparts, some of today's older HIV patients were diagnosed before the advent of highly active antiretroviral therapy (HAART). The psychosocial and behavioral outcomes of people living with HIV (PLWH) have been widely studied, and associated factors are well known. However, their evolution both in terms of age and diagnosis-specific cohort effects is not well understood.

METHODS

Data from the ANRS-VESPA2 cross-sectional survey, representative of French PLWH, were used to investigate whether psychosocial and behavioral outcomes such as quality of life, need for support and HIV status disclosure, evolve under both the influence of patients' age and diagnosis-specific cohort effects. A semi-parametric generalized additive model (GAM) was employed. The physical and mental components of health-related quality of life, the need for material and moral support, and HIV-status disclosure, constituted our outcomes.

RESULTS

Non-linear diagnosis-specific cohort effects were found for physical and mental QoL and HIV-status disclosure. Overall, physical QoL was better in recently diagnosed patients than in those diagnosed in the early 1980s. An increasing influence of diagnosis-specific cohort effects between 1983 and 1995 was observed. No cohort effects were noticeable between 1996 and 2000, while an increasing influence was apparent for patients diagnosed with HIV from 2000 to 2011 (year of study). For mental QoL, the only increase was observed in participants diagnosed with HIV between 1983 and 2000. The relationship between diagnosis-specific cohort effects and HIV status disclosure was negative overall: participants diagnosed after 2000 were much less likely to disclose than those diagnosed before 1995. The effect of age was significantly associated with all outcomes, with a non-linear influence on mental QoL and with the need for material/moral support.

CONCLUSIONS

Psychosocial and behavioral outcomes are complex processes which can be explained in different ways by a combination of the clinical and social contexts which PLWH are exposed to at the time of diagnosis, and by developmental characteristics. A greater understanding of these processes could inform healthcare policy-making for specific HIV generations and different HIV age groups.

A join point regression analysis of trends in mortality due to osteoporosis in Spain

Osteoporosis is a major health problem in terms of fracture probability and disability. The aim of this ecological study is to identify the temporal trends in osteoporosis mortality in Spain from 1999 to 2015. Data on the Spanish population and number of deaths due to osteoporosis were obtained from the Spanish National Institute for Statistics. Age-adjusted mortality rates were estimated. Join point regression was used to identify the years when changes in mortality s and annual percentage change in mortality rates took place. Women presented a greater mortality rate decrease (p < 0.001), though this mortality difference by sex was reduced by half at the end of the period. The higher the age, the faster the mortality rate declined in women, while no clear pattern could be identified in men. In women, significant changes in trends were identified in three age groups (50-54, 60-64 and 80-84 years old). A sustained decrease in osteoporosis-associated mortality was found in women aged 75-79 and ≥85 years and men aged 60-64. In conclusion, mortality caused by osteoporosis in Spain is decreasing faster in the older age ranges especially in women.

Quantitative modelling of hip fracture trends in 14 European countries: testing variations of a shared reversal over time

Qualitative similarities between hip fracture trends in different countries suggests variations of the same epidemic. We tested a single statistical shape to describe time trends in Europe, while allowing for country-level variability. Using data from 14 countries, we modelled incidence rates over time using linear mixed-effects models, including the fixed effects of calendar year and age. Random effects were tested to quantify country-level variability in background rates, timing of trend reversal and tempo of reversal. Mixture models were applied to identify clusters of countries defined by common behavioural features. A quadratic function of time, with random effects for background rates and timing of trend reversal, adjusted well to the observed data. Predicted trend reversal occurred on average in 1999 in women (peak incidence about 600 per 100 000) and 2000 in men (about 300 per 100 000). Mixture modelling of country-level effects suggested three clusters for women and two for men. In both sexes, Scandinavia showed higher rates but earlier trend reversals, whereas later trend reversals but lower peak incidences were found in Southern Europe and most of Central Europe. Our finding of a similar overall reversal pattern suggests that different countries show variations of a shared hip fracture epidemic.

Continuous decline in incidence of distal humeral fracture of older women in Finland

BACKGROUND

Low-trauma fractures (also called osteoporotic fragility fractures or fall-induced fractures) of older adults are a serious public health problem. However, very little population-based information is available on the nationwide numbers, incidences, and especially secular trends of elderly people's low-trauma fractures of the distal humerus.

METHODS

We assessed the current trends in the number and incidence of these fractures in 60-year-old or older women in Finland by taking into account all women who were admitted to Finnish hospitals for primary treatment of such fracture in 1970-2014.

RESULTS

The annual number of low-trauma distal humeral fractures among Finnish women 60 years of age or older rose over fivefold between 1970 and 1998 (from 42 to 224 fractures), but thereafter, the number decreased down to 198 fractures in 2014. The age-adjusted incidence (per 100,000 persons) of these fractures also increased in 1970-1998 (from 12 to 35) but decreased thereafter to 23 in 2014. The finding was similar in the age-specific patient groups (60-69, 70-79, and 80+): The incidence rose from 1970 till 1998 and decreased thereafter.

CONCLUSIONS

The steep rise in the rate of low-trauma distal humeral fractures in 60-year-old or older Finnish women from 1970 till late 1990s has been followed by a clearly declining fracture rate. The exact reasons for this secular change are unknown, but a cohort effect toward improved functional ability among elderly women, as well as measures to prevent falls and alleviate fall severity, could partly explain the phenomenon.

Recent hip fracture trends in Sweden and Denmark with age-period-cohort effects

This study used nationwide hip fracture data from Denmark and Sweden during 1987-2010 to examine effects of (birth) cohort and period. We found that time trends, cohort, and period effects were different in the two countries. Results also indicated that hip fracture rates may increase in the not so far future.

INTRODUCTION

The reasons for the downturn in hip fracture rates remain largely unclear but circumstances earlier in life seem important.

METHODS

We ascertained hip fractures in the populations ≥50 years in Denmark and Sweden in national discharge registers. Country- and sex-specific age-period-cohort (APC) effects during 1987-2010 were evaluated by log-likelihood estimates in Poisson regression models presented as incidence rate ratios (IRR).

RESULTS

There were 399,596 hip fractures in SE and 248,773 in DK. Age-standardized hip fracture rate was stable in SE men but decreased in SE women and in DK. Combined period + cohort effects were generally stronger in SE than DK and in women than men. IRR per period ranged from 1.05 to 1.30 in SE and 0.95 to 1.21 in DK. IRR per birth cohort ranged from 1.07 to 3.13 in SE and 0.77 to 1.67 in DK. Relative period effects decreased with successive period in SE and described a convex curve in DK. Relative cohort effects increased with successive birth cohort in both countries but with lower risks for DK women and men and SE women born around the 1930s (age 75-86 years today and responsible for most hip fractures) partly explaining the recent downturn. Men and women born thereafter however seem to have a higher hip fracture risk, and we expect a reversal of the present decline in rates, with increasing hip fracture rates in both Denmark and Sweden during the upcoming decade.

CONCLUSIONS

Time trends, cohort, and period effects were different in SE and DK. This may reflect differences in general health as evident in known differences in life expectancy, healthcare organization, and prevention such as use of anti-osteoporosis drugs. Analyses indicate that hip fracture rates may increase in the not so far future.

Continued decline in hip fracture incidence in Norway: a NOREPOS study

The previously reported decline in age-adjusted hip fracture rates in Norway during 1999-2008 continued after 2008. The annual number of hip fractures decreased in women and increased in men.

INTRODUCTION

Norway has among the highest hip fracture incidence rates ever reported despite previously observed declining rates from 1999 through 2008. The aim of the present study was to investigate whether this downward trend continued through 2013, and to compare gender-specific trends in 5 year age-groups during three time periods: 1999-2003, 2004-2008, and 2009-2013.

METHODS

All hip fractures (cervical, trochanteric, and sub-trochanteric) admitted to Norwegian hospitals were retrieved. Annual age-standardized incidence rates of hip fracture per 10,000 person-years by gender were calculated for the period 1999-2013. Time trends were tested by age-adjusted Poisson regression.

RESULTS

From 1999 through 2013 there were 140,136 hip fractures in persons aged 50 years and above. Age-adjusted hip fracture incidence rates declined by 20.4 % (95 % CI: 18.6-20.1) in women and 10.8 % (95 % CI: 7.8-13.8) in men, corresponding to an average annual age-adjusted decline of 1.5 % in women and 0.8 % in men. Except for the oldest men, hip fracture rates declined in all age-groups 70 years and older. The average annual number of fractures decreased in women (-0.3 %) and increased in men (+1.1 %).

CONCLUSIONS

During the past 15 years, hip fracture rates have declined in Norway. The forecasted growing number of older individuals might, however, cause an increase in the absolute number of fractures, with a substantial societal economic and public health burden.

Time to death in a prospective cohort of 252 patients treated for fracture of the proximal femur in a major hospital in Portugal

The objectives were to analyze one-year survival and mortality predictors in patients with fracture of the proximal femur (low/moderate trauma). A prospective cohort was formed by inviting all patients hospitalized in the Orthopedic Ward of the second largest hospital in Portugal (May 2008-April 2009). Survival was assessed at 3, 6, 9, and 12 months after fracture and related to demographic factors, lifestyle, and clinical history, as well as to data from medical records (fracture type, surgery date, surgical treatment, and preoperative risk). Of the 340 patients hospitalized, 252 were included (78.9% women). Mortality at 3, 6, 9, and 12 months was 21.2%, 25%, 28.8%, and 34.6% for men and 7.8%, 13.5%, 19.2%, and 21.4% for women, respectively. Predictors of death were male gender (HR = 2.54; 95%CI: 1.40-4.58), ASA score III/IV vs. I/II (HR = 1.95; 95%CI: 1.10-3.47), age (HR = 1.06; 95%CI: 1.03-1.10), and delay in days to surgery (HR = 1.07; 95%CI: 1.03-1.12). Factors related to death were mainly related to patients' characteristics at admission.

Increased risk of coronary heart disease in patients with hip fracture: a nationwide cohort study

The study indicates that hip fracture is independently associated with increased risk of coronary heart disease. In addition, the highest risk of coronary heart disease following hip fracture appeared within the first year after hip fracture, indicating the need for multidisciplinary care for the patients.

INTRODUCTION

Bone and vasculature are modulated through numerous common pathways. However, data on the risk of coronary heart disease (CHD) after hip fracture are scarce. Therefore, we investigated whether hip fracture increased the risk of CHD by conducting a large nationwide cohort study.

METHODS

Using universal insurance claims data from 2000 to 2010, we identified a study cohort of 6013 participants newly diagnosed with hip fracture and a control cohort of 23,802 participants. Both cohorts were followed up to the end of 2011 to evaluate the risk of CHD.

RESULTS

The overall incidence of CHD was 1.69-fold higher in the hip fracture cohort than it was in the control cohort (29.2 vs. 17.1 per 1000 person-years) with an adjusted hazard ratio of 1.51 (95 % confidence interval [CI] = 1.39-1.65). Sex-, age-, and comorbidity-specific analyses showed a higher relative risk of CHD for both women and men, all age groups, those with and without comorbidities, and patients with hip fracture compared with the control cohort. The highest risk of CHD was within the first year after hip fracture (adjusted HR = 1.72, 95 % CI = 1.45-2.04), and the risk remained high in the following years.

CONCLUSION

Hip fracture was independently associated with a subsequent risk of CHD.

The 21st-century landscape of adult fractures: cohort study of a complete adult regional population

Recent reports on adult fracture epidemiology have focused mainly on the hip in the elderly, in whom increasing rates lately have changed to a decline. New reports of the preponderance of nonhip fractures in health expenditure call for a wider scope. We therefore examined current overall and site-specific fracture epidemiology in adults. We ascertained all fractures diagnosed in inpatient and outpatient care in all men and women aged 20 years or older in Skåne County, Sweden, from 1999 to 2010 (10 million person-years). For each fracture type, we estimated age-specific and sex-specific rates and evaluated potential time trends. We found 205,908 fractures yielding an overall fracture rate of 192 per 10,000 person-years. The age-standardized overall fracture rate increased by 1.2 per 10,000 and year (95% confidence interval, 0.8 to 1.5), but time trends were different for different fracture types, age strata, and for men and women. For example, in both women and men aged ≥50 years the rates of proximal humerus fracture increased (0.6 and 0.2 per 10,000 and year, respectively) while hip fracture rates declined (-1.0 and -0.3 per 10,000/year, respectively). Overall age-specific number of fractures increased with age in women but was stable in men. The increasing overall fracture rate is a major concern in the context of a growing and aging population. Effective and affordable preventive strategies and treatments should be an urgent priority to meet the challenges, especially in older women in whom most fractures occur. Comprehensive current detailed data, as provided in this study, may serve as reference for projections and for cost calculations of fracture care in other settings before results of similar examinations are available there.

Secular trends in hip fractures worldwide: opposing trends East versus West

Despite wide variations in hip rates fractures worldwide, reasons for such differences are not clear. Furthermore, secular trends in the age-specific hip fracture rates are changing the world map of this devastating disease, with the highest rise projected to occur in developing countries. The aim of our investigation is to systematically characterize secular trends in hip fractures worldwide, examine new data for various ethnic groups in the United States, evidence for divergent temporal patterns, and investigate potential contributing factors for the observed change in their epidemiology. All studies retrieved through a complex Medline Ovid search between 1966 and 2013 were examined. For each selected study, we calculated the percent annual change in age-standardized hip fracture rates de-novo. Although occurring at different time points, trend breaks in hip fracture incidence occurred in most Western countries and Oceania. After a steep rise in age-adjusted rates in these regions, a decrease became evident sometimes between the mid-seventies and nineties, depending on the country. Conversely, the data is scarce in Asia and South America, with evidence for a continuous rise in hip fracture rates, with the exception of Hong-Kong and Taiwan that seem to follow Western trends. The etiologies of these secular patterns in both the developed and the developing countries have not been fully elucidated, but the impact of urbanization is at least one plausible explanation. Data presented here show close parallels between rising rates of urbanization and hip fractures across disparate geographic locations and cultures. Once the proportion of the urban population stabilized, hip fracture rates also stabilize or begin to decrease perhaps due to the influence of other factors such as birth cohort effects, changes in bone mineral density and BMI, osteoporosis medication use and/or lifestyle interventions such as smoking cessation, improvement in nutritional status and fall prevention.