Abstract
Summary
Medicare claims data were used to investigate associations between history of previous fractures, chronic conditions, and demographic characteristics and occurrence of fractures at six anatomic sites. The study confirmed previously established associations for hip and spine fractures and identified several new associations of interest for nonhip, nonspine fractures.
Introduction
This study investigates the associations of a history of fracture, comorbid chronic conditions, and demographic characteristics with incident fractures among Medicare beneficiaries. The majority of fracture incidence studies have focused on the hip and on white females. This study examines a greater variety of fracture sites and more population subgroups than prior studies.
Methods
We used Medicare claims data to examine the incidence of fracture at six anatomic sites in a random 5% sample of Medicare beneficiaries during the time period 2000 through 2005.
Results
For each type of incident fracture, women had a higher rate than men, and there was a positive association with age and an inverse association with income. Whites had a higher rate than nonwhites. Rates were lowest among African-Americans for all sites except ankle and tibia/fibula, which were lowest among Asian-Americans. Rates of hip and spine fracture were highest in the South, and fractures of other sites were highest in the Northeast. Fall-related conditions and depressive illnesses were associated with each type of incident fracture, conditions treated with glucocorticoids with hip and spine fractures and diabetes with ankle and humerus fractures. Histories of hip and spine fractures were associated positively with each site of incident fracture except ankle; histories of nonhip, nonspine fractures were associated with most types of incident fracture.
Conclusions
This study confirmed previously established associations for hip and spine fractures and identified several new associations of interest for nonhip, nonspine fractures.
Similar content being viewed by others
References
Melton LJ (1996) Epidemiology of hip fractures: implications of the exponential increase with age. Bone 18:121S–125S
Felsenberg D, Silman AJ, Lunt M, Armbrecht G, Ismail AA (2002) Incidence of vertebral fracture in Europe: results from the European Prospective Osteoporosis Study (EPOS). J Bone Miner Res 17:716–724
Chang KPCJ, Nguyen TV (2004) Incidence of hip and other osteoporotic fractures in elderly men and women: Dubbo Osteoporosis Epidemiology Study. J Bone Miner Res 19:532–536
Baron JA, Karagas M, Barrett J, Kniffin W, Malenda D, Mayor M, Keller RB (1996) Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age. Epidemiology 7:612–618
van Staa TP, Dennison EM, Leufkens HG, Cooper C (2001) Epidemiology of fractures in England and Wales. Bone 29:517–522
Jones G, Nguyen T, Sambrook PN, Kelly PJ, Gilbert C, Eisman JA (1994) Symptomatic fracture incidence in elderly men and women: the Dubbo Osteoporosis Epidemiology Study (DOES). Osteoporos Int 4:277–282
Sanders KM, Seeman E, Ugoni AM, Pasco JA, Martin TJ, Skoric B, Nicholson GC, Kotowicz MA (1999) Age- and gender-specific rate of fractures in Australia: a population-based study. Osteoporos Int 10:240–247
Baron JA, Barrett J, Malenka D, Fisher E, Kniffin W, Bubolz T, Tosteson T (1994) Racial differences in fracture risk. Epidemiology 5:42–47
Barrett-Connor E, Siris ES, Wehren LE, Miller PD, Abbott TA, Berger ML, Santora AC, Sherwood LM (2005) Osteoporosis and fracture risk in women of different ethnic groups. J Bone Miner Res 20:185–194
Cauley JA, Wampler NS, Barnhart JM, Wu L, Allison M, Chen Z, Hendrix S, Robbins J, Jackson RD (2008) Incidence of fractures compared to cardiovascular disease and breast cancer: The Women's Health Initiative Observational Study. Osteoporos Int 19:1717–1723
Cauley JA, Lui LY, Ensrud KE, Zmuda JM (2005) Bone mineral density and the risk of incident nonspinal fractures in black and white women. JAMA 293:2102–2108
Stone KL, Seeley DG, Lui LY, Cauley JA, Ensrud K, Browner WS, Nevitt MC, Cummings SR (2003) BMD at multiple sites and risk of fracture of multiple types: long-term results from the study of osteoporotic fractures. J Bone Miner Res 18:1947–1954
Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA, Berger M (2000) Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 15:721–739
Kanis JA, Johnell O, De Laet C, Johansson H, Oden A, Delmas P, Eisman J (2004) A meta-analysis of previous fracture and subsequent fracture risk. Bone 35:375–382
Nguyen ND, Pongchaiyakul C, Center JR, Eisman JA, Nguyen TV (2005) Identification of high-risk individuals for hip fracture: a 14-year prospective study. J Bone Miner Res 20:1921–1928
LaFleur J, McAdam-Marx C, Kirkness C, Brixner DI (2008) Clinical risk factors for fracture in postmenopausal osteoporotic women: a review of the recent literature. Ann Pharmacother 42:375–386
Cummings SR, Melton LJ (2002) Epidemiology and outcomes of osteoporotic fractures. Lancet 359:1761–1767
Cauley JA, Wu L, Wampler NS, Barnhart JM, Allison M, Chen Z, Jackson R, Robbins J (2007) Clinical risk factors for fractures in multi-ethnic women: The Women's Health Initiative. J Bone Miner Res 22:1816–1826
Nickolas TL, Leonard MB, Shane E (2008) Chronic kidney disease and bone fracture: a growing concern. Kidney Int 74:721–731
Whooley MA, Kip KE, Cauley JA, Ensrud KE, Nevitt MC, Browner WS, Study of Osteoporotic Fractures Research Group (1999) Depression, falls, and risk of fracture in older women. Arch Intern Med 159:484–490
De Laet C, Kanis JA, Oden A, Johanson H, Johnell O (2005) Body mass index as a predictor of fracture risk: a meta-analysis. Osteoporos Int 16:1330–1338
Kanis JA, Johansson H, Oden AJO, de Laet C, Melton LJ III, Tenenhouse A, Reeve J, Silman AJ, Pols HA, Eisman JA, McCloskey EV, Mellstrom D (2004) A meta-analysis of prior corticosteroid use and fracture risk. J Bone Miner Res 19:893–899
Delmas PD, Marin F, Marcus R, Misurski DA, Mitlak BH (2007) Beyond hip: importance of other nonspinal fractures. Am J Med 120:381–387
Griffin MR, Ray W, Fought RL, Melton JL (1992) Black-white differences in fracture rates. Am J Epidemiol 136:1378–1385
CDC (1996) Incidence and costs to Medicare of fractures among Medicare beneficiaries aged > or =65 years—United States, July 1991-June 1992. MMWR 45:877–883
Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB (2009) Incidence and mortality of hip fractures in the United States. JAMA 302:1573–1579
Stroup NE, Freni-Titulaer LWJ, Schwartz JJ (1990) Unexpected geographic variation in rates of hospitalization for patients who have fracture of the hip. J Bone Joint Surg Am 72:1294–1298
Karagas MR, Baron JA, Barrett JA, Jacobsen SJ (1996) Patterns of fracture among the United States elderly: geographic and fluoride effects. Ann Epidemiol 6:209–216
Lauderdale DS, Thisted RA, Goldberg J (1998) Is geographic variation in hip fracture rates related to current or former region of residence? Epidemiology 9:574–577
Sporer SM, Weinstein JN, Koval KJ (2006) The geographic incidence and treatment variation of common fractures of elderly patients. J Am Acad Orthop Surg 14:246–255
Jacobsen SJ, Goldberg J, Miles TP, Brody JA, Stiers W, Rimm AA (1990) Regional variation in the incidence of hip fracture. US white women aged 65 years and older. JAMA 264:500–502
Jacobsen SJ, Cooper C, Gottlieb MS, Goldberg J, Yahnke DP, Melton LJ 3rd (1992) Hospitalization with vertebral fracture among the aged: a national population-based study, 1986–1989. Epidemiology 3:515–518
Hinton RY, Lennox DW, Ebert FR, Jacobsen SJ, Smith GS (1995) Relative rates of fracture of the hip in the United States. Geographic, sex, and age variations. Bone Joint Surg Am 77:695–702
Koval KJ, Lurie J, Zhou W, Sparks MB, Cantu RV, Sporer SM, Weinstein J (2005) Ankle fractures in the elderly: what you get depends on where you live and who you see. J Orthop Trauma 19:635–639
Lauderdale DS, Jacobsen SJ, Furner SE, Levy PS, Brody JA, Goldberg J (1997) Hip fracture incidence among elderly Asian-American populations. Am J Epidemiol 146:502–509
Lauderdale DS, Jacobsen SJ, Furner SE, Levy PS, Brody JA, Goldberg J (1998) Hip fracture incidence among elderly Hispanics. Am J Public Health 88:1245–1247
Yuan Z, Dawson N, Cooper GS, Einstadter D, Cebul R, Rimm AA (2001) Effects of alcohol-related disease on hip fracture and mortality: a retrospective cohort study of hospitalized Medicare beneficiaries. Am J Public Health 91:1089–1093
Sugarman JR, Connell FA, Hansen A, Helgerson SD, Jessup MC, Lee H (2002) Hip fracture incidence in nursing home residents and community-dwelling older people, Washington State, 1993–1995. J Am Geriatr Soc 50:1638–1643
Colón-Emeric CS, Biggs DP, Schenck AP, Lyles KW (2003) Risk factors for hip fracture in skilled nursing facilities: who should be evaluated? Osteoporos Int 14:484–489
Lamont EB, Lauderdale DS (2003) Low risk of hip fracture among elderly breast cancer survivors. Ann Epidemiol 13:698–703
Baxter NN, Habermann EB, Tepper JE, Durham SB, Virnig BA (2005) Risk of pelvic fractures in older women following pelvic irradiation. JAMA 294:2587–2593
Gage BF, Birman-Deych E, Radford MJ, Nilasena DS, Binder DF (2006) Risk of osteoporotic fracture in elderly patients taking warfarin. Arch Intern Med 166:241–246
Liperoti R, Onder G, Lapane KL, Mor V, Friedman JH, Bernabei R, Gambassi G (2007) Conventional or atypical antipsychotics and the risk of femur fracture among elderly patients: results of a case-control study. J Clin Psychiatry 68:929–934
Lyles KWSA, Colón-Emeric CS (2008) Hip and other osteoporotic fractures increase the risk of subsequent fractures in nursing home residents. Osteoporos Int 19:1225–1233
Buccaneer Computer Systems and Services, Inc. Chronic Condition Data Warehouse User Manual; 2008; Available from: http://www.ccwdata.org/downloads/CCW%20User%20Manual.pdf
Ray WA, Griffin MR, Fought RL, Adams ML (1992) Identification of fractures from computerized Medicare files. J Clin Epidemiol 45:703–714
Curtis JR, Mudano A, Solomon DH, Kim Y, Saag KG (2007) Identifying clinical vertebral fracture using administrative claims data: a validation study. J Bone Miner Res 22:Abstract M354:S199.
Morrill R, Cromartie J, Hart LG (1999) Metropolitan, urban, and rural commuting area: toward a better depiction of the U.S. settlement system. Urban Geogr 20:727–748
Rural-Urban Commuting Area Codes. WWAMI Rural Health Research Center. Available from: http://depts.washington.edu/uwruca/
U.S. Census Bureau Census 2000 Summary File 3 (SF 3)—Sample Data. Available at http://www.census.gov/
Leslie WD, O’Donnell S, Jean S, Lagace C, Walsh P, Bancej C, Morin S, Hanley DA, Papaioannou A (2009) Trends in hip fracture rates in Canada. JAMA 302:883–889
Zingmond DS, Soohoo NF, SL S (2006) The role of socioeconomic status on hip fracture. Osteoporos Int 17:1562–1568
Bacon WE, Hadden WC (2000) Occurrence of hip fractures and socioeconomic position. J Aging Health 12:193–203
van Staa TP, Leufkens HGM, Cooper C (2002) The epidemiology of corticosteroid-induced osteoporosis: a metaanalysis. Osteoporos Int 10:777–787
Ismail AA, Cockerill W, Cooper C, Finn JD, Abendroth K, Parisi G, Banzer D, Benevolenskaya LI, Bhalla AK, Armas JB, Cannata JB, Delmas PD (2001) Prevalent vertebral deformity predicts incident hip though not distal forearm fracture: results from the European Prospective Osteoporosis Study. Osteoporos Int 12:85–90
Cuddihy MT, Gabriel SE, Crowson CS, O’Fallon WM, Melton LJ 3rd (1999) Forearm fractures as predictors of subsequent osteoporotic fractures. Osteoporos Int 9:469–475
AEJ MLJ, Cooper C, O’Fallon WM, Riggs BL (1999) Vertebral fractures predict subsequent fractures. Osteoporos Int 10:214–221
Black DM, Arden NK, Palermo L, Pearson J, Cummings SR (1999) Prevalent vertebral deformities predict hip fractures and new vertebral deformities but not wrist fractures. Study of Osteoporotic Fractures Research Group. J Bone Miner Res 14:821–828
Davis JW, Grove JS, Wasnich RD, Ross PD (1999) Spatial relationships between prevalent and incident spine fractures. Bone 24:261–264
Ross PD, Genant HK, Davis JW, Miller PD, Wasnich RD (1993) Predicting vertebral fracture incidence from prevalent fractures and bone density among non-black, osteoporotic women. Osteoporos Int 3:120–126
Mezuk B, Eaton W, Golden SH (2008) Depression and osteoporosis: epidemiology and potential mediating pathways. Osteoporos Int 19:1–12
Rolland Y, Abellan van Kan G, Benetos A, Blain H, Bonnefoy M, Chassagne P, Jeandel C, Laroche M, Nourhashemi F, Orcel P, Piette F, Ribot C, Ritz P, Roux C, Taillandier J, Tremollieres F, Weryha G, Vellas B (2008) Frailty, osteoporosis and hip fracture: causes, consequences and therapeutic perspectives. J Nutr Health Aging 12:335–346
Liu B, Anderson G, Mittmann N, To T, Axcell T, Shear N (1998) Use of selective serotonin-reuptake inhibitors of tricyclic antidepressants and risk of hip fractures in elderly people. Lancet 351:1303–1307
Robbins J, Hirsch C, Whitmer R, Cauley J, Harris T (2001) The association of bone mineral density and depression in an older population. J Am Geriatr Soc 49:732–736
Bonds DE, Larson JC, Schwartz AV, Strotmeyer ES, Robbins J, Rodriguez BL, Johnson KC, Margolis KL (2006) Risk of fracture in women with type 2 diabetes: the Women’s Health Initiative Observational Study. J Clin Endocrinol Metab 19:3404–3410
Holmberg AH, Johnell O, Nilsson PM (2006) Risk factors for fragility fracture in middle age. A prospective population-based study of 33, 000 men and women. Osteoporos Int 17:1065–1077
Schwartz A, Sellmeyer D, Ensrud K (2001) Older women with diabetes have an increased risk of fracture: a prospective study. J Clin Endocrinol Metab 86:32–38
Vestergaard P (2007) Discrepancies in bone mineral density and fracture risk in patients with type 1 and type 2 diabetes—a meta-analysis. Osteoporos Int 81:427–444
Janghorbani M, Van Dam RM, Willett WC, Hu FB (2007) Systematic review of Type 1 and Type 2 diabetes mellitus and risk of fracture. Am J Epidemiol 166:495–505
Schwartz AV (2003) Diabetes mellitus: does it affect bone? Calcif Tissue Int 73:515–519
Thrailkill KM, Lumpkin CK Jr, Bunn RC, Kemp SF, Fowlkes JL (2005) Is insulin an anabolic agent in bone? Dissecting the diabetic bone for clues. Am J Physiol Endocrinol Metab 289:E735–E745
Beck TJ, Oreskovic TL, Stone KL, Ruff CB, Ensrud K, Nevitt MC, Genant HK, Cummings SR (2001) Structural adaptation to changing skeletal load in the progression toward hip fragility: the study of osteoporotic fractures. J Bone Miner Res 16:1108–1119
Geusens P, Milisen K, Dejaeger E, Boonen S (2003) Falls and fractures in postmenopausal women: a review. J Br Menopause Soc 9:101–106
Weinstein JN, Birkmeyer JD (eds) (2000) The Dartmouth Atlas of Musculoskeletal Health Care. American Hospital Publishing, Chicago, IL
Finkelstein JS, Lee ML, Sowers M, Ettinger B, Neer RM, Kelsey JL, Cauley JA, Huang MH, Greendale GA (2002) Ethnic variation in bone density in premenopausal and early perimenopausal women: effects of anthropometric and lifestyle factors. J Clin Endocrinol Metab 87:3057–3067
Pothiwala P, Evans EM, Chapman-Novakofski KM (2006) Ethnic variation in risk for osteoporosis among women: a review of biological and behavioral factors. J Womens Health (Larchmt) 15:709–719
International Osteoporosis Foundation, Fixed risk factors. Available from: http://www.iofbonehealth.org
Fang J, Freeman R, Jeganathan R, Alderman MH (2004) Variations in hip fracture hospitalization rates among different race/ethnicity groups in New York City. Ethn Dis 14:280–284
Cummings SR, Cauley JA, Palermo L, Ross PD, Wasnich RD, Black D, Faulkner KG (1994) Racial differences in hip axis lengths might explain racial differences in rates of hip fracture. Study of Osteoporotic Fractures Research Group. Osteoporos Int 4:226–229
Brownbill RA, Ilich JZ (2003) Hip geometry and its role in fracture: what do we know so far? Curr Osteoporos Rep 1:25–31
Seeley DG, Kelsey J, Jergas M, Nevitt MC (1996) Predictors of ankle and foot fractures in older women. The Study of Osteoporotic Fractures Research Group. J Bone Miner Res 11:1347–1355
Hasselman CT, Vogt MT, Stone KL, Cauley JA, Conti SF (2003) Foot and ankle fractures in elderly white women. Incidence and risk factors. J Bone Joint Surg Am 85-A:820–824
Guggenbuhl P, Meadeb J, Chales G (2005) Osteoporotic fractures of the proximal humerus, pelvis, and ankle: epidemiology and diagnosis. Joint Bone Spine 72:372–375
Baron JA, Karagas MR (1992) Medicare studies of vertebral fractures. Epidemiology 3:475–476
Barrett JA, Baron JA, Karagas MR, ML B (1999) Fracture risk in the U.S. Medicare population. J Clin Epidemiol 52:243–249
Eicheldinger C, Bonito A (2008) More accurate racial and ethnic codes for Medicare administrative data. Health Care Financ Rev 29:27–42
Conflicts of interest
This research was supported by a contract between UAB and Amgen, Inc. Only the authors from UAB had access to the Medicare data used. The analysis, presentation, and interpretation of the results were solely the responsibility of the authors. Some of the investigators (JRC, KGS) also receive salary support from the National Institutes of Health (AR053351, AR052361), the Agency for Healthcare Research and Quality (U18 HS016956), and the Arthritis Foundation (JRC). Two investigators received research support from Novartis, Merck, Eli Lilly, Amgen (JRC, KGS), and Procter & Gamble (JRC), in a consulting and/or advisory board role for Procter & Gamble (JRC), Novartis, Merck, Eli Lilly, and Amgen (KGS) and as members of the speakers bureau for Novartis (JRC, KGS) and for Procter & Gamble and Eli Lilly (JRC).
Author information
Authors and Affiliations
Corresponding author
Additional information
An erratum to this article can be found at http://dx.doi.org/10.1007/s00198-010-1347-6
Electronic supplementary material
Below is the link to the electronic supplementary material.
ESM 1
(PDF 31 kb)
Appendix
Appendix
Rights and permissions
About this article
Cite this article
Taylor, A.J., Gary, L.C., Arora, T. et al. Clinical and demographic factors associated with fractures among older Americans. Osteoporos Int 22, 1263–1274 (2011). https://doi.org/10.1007/s00198-010-1300-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00198-010-1300-8