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Changes in number and incidence of hip fractures over 12 years in France
Bone 81 (2015) 131–137
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Original Full Length Article
Changes in number and incidence of hip fractures over 12 years in France Karine Briot a,⁎, Milka Maravic b, Christian Roux a a b
INSERM U1153, Paris Descartes University, Rheumatology Department, Cochin Hospital, Paris, France Rheumatology Department Lariboisière Hospital, Paris, France
a r t i c l e
i n f o
Article history: Received 1 March 2015 Revised 5 June 2015 Accepted 7 July 2015 Available online 9 July 2015 Keywords: Hip fracture Osteoporosis Incidence Epidemiology
a b s t r a c t The incidence of hip fractures decreased in France in both genders, especially in the elderly, from 2002 to 2008, in parallel with availability of bone densitometry and effective anti-osteoporotic treatments. However prescriptions of these treatments are decreasing, since 2008, and recent studies show declining of osteoporosis management after fragility fractures. The aim of this study was to assess the incidence of hip fractures in men and women aged 60 years and over, from 2002 to 2013 in France. Data were drawn from the French Hospital National Database which includes all hospitalizations of the country. Hospital data for hip fractures between 2002 and 2013 were numbered and the incidence rates per 1,000,000 adjusted on age (60–74; 74–84, and ≥85 years), and gender was calculated using the data of the French population. The number of hip fractures increased in women (+5%; from 49,287 in 2002 to 50,215) and in men (+22%, from 12,716 to 15,482) aged over 60 years. Between 2002 and 2013, the French population increased by 21 and 29% in women and men of this age group; thus, incidence of hip fractures decreased by 14% in women (6929 and 5987 per million in 2002 and 2013, respectively) and a slight decrease of −1% was observed in men (2344 and 2316). The decrease in incidence is also confirmed in the very elderly (≥85 years), with a decrease of −29% and −24% in women and men respectively. Over the last 12 years, the incidence of hip fractures decreased in France in women and men aged over 60 years. This decrease is also observed in the subjects (≥85 years and older in both genders). Further studies are needed to assess potential changes in risk factors of hip fractures during the last decade. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Hip fractures are a major public health concern because of their consequences in morbidity, costs and mortality. They are associated with a reduction of expected survival of 10–20% in the first year following the fracture, and a greater risk of dying persisting for at least 5 years afterwards [1–3]. The number of hip fractures is increasing worldwide, because of the increase in the number of frail elderly people at high risk of falls and fractures. But hip fracture incidence varies among countries [4,5]. During the past decade, hip fracture incidence has declined in most Western countries and Oceania [5–14], reached a plateau [15,16] and increased in some countries in Asia and South America [5,17]. In France, we previously showed that the incidence of hip fractures decreased in both genders from 2002 to 2008 [18]. This observation was associated with different factors, including the availability of bone densitometry and effective anti-osteoporotic treatments [18], although no causal association has been demonstrated. However, recent studies show declining of osteoporosis management after fragility fractures. In a retrospective analysis of 96,887 men and women aged 50 years or more, hospitalized for hip fracture over a period ⁎ Corresponding author at: Rheumatology Department, Cochin Hospital, 27 rue du Faubourg St Jacques, 75014 Paris, France. E-mail address: [email protected] (K. Briot).
http://dx.doi.org/10.1016/j.bone.2015.07.009 8756-3282/© 2015 Elsevier Inc. All rights reserved.
of 1 year, the estimated probability of receiving osteoporosis medication within 12 months after discharge from hospital significantly declined over a 10-year period from 40.2% in 2002, to 20.5% in 2011 [19]. Antiosteoporotic treatment uptake decreased progressively in Europe since 2008 including in France [20]. According to a retrospective analysis conducted in patients hospitalized in 2010–2011 for a major osteoporotic fracture (59% were hip fractures) in a tertiary hospital in Paris, France, only 4% and 10% of patients discharged to home and admitted to a rehabilitation center respectively received an antiosteoporotic treatment [21]. Thus, our hypothesis was that the decrease in hip fracture incidence observed between 2002 and 2008 could wane thereafter, because of the recent changes in management of osteoporotic patients and prescriptions of antiosteoporotic drugs. The aim of this study was to assess the trends of occurrence of hip fractures, numbers, and incidences from 2002 to 2013, in women and men aged 60 years and over in France.
2. Methods 2.1. Data We assessed the number of hospitalizations for hip fractures in the French metropolitan population aged 60 years and older from 2002 to 2013. Data were obtained from the French Hospital National Database
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which includes all hospitalizations occurring in public and private acute care settings in France. This system for financing French hospitals is mandatory since 2004 in public hospitals and since 2005 in private hospitals. An internal control of completeness and quality of coding is performed monthly in each hospital. An external control is performed yearly by physicians of the National Medical Insurance Service. Hip fractures were defined by their ICD-10 diagnosis codes: S72.0, S72.1, and S72.2 (ICD-10 codes). We selected hospitalizations for which the primary diagnosis was hip fracture in people aged 60 years and over with the initial surgical treatment performed during the same hospitalization managed in metropolitan France. The selected hospitalizations represented 82% of all hospitalizations with hip fractures encoded as primary diagnosis. The remaining reasons for hospitalizations were other surgical management related to polytraumatism, removal or change of prosthesis, reduction of prosthesis, removal of osteosynthesis material, or fractures occurring in a context of cancer or mention of cancer or prosthesis complications as secondary diagnosis. Rehospitalizations and transfers were not retained. 2.2. Population Population data used for the present study were those published in 2014 by the National Institute for Statistics and Economic Studies (Institut national de la statistique et des études économiques, www. insee.fr) for metropolitan France. Age classes (0–19, 0–39, 40–59, 60–74, and over 74 years) were available by gender from 2002 to 2004 and for each age and gender since 2005. We defined three age groups: 60–74, 75–84, and ≥ 85 years. For data before 2005, we used the proportion of 2005 to estimate the population in 75–84 and ≥85 years assuming no major change in the structure of the population over 3 years. 2.3. Analysis Incidences of hospitalization for surgical treatment of hip fractures were calculated as the number of cases per 1,000,000 inhabitants per year, by sex and age group and were stratified by sex and age (three age groups: 60–74, 74–84, and ≥85 years from the period 2002–2013). The absolute numbers and incidences of hip fractures provided were population-based. We described the changes in number of hospitalizations for hip fracture and the changes in the French population. We calculated the incidence of hip fractures from 2002 to 2013 for all patients aged over 60 years and in the three age classes, as previously described, and compared the data in 2013 using the data of 2002 as reference. We tested the linear trend of age-specific incidence using
the test for trend in proportion (R Version 2.15.2) in order to assess any potential changes of the trend during the period of observation (α = 0.05). 3. Results 3.1. Numbers of hip fractures in people aged 60 years and over Tables 1 and 2 describe the changes in the number of hip fractures from 2002 to 2013 in women and men, respectively. The number of hip fractures increased in women (+ 4.8%; from 49,287 in 2002 to 51,661 in 2013) and in men (+21%, from 12,716 in 2002 to 15,482 in 2013). Between 2002 and 2013, the French population aged over 60 years increased by 21 and 29% in women and in men, respectively. In women aged 60–74, and 75–84 years, there was a decrease in the number of fractures (− 11% and − 12%, respectively) (Fig. 1). Such a decrease was not observed in men (Tables 1 and 2). In the youngest group, the nadir was in 2009 (i.e. − 16%) (Table 1). The increase in people aged over 60 years and over is actually explained by the results in the oldest. In women and men aged ≥85 years there was a 22% and 52% increase in the number of hip fractures respectively, in parallel with a dramatic increase in the number of people aged ≥ 85 years: + 70 and + 100% in women and men, respectively. In the elderly subjects (≥85 years), the hip fracture increase begun in 2004 (Fig. 1). 3.2. Incidence of hip fractures in people aged 60 years and over The incidence of hip fractures over 60 years decreased by 14% in women (6929 and 5987 per million in 2002 and 2013, respectively) and a slight decrease of 1.4% was observed in men (2344 and 2316 per million in 2002 and 2013, respectively). As shown in Figs. 2, 3 and 4, the incidence of hip fractures decreased in all age groups (i.e., 60–74, 75–84 and ≥85 years). The age-specific incidence decrease was − 25.9, − 20, and − 29.5% in women aged 60–74, 75–84, and ≥ 85 years respectively. In men, the age-specific incidence decrease was −17.3, −19.5 and −24.2% in 60–74, 75–84, and ≥85 years respectively. Figs. 3 and 4 showed an apparent stabilization from 2011 in women. However, the test for linear trend showed that the changes over 12 years are statistically significant for each age class and gender (p b 0.00001). 4. Discussion This study shows a decrease in hip fracture incidence in France over the last decade (2002–2013). Although there was a huge increase in the
Table 1 Absolute numbers and incidence of hip fractures in women aged 60 years and over. Year 2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Hospitalization (n.) 60–74 6568 75–84 18,668 N84 24,051 N59 49,287
6394 19,447 22,913 48
6068 20,271 21,144 47,483
5919 20,252 22,045 48,216
5816 19,829 22,688 48,333
5741 19,316 23,865 48,922
5564 18,749 24,879 49,192
5515 18,396 25,577 49,488
5599 17,819 26,674 50,092
5640 17,221 27,072 49,933
5558 16,599 28,058 50,215
5842 16,413 29,406 51,661
Population 60–74 4,210,517 75–84 2,168,450 N84 733,728 N59 7,112,695
4,194,641 2,225,294 752,963 7,172,898
4,192,542 2,278,274 770,889 7,241,705
4,201,718 2,324,372 786,487 7,312,577
4,196,846 2,386,353 855,087 7,438,286
4,282,120 2,398,822 930,452 7,611,394
4,382,599 2,415,501 995,701 7,793,801
4,502,200 2,419,969 1,058,395 7,980,564
4,618,621 2,428,155 1,117,014 8,163,790
4,750,202 2,404,219 1,160,349 8,314,770
4,862,769 2,397,376 1,215,320 8,475,465
4,989,780 2,383,138 1,256,513 8,629,431
Incidence/1,000,000 60–74 1560 75–84 8609 N84 32,779 N59 6929
1524 8739 30,430 6797
1447 8898 27,428 6557
1409 8713 28,030 6593
1386 8309 26,533 6498
1341 8052 25,649 6427
1270 7762 24,986 6312
1224 7602 24,166 6201
1212 7338 23,880 6136
1187 7162 23,331 6005
1143 6924 23,087 5925
1171 6887 23,116 5987
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Table 2 Absolute numbers and incidence of hip fractures in men aged 60 years and over. Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Hospitalization (n.) 60–74 3130 75–84 5076 N84 4510 N59 12,716
3065 5536 4248 12,849
2848 5581 4026 12,455
2991 5670 4408 13,069
2937 5527 4744 13,208
2913 5591 5276 13,780
3086 5823 5557 14,466
3034 5569 5877 14,480
3270 5606 6209 15,085
3243 5330 6349 14,922
3145 5204 6446 14,795
3324 5293 6865 15,482
Population 60–74 3,580,072 75–84 1,341,534 N84 273,031 N59 5,194,637
3,584,051 1,386,325 282,146 5,252,522
3,601,632 1,428,569 290,744 5,320,945
3,626,588 1,474,549 300,102 5,401,239
3,642,824 1,506,484 338,038 5,487,346
3,753,357 1,526,811 376,455 5,656,623
3,879,156 1,554,441 408,014 5,841,611
4,017,748 1,571,767 437,037 6,026,552
4,148,471 1,594,086 462,671 6,205,228
4,271,721 1,609,117 494,427 6,375,265
4,381,475 1,627,053 523,432 6,531,960
4,495,822 1,640,001 547,150 6,682,973
Incidence/1,000,000 60–74 874 75–84 3784 N84 16,518 N59 2344
855 3993 15,056 2446
791 3907 13,847 2341
825 3845 14,688 2420
806 3669 14,034 2374
776 3662 14,015 2436
796 3746 13,620 2476
755 3543 13,447 2402
788 3517 13,420 2431
759 3312 12,841 2341
717 3198 12,315 2265
739 3227 12,547 2316
number of fractures in the patients aged over 85 years, there was also a high decrease in incidence in this age group. We do not confirm our hypothesis of change of hip fracture incidence after 2008 related to the changes in anti-osteoporotic treatments prescriptions. 4.1. Number of hip fractures The aging of the population increases dramatically the number of elderly people at risk for hip fracture. During our follow-up, the number of women and men aged N60 years increased by 21 and 29%, leading to a 4.8 and 21% increase in the number of hip fractures over a decade in women and men, respectively. However, the changes in the number of fractures were different according to age, in women. In the youngest age group of women (60–74 years), there was actually a decrease of 11% of the absolute number of hip fractures, and most of this decrease was observed between 2002 and 2008. In women aged 75–84 years, a 12% decrease in the number of hip fractures was observed, without a plateau. These results contrast dramatically with the huge increase in the number of fractures in women aged ≥85 years. As a consequence, hip fractures in the very elderly represented 49% and 57% of the total number of fractures in women in 2002 and 2013 respectively; a similar change was observed in men aged ≥85 years, representing 35% and 44%
of the total number of fractures respectively. Thus the burden related to hip fractures will rise over time, as the proportion of frail elderly persons at high risk of falls and fractures is expected to increase dramatically in the next decades. Indeed, human senescence has been delayed: the age at which remaining life expectancy is ten years has been postponed by 8 years in Sweden, 12 years in Japan; in some countries the number of centenarians climbs vertically [22,23]. This suggests that the very elderly should receive a high priority for hip fractures prevention. 4.2. Hip fracture incidence changes In contrast to the increase in the number of hip fractures, a large decrease in incidence was observed in the very elderly subjects, confirming previous studies not only in women but also in men [10]. The decrease was 29.5% and 24.2% in women and men aged ≥ 85 years. In this population class, we observed an increase from 2002 to 2013 in the number of subjects in the French population: from 733,728 to 1, 256, 513 and 273,031 to 547,150 in women and men, respectively. This is relevant as 57 and 44% of the total number of hip fractures occurred in women and men aged ≥85 years and such a result should prevent any overestimation of the incidence of fractures, based on estimation from the incidence observed in younger populations.
Fig. 1. Number of hip fractures in women aged over 60 years and over in France.
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Incidence per 1,000,000 inhabitants per year
4.3. Potential explanations of the changes
35000
30000
25000
20000 2002 2013
15000
10000
5000
0 60-74
75-84
>84
Age groups Fig. 2. Age-specific incidence in women N60 years in France in 2002 and 2013.
The rules of payment of the hospital expenses changed in France in 2004 leading to change in coding practice; this may explain the dramatic change in the number of hip fractures in the very elderly (Fig. 1). However, the coding practice change had no impact in other categories of patients. This observation could be also explained by a healthier cohort effect: after the age of 85 the subjects still at risk represent a healthier population, as those at very high risk have already had hip fractures or have died. Comparison with other countries, on the basis of their national hospital database gave contrasting results. Recent studies showed that the absolute number of hip fractures increases in all countries with the increasing elderly population, but the age-adjusted incidence of hip fracture does not behave similarly. Our results confirm those of previous studies that suggested national declines [5,12,24,25]; however in other studies, hip fracture incidence increased [5,15]. Contrasting results are due to several factors, as the age of the studied population: whole population [8], ≥ 40 years [18], ≥ 45 years [24], ≥ 50 years [12, 16], and ≥ 65 years [26,27], and the duration of the observation from 4 years to 21 years [8]. Some differences may occur in the period of follow-up, in the population used for the calculation of incidence for each studied year, and in the method of the selection of hospitalization data.
There are several potential explanations for the changes in incidence of hip fracture observed during the last decade. Improvement of the fracture prevention management, including bone densitometry testing and prescription of antiosteoporotic treatments may have an impact on hip fracture incidence changes. Medical management of patients with fracture has been improved by health care internal network or fracture liaison service (FLS) organized in some large hospitals in France [28,29], with a high rate of antiosteoporotic treatment prescription after fracture and a high level of persistence with osteoporosis treatment [28,29]. However the number of FLS is very limited in France and even, with such an optimal care, the uptake and adherence with therapies are limited [8,27]. A relevant association between an increase in the number of BMD tests, an increase in the number of antiosteoporotic treatments and a decrease in osteoporotic fractures was shown in Canada (between 1992 and 2001) [30]. In a study based on the sample Medicare claims from 1985 to 2005, the authors showed a decrease in incidence of hip fractures after 1995, which temporally corresponds with the market release of bisphosphonates [27]. However, a study performed in Canada over a 21-year period (1985–2005) found that decline hip fracture incidence began before the availability of bone densitometry or use of bisphosphonates [8]. Moreover, although there is a huge difference in prescribing rates of anti-osteoporotic drugs among provinces of the country, there is no difference between provinces in hip fracture incidence [31]. In France, oral bisphosphonates are available and reimbursed since 2000 and bone densitometry, since 2006. However, using the sales data, a report of osteoporosis in France showed that the prescription of antiosteoporotic treatments decreased since 2008; proportions of persons over the age of 50 years who were treated increased from 1.21% in 2001 to 7.18% in 2008, but fell back to 6.30% in 2011 [20]. The decrease in the incidence of hip fractures among men in our study indicates that increased osteoporosis screening and pharmacotherapy is not the main explanation for the decline of hip fractures, as men could have been less exposed to antiosteoporotic medication and preventive measures [32]. Our hypothesis of a possible waning of decrease in hip fracture incidence between 2008 and 2013, because of the changes in management and prescriptions was not confirmed. However, in the group of women aged 60–74 years there is a plateau in the number of hip fractures per year since 2008. Whether or not this is related to changes in anti-osteoporotic drug prescriptions needs longer studies, as it was not observed in other age groups. Osteoporotic fracture could be a symptom of a poor patient's health status, rather than the cause [33] and the increasing survival of the
Hip fracture incidence rate (per 1,000,000 person-years) 8,000 7,000 6,000 5,000 Incidence rate in women≥ 60 years
4,000
Incidence rate in men≥ 60 years 3,000 2,000 1,000 0 2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Fig. 3. Overall sex-specific trends in hip fracture incidence (per 1000, 000 person-years) in women and men aged 60 years and older in France between 2002 and 2013.
K. Briot et al. / Bone 81 (2015) 131–137
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Fig. 4. Sex and age specific (60–74, 75–84, ≥85 years) trends in hip fracture incidence (per 1,000,000 person-years) in women (a) and men (b) in France between 2002 and 2013.
frailest elderly may contribute to the age effect on decrease of hip fracture incidence. In Switzerland, the reversal of the hip fracture secular trend in elderly women was explained by a decrease in the incidence in institution-dwelling elderly women [10]. Nutritional lifestyle changes as calcium and vitamin D supplementation may also contribute to the decrease in hip fracture incidence, especially amongst elderly subjects; however, there is no evidence of an increase of vitamin D intake in Europe [34,35]. Reduction of fall-related comorbidities [36] and prevention of falls may also explain the decrease incidence. Studies showed that the most effective strategies to decrease fall risk in community-living elderly include regular physical training and modification of the fall risk factors: wearing antislip shoes, reducing psychotropic medication and polymedication, vitamin D supplementation, and cataract surgery [37]. The improvement of health status of elderly subjects could have contributed to fall reduction [37]. Fall prevention programs are associated with an overall relative reduction of fracture risk [38] National prevention programs have been publicly released on awareness of the risk of falls in France before 2008. However these efforts have not been maintained and we are not aware of repetition of these programs between 2008 and 2013 [39]. A recent analysis suggested the impact of urbanization, as a plausible explanation for wide variations in hip fractures rates worldwide,
showing close parallels between rising rates of urbanization and hip fractures across disparate geographic locations and cultures [5]. The mechanisms by which urbanization may impact hip fracture rates are not known, but may include decreased physical activity and increased in body weight and obesity [40,41]. Higher body weight has been associated with greater BMD and lower rates of bone loss [41]. A meta-analysis showed a lower risk of hip fractures with higher body mass index (BMI) [42], although obesity did not prevent all types of fractures [43,44]. Recent studies suggest an increase of BMI during the last decades [45]; however we do not have BMI changes in our studied population. Some studies reported the impact of birth cohort effect on hip fracture risk, and the importance to consider that intrauterine and childhood periods of development and severe environmental factors which occur early in the life course may influence the peak bone mass achieved and cause increased fracture rates in later generations [4]. A consistent decline in the incidence of hip fracture in all 10-year birth cohorts in New Zealand since those born between 1883 and 1892 was shown, concomitant with increasing health and improvements in measures of physical status in later birth cohorts [11]. Other examples (the Dutch famine and concentration camp survivors) [46] suggest that profound insults of this type might reduce BMD values in the
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offspring and may explain some European observations. However, the incidence trends for hip fracture have been observed in countries (Canada, Australia and the United States) that did not experience such any major population-wide environmental stressors. Our study has some limitations. We used administrative data and as this database is anonymous, we could not check the diagnosis of osteoporotic fracture in the patients' files. The rules of payment of the hospital expenses changed in France in 2004, and this may have had an important effect on coding practice and improvement of data completeness. However, even if this change had a significant impact on the result, it reinforced the decreasing incidence trend observed in whole population and in the oldest people (≥85 years), whatever the gender. A hip fracture on the controlateral side may occur in a given patient within the same year. However, since 2006, 2% to 5% of patients have been hospitalized for a fracture of the opposite hip within the same year and we considered that the small proportion has no significant impact on the hip incidence trends. These findings are not generalizable to other low trauma fractures such as Colle's or humerus fractures. Finally, we are not able to directly link patients to their pharmaceutical treatments or bone densitometry exams. Over the last 12 years, the incidence of hip fractures decreased in France in women and men aged over 60 years. This decrease is large in the elderly (≥85 years) in both genders. Further studies are needed to assess potential changes in hip fractures risk factors during the last decade. Disclosures K Briot: Research grants and/or honoraria from Amgen, MSD, Lilly, Pfizer. M Maravic: Milka Maravic has been an employee of AstraZeneca France, from 12 November 2014. AstaZeneca was not involved in this manuscript. No funding from AstraZeneca was received for this manuscript, based on a study conducted before November 2014. C Roux: Research grants and/or honoraria and/or travel reimbursements from Amgen, MSD, Lilly, Novartis. Acknowledgments This work is supported by the College Français des Médecins Rhumatologues (www.cfmr.fr). References [1] D. Bliuc, N.D. Nguyen, V.E. Milch, T.V. Nguyen, J.A. Eisman, J.R. Center, Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women, JAMA 301 (2009) 513–521. [2] I.M. Giversen, Time trends of mortality after first hip fractures, Osteoporos. Int. 18 (2007) 721–732. [3] S. Haleem, L. Lutchman, R. Mayahi, J.E. Grice, M.J. Parker, Mortality following hip fracture: trends and geographical variations over the last 40 years, Injury 39 (2008) 1157–1163. [4] C. Cooper, Z.A. Cole, C.R. Holroyd, S.C. Earl, N.C. Harvey, E.M. Dennison, L.J. Melton, S.R. Cummings, J.A. Kanis, IOF CSA Working Group on Fracture Epidemiology, Secular trends in the incidence of hip and other osteoporotic fractures, Osteoporos. Int. 22 (2001) 1277–1288. [5] G. Ballane, J.A. Cauley, M.M. Luckey, Gel-H. Fuleihan, Secular trends in hip fractures worldwide: opposing trends East versus West, J. Bone Miner. Res. 29 (2014) 1745–1755. [6] A. Vanasse, M.G. Orzanco, P. Dagenais, T. Ouarda, J. Courteau, S. Asghari, F. Chebana, B. Martel, P. Gosselin, Secular trends of hip fractures in Québec, Canada, Osteoporos. Int. 23 (2012) 1665–1672. [7] K.P. Chang, J.R. Center, T.V. Nguyen, J.A. Eisman, Incidence of hip and other osteoporotic fractures in elderly men and women: Dubbo Osteoporosis Epidemiology Study, J. Bone Miner. Res. 19 (2004) 532–536. [8] W.D. Leslie, S. O'Donnell, S. Jean, C. Lagacé, P. Walsh, C. Bancej, S. Morin, D.A. Hanley, A. Papaioannou, Osteoporosis Surveillance Expert Working Group, Trends in hip fracture rates in Canada, JAMA 302 (2009) 883–889. [9] W.D. Leslie, M. Sadatsafavi, L.M. Lix, M. Azimaee, S. Morin, C.J. Metge, P. Caetano, Secular decreases in fracture rates 1986–2006 for Manitoba, Canada: a population-based analysis, Osteoporos. Int. 22 (2011) 2137–2143.
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Original Full Length Article
Changes in number and incidence of hip fractures over 12 years in France Karine Briot a,⁎, Milka Maravic b, Christian Roux a a b
INSERM U1153, Paris Descartes University, Rheumatology Department, Cochin Hospital, Paris, France Rheumatology Department Lariboisière Hospital, Paris, France
a r t i c l e
i n f o
Article history: Received 1 March 2015 Revised 5 June 2015 Accepted 7 July 2015 Available online 9 July 2015 Keywords: Hip fracture Osteoporosis Incidence Epidemiology
a b s t r a c t The incidence of hip fractures decreased in France in both genders, especially in the elderly, from 2002 to 2008, in parallel with availability of bone densitometry and effective anti-osteoporotic treatments. However prescriptions of these treatments are decreasing, since 2008, and recent studies show declining of osteoporosis management after fragility fractures. The aim of this study was to assess the incidence of hip fractures in men and women aged 60 years and over, from 2002 to 2013 in France. Data were drawn from the French Hospital National Database which includes all hospitalizations of the country. Hospital data for hip fractures between 2002 and 2013 were numbered and the incidence rates per 1,000,000 adjusted on age (60–74; 74–84, and ≥85 years), and gender was calculated using the data of the French population. The number of hip fractures increased in women (+5%; from 49,287 in 2002 to 50,215) and in men (+22%, from 12,716 to 15,482) aged over 60 years. Between 2002 and 2013, the French population increased by 21 and 29% in women and men of this age group; thus, incidence of hip fractures decreased by 14% in women (6929 and 5987 per million in 2002 and 2013, respectively) and a slight decrease of −1% was observed in men (2344 and 2316). The decrease in incidence is also confirmed in the very elderly (≥85 years), with a decrease of −29% and −24% in women and men respectively. Over the last 12 years, the incidence of hip fractures decreased in France in women and men aged over 60 years. This decrease is also observed in the subjects (≥85 years and older in both genders). Further studies are needed to assess potential changes in risk factors of hip fractures during the last decade. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Hip fractures are a major public health concern because of their consequences in morbidity, costs and mortality. They are associated with a reduction of expected survival of 10–20% in the first year following the fracture, and a greater risk of dying persisting for at least 5 years afterwards [1–3]. The number of hip fractures is increasing worldwide, because of the increase in the number of frail elderly people at high risk of falls and fractures. But hip fracture incidence varies among countries [4,5]. During the past decade, hip fracture incidence has declined in most Western countries and Oceania [5–14], reached a plateau [15,16] and increased in some countries in Asia and South America [5,17]. In France, we previously showed that the incidence of hip fractures decreased in both genders from 2002 to 2008 [18]. This observation was associated with different factors, including the availability of bone densitometry and effective anti-osteoporotic treatments [18], although no causal association has been demonstrated. However, recent studies show declining of osteoporosis management after fragility fractures. In a retrospective analysis of 96,887 men and women aged 50 years or more, hospitalized for hip fracture over a period ⁎ Corresponding author at: Rheumatology Department, Cochin Hospital, 27 rue du Faubourg St Jacques, 75014 Paris, France. E-mail address: [email protected] (K. Briot).
http://dx.doi.org/10.1016/j.bone.2015.07.009 8756-3282/© 2015 Elsevier Inc. All rights reserved.
of 1 year, the estimated probability of receiving osteoporosis medication within 12 months after discharge from hospital significantly declined over a 10-year period from 40.2% in 2002, to 20.5% in 2011 [19]. Antiosteoporotic treatment uptake decreased progressively in Europe since 2008 including in France [20]. According to a retrospective analysis conducted in patients hospitalized in 2010–2011 for a major osteoporotic fracture (59% were hip fractures) in a tertiary hospital in Paris, France, only 4% and 10% of patients discharged to home and admitted to a rehabilitation center respectively received an antiosteoporotic treatment [21]. Thus, our hypothesis was that the decrease in hip fracture incidence observed between 2002 and 2008 could wane thereafter, because of the recent changes in management of osteoporotic patients and prescriptions of antiosteoporotic drugs. The aim of this study was to assess the trends of occurrence of hip fractures, numbers, and incidences from 2002 to 2013, in women and men aged 60 years and over in France.
2. Methods 2.1. Data We assessed the number of hospitalizations for hip fractures in the French metropolitan population aged 60 years and older from 2002 to 2013. Data were obtained from the French Hospital National Database
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which includes all hospitalizations occurring in public and private acute care settings in France. This system for financing French hospitals is mandatory since 2004 in public hospitals and since 2005 in private hospitals. An internal control of completeness and quality of coding is performed monthly in each hospital. An external control is performed yearly by physicians of the National Medical Insurance Service. Hip fractures were defined by their ICD-10 diagnosis codes: S72.0, S72.1, and S72.2 (ICD-10 codes). We selected hospitalizations for which the primary diagnosis was hip fracture in people aged 60 years and over with the initial surgical treatment performed during the same hospitalization managed in metropolitan France. The selected hospitalizations represented 82% of all hospitalizations with hip fractures encoded as primary diagnosis. The remaining reasons for hospitalizations were other surgical management related to polytraumatism, removal or change of prosthesis, reduction of prosthesis, removal of osteosynthesis material, or fractures occurring in a context of cancer or mention of cancer or prosthesis complications as secondary diagnosis. Rehospitalizations and transfers were not retained. 2.2. Population Population data used for the present study were those published in 2014 by the National Institute for Statistics and Economic Studies (Institut national de la statistique et des études économiques, www. insee.fr) for metropolitan France. Age classes (0–19, 0–39, 40–59, 60–74, and over 74 years) were available by gender from 2002 to 2004 and for each age and gender since 2005. We defined three age groups: 60–74, 75–84, and ≥ 85 years. For data before 2005, we used the proportion of 2005 to estimate the population in 75–84 and ≥85 years assuming no major change in the structure of the population over 3 years. 2.3. Analysis Incidences of hospitalization for surgical treatment of hip fractures were calculated as the number of cases per 1,000,000 inhabitants per year, by sex and age group and were stratified by sex and age (three age groups: 60–74, 74–84, and ≥85 years from the period 2002–2013). The absolute numbers and incidences of hip fractures provided were population-based. We described the changes in number of hospitalizations for hip fracture and the changes in the French population. We calculated the incidence of hip fractures from 2002 to 2013 for all patients aged over 60 years and in the three age classes, as previously described, and compared the data in 2013 using the data of 2002 as reference. We tested the linear trend of age-specific incidence using
the test for trend in proportion (R Version 2.15.2) in order to assess any potential changes of the trend during the period of observation (α = 0.05). 3. Results 3.1. Numbers of hip fractures in people aged 60 years and over Tables 1 and 2 describe the changes in the number of hip fractures from 2002 to 2013 in women and men, respectively. The number of hip fractures increased in women (+ 4.8%; from 49,287 in 2002 to 51,661 in 2013) and in men (+21%, from 12,716 in 2002 to 15,482 in 2013). Between 2002 and 2013, the French population aged over 60 years increased by 21 and 29% in women and in men, respectively. In women aged 60–74, and 75–84 years, there was a decrease in the number of fractures (− 11% and − 12%, respectively) (Fig. 1). Such a decrease was not observed in men (Tables 1 and 2). In the youngest group, the nadir was in 2009 (i.e. − 16%) (Table 1). The increase in people aged over 60 years and over is actually explained by the results in the oldest. In women and men aged ≥85 years there was a 22% and 52% increase in the number of hip fractures respectively, in parallel with a dramatic increase in the number of people aged ≥ 85 years: + 70 and + 100% in women and men, respectively. In the elderly subjects (≥85 years), the hip fracture increase begun in 2004 (Fig. 1). 3.2. Incidence of hip fractures in people aged 60 years and over The incidence of hip fractures over 60 years decreased by 14% in women (6929 and 5987 per million in 2002 and 2013, respectively) and a slight decrease of 1.4% was observed in men (2344 and 2316 per million in 2002 and 2013, respectively). As shown in Figs. 2, 3 and 4, the incidence of hip fractures decreased in all age groups (i.e., 60–74, 75–84 and ≥85 years). The age-specific incidence decrease was − 25.9, − 20, and − 29.5% in women aged 60–74, 75–84, and ≥ 85 years respectively. In men, the age-specific incidence decrease was −17.3, −19.5 and −24.2% in 60–74, 75–84, and ≥85 years respectively. Figs. 3 and 4 showed an apparent stabilization from 2011 in women. However, the test for linear trend showed that the changes over 12 years are statistically significant for each age class and gender (p b 0.00001). 4. Discussion This study shows a decrease in hip fracture incidence in France over the last decade (2002–2013). Although there was a huge increase in the
Table 1 Absolute numbers and incidence of hip fractures in women aged 60 years and over. Year 2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Hospitalization (n.) 60–74 6568 75–84 18,668 N84 24,051 N59 49,287
6394 19,447 22,913 48
6068 20,271 21,144 47,483
5919 20,252 22,045 48,216
5816 19,829 22,688 48,333
5741 19,316 23,865 48,922
5564 18,749 24,879 49,192
5515 18,396 25,577 49,488
5599 17,819 26,674 50,092
5640 17,221 27,072 49,933
5558 16,599 28,058 50,215
5842 16,413 29,406 51,661
Population 60–74 4,210,517 75–84 2,168,450 N84 733,728 N59 7,112,695
4,194,641 2,225,294 752,963 7,172,898
4,192,542 2,278,274 770,889 7,241,705
4,201,718 2,324,372 786,487 7,312,577
4,196,846 2,386,353 855,087 7,438,286
4,282,120 2,398,822 930,452 7,611,394
4,382,599 2,415,501 995,701 7,793,801
4,502,200 2,419,969 1,058,395 7,980,564
4,618,621 2,428,155 1,117,014 8,163,790
4,750,202 2,404,219 1,160,349 8,314,770
4,862,769 2,397,376 1,215,320 8,475,465
4,989,780 2,383,138 1,256,513 8,629,431
Incidence/1,000,000 60–74 1560 75–84 8609 N84 32,779 N59 6929
1524 8739 30,430 6797
1447 8898 27,428 6557
1409 8713 28,030 6593
1386 8309 26,533 6498
1341 8052 25,649 6427
1270 7762 24,986 6312
1224 7602 24,166 6201
1212 7338 23,880 6136
1187 7162 23,331 6005
1143 6924 23,087 5925
1171 6887 23,116 5987
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Table 2 Absolute numbers and incidence of hip fractures in men aged 60 years and over. Year
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Hospitalization (n.) 60–74 3130 75–84 5076 N84 4510 N59 12,716
3065 5536 4248 12,849
2848 5581 4026 12,455
2991 5670 4408 13,069
2937 5527 4744 13,208
2913 5591 5276 13,780
3086 5823 5557 14,466
3034 5569 5877 14,480
3270 5606 6209 15,085
3243 5330 6349 14,922
3145 5204 6446 14,795
3324 5293 6865 15,482
Population 60–74 3,580,072 75–84 1,341,534 N84 273,031 N59 5,194,637
3,584,051 1,386,325 282,146 5,252,522
3,601,632 1,428,569 290,744 5,320,945
3,626,588 1,474,549 300,102 5,401,239
3,642,824 1,506,484 338,038 5,487,346
3,753,357 1,526,811 376,455 5,656,623
3,879,156 1,554,441 408,014 5,841,611
4,017,748 1,571,767 437,037 6,026,552
4,148,471 1,594,086 462,671 6,205,228
4,271,721 1,609,117 494,427 6,375,265
4,381,475 1,627,053 523,432 6,531,960
4,495,822 1,640,001 547,150 6,682,973
Incidence/1,000,000 60–74 874 75–84 3784 N84 16,518 N59 2344
855 3993 15,056 2446
791 3907 13,847 2341
825 3845 14,688 2420
806 3669 14,034 2374
776 3662 14,015 2436
796 3746 13,620 2476
755 3543 13,447 2402
788 3517 13,420 2431
759 3312 12,841 2341
717 3198 12,315 2265
739 3227 12,547 2316
number of fractures in the patients aged over 85 years, there was also a high decrease in incidence in this age group. We do not confirm our hypothesis of change of hip fracture incidence after 2008 related to the changes in anti-osteoporotic treatments prescriptions. 4.1. Number of hip fractures The aging of the population increases dramatically the number of elderly people at risk for hip fracture. During our follow-up, the number of women and men aged N60 years increased by 21 and 29%, leading to a 4.8 and 21% increase in the number of hip fractures over a decade in women and men, respectively. However, the changes in the number of fractures were different according to age, in women. In the youngest age group of women (60–74 years), there was actually a decrease of 11% of the absolute number of hip fractures, and most of this decrease was observed between 2002 and 2008. In women aged 75–84 years, a 12% decrease in the number of hip fractures was observed, without a plateau. These results contrast dramatically with the huge increase in the number of fractures in women aged ≥85 years. As a consequence, hip fractures in the very elderly represented 49% and 57% of the total number of fractures in women in 2002 and 2013 respectively; a similar change was observed in men aged ≥85 years, representing 35% and 44%
of the total number of fractures respectively. Thus the burden related to hip fractures will rise over time, as the proportion of frail elderly persons at high risk of falls and fractures is expected to increase dramatically in the next decades. Indeed, human senescence has been delayed: the age at which remaining life expectancy is ten years has been postponed by 8 years in Sweden, 12 years in Japan; in some countries the number of centenarians climbs vertically [22,23]. This suggests that the very elderly should receive a high priority for hip fractures prevention. 4.2. Hip fracture incidence changes In contrast to the increase in the number of hip fractures, a large decrease in incidence was observed in the very elderly subjects, confirming previous studies not only in women but also in men [10]. The decrease was 29.5% and 24.2% in women and men aged ≥ 85 years. In this population class, we observed an increase from 2002 to 2013 in the number of subjects in the French population: from 733,728 to 1, 256, 513 and 273,031 to 547,150 in women and men, respectively. This is relevant as 57 and 44% of the total number of hip fractures occurred in women and men aged ≥85 years and such a result should prevent any overestimation of the incidence of fractures, based on estimation from the incidence observed in younger populations.
Fig. 1. Number of hip fractures in women aged over 60 years and over in France.
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K. Briot et al. / Bone 81 (2015) 131–137
Incidence per 1,000,000 inhabitants per year
4.3. Potential explanations of the changes
35000
30000
25000
20000 2002 2013
15000
10000
5000
0 60-74
75-84
>84
Age groups Fig. 2. Age-specific incidence in women N60 years in France in 2002 and 2013.
The rules of payment of the hospital expenses changed in France in 2004 leading to change in coding practice; this may explain the dramatic change in the number of hip fractures in the very elderly (Fig. 1). However, the coding practice change had no impact in other categories of patients. This observation could be also explained by a healthier cohort effect: after the age of 85 the subjects still at risk represent a healthier population, as those at very high risk have already had hip fractures or have died. Comparison with other countries, on the basis of their national hospital database gave contrasting results. Recent studies showed that the absolute number of hip fractures increases in all countries with the increasing elderly population, but the age-adjusted incidence of hip fracture does not behave similarly. Our results confirm those of previous studies that suggested national declines [5,12,24,25]; however in other studies, hip fracture incidence increased [5,15]. Contrasting results are due to several factors, as the age of the studied population: whole population [8], ≥ 40 years [18], ≥ 45 years [24], ≥ 50 years [12, 16], and ≥ 65 years [26,27], and the duration of the observation from 4 years to 21 years [8]. Some differences may occur in the period of follow-up, in the population used for the calculation of incidence for each studied year, and in the method of the selection of hospitalization data.
There are several potential explanations for the changes in incidence of hip fracture observed during the last decade. Improvement of the fracture prevention management, including bone densitometry testing and prescription of antiosteoporotic treatments may have an impact on hip fracture incidence changes. Medical management of patients with fracture has been improved by health care internal network or fracture liaison service (FLS) organized in some large hospitals in France [28,29], with a high rate of antiosteoporotic treatment prescription after fracture and a high level of persistence with osteoporosis treatment [28,29]. However the number of FLS is very limited in France and even, with such an optimal care, the uptake and adherence with therapies are limited [8,27]. A relevant association between an increase in the number of BMD tests, an increase in the number of antiosteoporotic treatments and a decrease in osteoporotic fractures was shown in Canada (between 1992 and 2001) [30]. In a study based on the sample Medicare claims from 1985 to 2005, the authors showed a decrease in incidence of hip fractures after 1995, which temporally corresponds with the market release of bisphosphonates [27]. However, a study performed in Canada over a 21-year period (1985–2005) found that decline hip fracture incidence began before the availability of bone densitometry or use of bisphosphonates [8]. Moreover, although there is a huge difference in prescribing rates of anti-osteoporotic drugs among provinces of the country, there is no difference between provinces in hip fracture incidence [31]. In France, oral bisphosphonates are available and reimbursed since 2000 and bone densitometry, since 2006. However, using the sales data, a report of osteoporosis in France showed that the prescription of antiosteoporotic treatments decreased since 2008; proportions of persons over the age of 50 years who were treated increased from 1.21% in 2001 to 7.18% in 2008, but fell back to 6.30% in 2011 [20]. The decrease in the incidence of hip fractures among men in our study indicates that increased osteoporosis screening and pharmacotherapy is not the main explanation for the decline of hip fractures, as men could have been less exposed to antiosteoporotic medication and preventive measures [32]. Our hypothesis of a possible waning of decrease in hip fracture incidence between 2008 and 2013, because of the changes in management and prescriptions was not confirmed. However, in the group of women aged 60–74 years there is a plateau in the number of hip fractures per year since 2008. Whether or not this is related to changes in anti-osteoporotic drug prescriptions needs longer studies, as it was not observed in other age groups. Osteoporotic fracture could be a symptom of a poor patient's health status, rather than the cause [33] and the increasing survival of the
Hip fracture incidence rate (per 1,000,000 person-years) 8,000 7,000 6,000 5,000 Incidence rate in women≥ 60 years
4,000
Incidence rate in men≥ 60 years 3,000 2,000 1,000 0 2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Fig. 3. Overall sex-specific trends in hip fracture incidence (per 1000, 000 person-years) in women and men aged 60 years and older in France between 2002 and 2013.
K. Briot et al. / Bone 81 (2015) 131–137
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Fig. 4. Sex and age specific (60–74, 75–84, ≥85 years) trends in hip fracture incidence (per 1,000,000 person-years) in women (a) and men (b) in France between 2002 and 2013.
frailest elderly may contribute to the age effect on decrease of hip fracture incidence. In Switzerland, the reversal of the hip fracture secular trend in elderly women was explained by a decrease in the incidence in institution-dwelling elderly women [10]. Nutritional lifestyle changes as calcium and vitamin D supplementation may also contribute to the decrease in hip fracture incidence, especially amongst elderly subjects; however, there is no evidence of an increase of vitamin D intake in Europe [34,35]. Reduction of fall-related comorbidities [36] and prevention of falls may also explain the decrease incidence. Studies showed that the most effective strategies to decrease fall risk in community-living elderly include regular physical training and modification of the fall risk factors: wearing antislip shoes, reducing psychotropic medication and polymedication, vitamin D supplementation, and cataract surgery [37]. The improvement of health status of elderly subjects could have contributed to fall reduction [37]. Fall prevention programs are associated with an overall relative reduction of fracture risk [38] National prevention programs have been publicly released on awareness of the risk of falls in France before 2008. However these efforts have not been maintained and we are not aware of repetition of these programs between 2008 and 2013 [39]. A recent analysis suggested the impact of urbanization, as a plausible explanation for wide variations in hip fractures rates worldwide,
showing close parallels between rising rates of urbanization and hip fractures across disparate geographic locations and cultures [5]. The mechanisms by which urbanization may impact hip fracture rates are not known, but may include decreased physical activity and increased in body weight and obesity [40,41]. Higher body weight has been associated with greater BMD and lower rates of bone loss [41]. A meta-analysis showed a lower risk of hip fractures with higher body mass index (BMI) [42], although obesity did not prevent all types of fractures [43,44]. Recent studies suggest an increase of BMI during the last decades [45]; however we do not have BMI changes in our studied population. Some studies reported the impact of birth cohort effect on hip fracture risk, and the importance to consider that intrauterine and childhood periods of development and severe environmental factors which occur early in the life course may influence the peak bone mass achieved and cause increased fracture rates in later generations [4]. A consistent decline in the incidence of hip fracture in all 10-year birth cohorts in New Zealand since those born between 1883 and 1892 was shown, concomitant with increasing health and improvements in measures of physical status in later birth cohorts [11]. Other examples (the Dutch famine and concentration camp survivors) [46] suggest that profound insults of this type might reduce BMD values in the
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offspring and may explain some European observations. However, the incidence trends for hip fracture have been observed in countries (Canada, Australia and the United States) that did not experience such any major population-wide environmental stressors. Our study has some limitations. We used administrative data and as this database is anonymous, we could not check the diagnosis of osteoporotic fracture in the patients' files. The rules of payment of the hospital expenses changed in France in 2004, and this may have had an important effect on coding practice and improvement of data completeness. However, even if this change had a significant impact on the result, it reinforced the decreasing incidence trend observed in whole population and in the oldest people (≥85 years), whatever the gender. A hip fracture on the controlateral side may occur in a given patient within the same year. However, since 2006, 2% to 5% of patients have been hospitalized for a fracture of the opposite hip within the same year and we considered that the small proportion has no significant impact on the hip incidence trends. These findings are not generalizable to other low trauma fractures such as Colle's or humerus fractures. Finally, we are not able to directly link patients to their pharmaceutical treatments or bone densitometry exams. Over the last 12 years, the incidence of hip fractures decreased in France in women and men aged over 60 years. This decrease is large in the elderly (≥85 years) in both genders. Further studies are needed to assess potential changes in hip fractures risk factors during the last decade. Disclosures K Briot: Research grants and/or honoraria from Amgen, MSD, Lilly, Pfizer. M Maravic: Milka Maravic has been an employee of AstraZeneca France, from 12 November 2014. AstaZeneca was not involved in this manuscript. No funding from AstraZeneca was received for this manuscript, based on a study conducted before November 2014. C Roux: Research grants and/or honoraria and/or travel reimbursements from Amgen, MSD, Lilly, Novartis. Acknowledgments This work is supported by the College Français des Médecins Rhumatologues (www.cfmr.fr). References [1] D. Bliuc, N.D. Nguyen, V.E. Milch, T.V. Nguyen, J.A. Eisman, J.R. Center, Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women, JAMA 301 (2009) 513–521. [2] I.M. Giversen, Time trends of mortality after first hip fractures, Osteoporos. Int. 18 (2007) 721–732. [3] S. Haleem, L. Lutchman, R. Mayahi, J.E. Grice, M.J. Parker, Mortality following hip fracture: trends and geographical variations over the last 40 years, Injury 39 (2008) 1157–1163. [4] C. Cooper, Z.A. Cole, C.R. Holroyd, S.C. Earl, N.C. Harvey, E.M. Dennison, L.J. Melton, S.R. Cummings, J.A. Kanis, IOF CSA Working Group on Fracture Epidemiology, Secular trends in the incidence of hip and other osteoporotic fractures, Osteoporos. Int. 22 (2001) 1277–1288. [5] G. Ballane, J.A. Cauley, M.M. Luckey, Gel-H. Fuleihan, Secular trends in hip fractures worldwide: opposing trends East versus West, J. Bone Miner. Res. 29 (2014) 1745–1755. [6] A. Vanasse, M.G. Orzanco, P. Dagenais, T. Ouarda, J. Courteau, S. Asghari, F. Chebana, B. Martel, P. Gosselin, Secular trends of hip fractures in Québec, Canada, Osteoporos. Int. 23 (2012) 1665–1672. [7] K.P. Chang, J.R. Center, T.V. Nguyen, J.A. Eisman, Incidence of hip and other osteoporotic fractures in elderly men and women: Dubbo Osteoporosis Epidemiology Study, J. Bone Miner. Res. 19 (2004) 532–536. [8] W.D. Leslie, S. O'Donnell, S. Jean, C. Lagacé, P. Walsh, C. Bancej, S. Morin, D.A. Hanley, A. Papaioannou, Osteoporosis Surveillance Expert Working Group, Trends in hip fracture rates in Canada, JAMA 302 (2009) 883–889. [9] W.D. Leslie, M. Sadatsafavi, L.M. Lix, M. Azimaee, S. Morin, C.J. Metge, P. Caetano, Secular decreases in fracture rates 1986–2006 for Manitoba, Canada: a population-based analysis, Osteoporos. Int. 22 (2011) 2137–2143.
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