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East-west gradient in hip fracture incidence in Spain: how much can we explain by following the pattern of risk factors?

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Abstract

Summary

Our objective was to analyze the incidence and trend of hip fracture in Spain and its distribution by Autonomous Community (AC). In Spain, the age-adjusted incidence rate of hip fracture is decreasing. There is great variability in the incidence and tendency of hip fracture among the different ACs. Genetic, demographic, and climatic factors and cohort effect factors of the civil war explain 96% of this variability.

Introduction

In Spain, there is great variability between the different Autonomous Communities (ACs) in the incidence of hip fracture. The objectives of our study are (1) to estimate the incidence rate and trend of hospital admissions for hip fracture in Spain and by ACs and (2) to analyze risk factors/markers that could explain the variability in the incidence and trend between different ACs.

Method

This work includes 2 studies (TREND-HIP and VAR-HIP). TREND-HIP: retrospective, national, observational study based on the administrative database of the National Health System that includes a Minimum Basic Data Set (MBDS) of hospital admissions. VAR-HIP: ecological study based on the analysis of the results obtained in TREND-HIP study, with different risk factors/markers obtained from different sources.

Results

In the 17 years included in the analysis, there were 744,848 patients diagnosed with hip fracture. The global age-adjusted rate of hip fracture at the national level was 315.38/100,000 person*year (95% CI 312.36–317.45); by AC, the rate varied from 213.97 in the Canary Islands to 363.13 in the Valencia and Cataluña communities. We observe an east-west gradient in Spain. The trend for both sexes was − 0.67% (95% CI 0.9990–0.9957) (p < 0.001). In the analysis of risk factors/markers that explain this distribution, we found significant correlations with genetic factors, demographics, climatic factors and the time a region was on the Republican side of the civil war. The linear regression model that includes the factors that show significant correlation explains 96% of the variability observed.

Conclusion

In Spain, the age-adjusted incidence rate for hip fracture is decreasing. There is a great variability in the incidence and tendency of hip fracture among the different ACs. Genetic, demographic, climatic factors and the cohort effect of the civil war explain 96% of this variability.

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References

  1. Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A (2007) Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 22:465–475

    Article  Google Scholar 

  2. Svedbom A, Hernlund E, Ivergard M, Compston J, Cooper C, Stenmark J, EV MC, Jonsson B, Kanis JA, Svedbom A, Hernlund E, Ivergard M, Compston J, Cooper C, Stenmark J, EV MC, Jonsson B, Kanis JA, EU Review Panel of IOF (2013) Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporos 8:13,0

    Article  Google Scholar 

  3. Auais M, Morin S, Nadeau L, Finch L, Mayo N (2013) Changes in frailty-related characteristics of the hip fracture population and their implications for healthcare services: evidence from Quebec, Canada. Osteoporos Int 24:2713–2724. https://doi.org/10.1007/s00198-013-2390-x

    Article  CAS  PubMed  Google Scholar 

  4. Etxebarria-Foronda I, Arrospide A, Soto-Gordoa M, Caeiro JR, Abecia LC, Mar J (2015) Regional variability in changes in the incidence of hip fracture in the Spanish population (2000–2012). Osteoporos Int 26:1491–1497. https://doi.org/10.1007/s00198-014-3015-8

    Article  CAS  PubMed  Google Scholar 

  5. Azagra R, Lopez-Exposito F, Martin-Sanchez JC, Aguye-Batista A, Gabriel-Escoda P, Zwart M, Diaz-Herrera MA, Pujol-Salud J, Iglesias-Martinez M, Puchol-Ruiz N (2015) Incidence of hip fracture in Spain (1997–2010). Med Clin (Barc) 145:465–470

    Article  Google Scholar 

  6. Bernal-Delgado E, Garcia-Armesto S, Peiro S, Atlas VPM Group (2014) Atlas of variations in medical practice in Spain: the Spanish National Health Service under scrutiny. Health Policy 114:15–30

    Article  Google Scholar 

  7. Simard M, Sirois C, Candas B (2018) Validation of the combined comorbidity index of Charlson and Elixhauser to predict 30-day mortality across ICD-9 and ICD-10. Med Care 56:441–447. https://doi.org/10.1097/MLR.0000000000000905

    Article  PubMed  Google Scholar 

  8. Bycroft C, Fernandez-Rozadilla C, Ruiz-Ponte C, Quintela I, Carracedo A, Donnelly P, Myers S (2019) Patterns of genetic differentiation and the footprints of historical migrations in the Iberian Peninsula. Nat Commun:10–55-w. https://doi.org/10.1038/s41467-018-08272-w

  9. Ballane G, Cauley JA, Luckey MM, Fuleihan G (2014) Secular trends in hip fractures worldwide: opposing trends East versus West. J Bone Miner Res 29:1745–1755

    Article  Google Scholar 

  10. Bhimjiyani A, Neuburger J, Jones T, Ben-Shlomo Y, Gregson CL (2018) Inequalities in hip fracture incidence are greatest in the North of England: regional analysis of the effects of social deprivation on hip fracture incidence across England. Public Health 162:25–31

    Article  CAS  Google Scholar 

  11. Defer A, Schober HC, Mohrke W, Abendroth K, Hofbauer LC, Task Group for Treatment Research at German Society of Osteology, Federal Association of German Osteologists (Bundesverband der Osteologen Deutschland e V), Regional Committee of Experts on Osteoporosis (Regionaler Expertenkreis Osteoporose (REKO) Deutschland e V) (2014) Are there still east-to-west differences in the incidence of hip fractures in Germany? Arch Osteoporos 9:19 DOI https://doi.org/10.1007/s11657-014-0195-y.

  12. Wildner M, Clark DE (2001) Hip fracture incidence in east and west germany: reassessement ten years after unificatio. Osteoporos Int 12:136–139

    Article  CAS  Google Scholar 

  13. 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. J Bone Joint Surg Am 77:695–702

    Article  CAS  Google Scholar 

  14. Karagas MR, Lu-Yao GL, Barrett JA, Beach ML, Baron JA (1996) Heterogeneity of hip fracture: age, race, sex, and geographic patterns of femoral neck and trochanteric fractures among the US elderly. Am J Epidemiol 143:677–682

    Article  CAS  Google Scholar 

  15. Alvarez-Nebreda ML, Jimenez AB, Rodriguez P, Serra JA (2008) Epidemiology of hip fracture in the elderly in Spain. Bone 42:278–285

    Article  Google Scholar 

  16. de Pina MF, Alves SM, Barbosa M, Barros H (2008) Hip fractures cluster in space: an epidemiological analysis in Portugal. Osteoporos Int 19:1797–1804

    Article  Google Scholar 

  17. Barbier S, Ecochard R, Schott AM, Colin C, Delmas PD, Jaglal SB, Couris CM (2009) Geographical variations in hip fracture risk for women: strong effects hidden in standardised ratios. Osteoporos Int 20:371–377. https://doi.org/10.1007/s00198-008-0687-y

    Article  CAS  PubMed  Google Scholar 

  18. Jean S, O’Donnell S, Lagace C, Walsh P, Bancej C, Brown JP, Morin S, Papaioannou A, Jaglal SB, Leslie WD, Osteoporosis Surveillance Expert Working Group (2013) Trends in hip fracture rates in Canada: an age-period-cohort analysis. J Bone Miner Res 28:1283–1289

    Article  Google Scholar 

  19. Chau PH, Wong M, Lee A, Ling M, Woo J (2013) Trends in hip fracture incidence and mortality in Chinese population from Hong Kong 2001–09. Age Aging 42:229–233

    Article  Google Scholar 

  20. Chen FP, Shyu YC, Fu TS, Sun CC, Chao AS, Tsai TL, Huang TS (2016) Secular trends in incidence and recurrence rates of hip fracture: a nationwide population-based study. Osteoporos Int

  21. Karayiannis PN, McAlinden MG (2016) Falling age-related incidence of hip fractures in women, but not men, in Northern Ireland: 2001–2011. Osteoporos Int 27:3377–3381

    Article  CAS  Google Scholar 

  22. Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB (2009) Incidence and mortality of hip fractures in the United States. JAMA 302:1573–1579

    Article  CAS  Google Scholar 

  23. Azagra R, Lopez-Exposito F, Martin-Sanchez JC, Aguye A, Moreno N, Cooper C, Diez-Perez A, Dennison EM (2014) Changing trends in the epidemiology of hip fracture in Spain. Osteoporos Int 25:1267–1274

    Article  CAS  Google Scholar 

  24. Mazzucchelli Esteban R, Perez-Fernandez E, Crespi-Villarias N, Garcia-Vadillo A, Rodriguez-Caravaca G, Gil de Miguel A, Carmona L (2017) Trends in osteoporotic hip fracture epidemiology over a 17-year period in a Spanish population Alcorcon 1999–2015. Arch Osteoporos:12–8–6. https://doi.org/10.1007/s11657-017-0376-6

  25. Pueyo-Sanchez MJ, Larrosa M, Suris X, Casado E, Auleda J, Fuste J, Ortun V (2016) Secular trend in the incidence of hip fracture in Catalonia, Spain, 2003–2014. Age Aging.

    Book  Google Scholar 

  26. Hernandez JL, Olmos JM, Alonso MA, Gonzalez-Fernandez CR, Martinez J, Pajaron M, Llorca J, Gonzalez-Macias J (2006) Trend in hip fracture epidemiology over a 14-year period in a Spanish population. Osteoporos Int 17:464–470

    Article  Google Scholar 

  27. Sosa M, Saavedra P, de Tejada MJ, Navarro M, Cabrera D, Melton LJ,3rd (2015) Trends in the incidence of hip fracture in Gran Canaria, Canary Islands, Spain: 2007–2011 versus 1989–1993. Osteoporos Int 26:1361–1366

  28. Kelly PJ, Nguyen T, Hopper J, Pocock N, Sambrook P, Eisman J (1993) Changes in axial bone density with age: a twin study. J Bone Miner Res 8:11–17. https://doi.org/10.1002/jbmr.5650080103

    Article  CAS  PubMed  Google Scholar 

  29. Zhai G, Andrew T, Kato BS, Blake GM, Spector TD (2009) Genetic and environmental determinants on bone loss in postmenopausal Caucasian women: a 14-year longitudinal twin study. Osteoporos Int 20:949–53 953 https://doi.org/10.1007/s00198-008-0751-7

  30. Cummings SR, Nevitt MC, Browner WS, Stone K, Fox KM, Ensrud KE, Cauley J, Black D, Vogt TM (1995) Risk Factors for Hip Fracture in White Women. N Engl J Med 332:767–774. https://doi.org/10.1056/NEJM199503233321202

    Article  CAS  PubMed  Google Scholar 

  31. Andrew T, Antioniades L, Scurrah KJ, MacGregor AJ, Spector TD (2005) Risk of wrist fracture in women is heritable and is influenced by genes that are largely independent of those influencing BMD. J Bone Miner Res 20:67–74. https://doi.org/10.1359/JBMR.041015

    Article  PubMed  Google Scholar 

  32. Michaelsson K, Melhus H, Ferm H, Ahlbom A, Pedersen NL (2005) Genetic liability to fractures in the elderly. Arch Intern Med 165:1825–1830

    Article  Google Scholar 

  33. Kannus P, Palvanen M, Kaprio J, Parkkari J, Koskenvuo M (1999) Genetic factors and osteoporotic fractures in elderly people: prospective 25 year follow up of a nationwide cohort of elderly Finnish twins. BMJ 319:1334–1337

    Article  CAS  Google Scholar 

  34. Mazzucchelli Ramón, Pérez Fernández Elia, Crespí Natalia, García-Vadillo Juan Alberto Trend in osteoporotic hip fracture epidemiology over a 17-year period in a Spanish population: Alcorcón 1999–2015. en prensa.

  35. Cooper C, Cole ZA, Holroyd CR, Earl SC, Harvey NC, Dennison EM, Melton LJ, Cummings SR, Kanis JA, CSA IOF, Working Group on Fracture Epidemiology (2011) Secular trends in the incidence of hip and other osteoporotic fractures. Osteoporos Int 22:1277–1288

    Article  CAS  Google Scholar 

  36. Canabate Cabezuelos J, Martinez-Carrion JM (2018) Nutritional crisis and social inequality in the Spanish autarchy. A case study from adult height. Nutr Hosp 35:108–115. https://doi.org/10.20960/nh.2092

    Article  PubMed  Google Scholar 

  37. Bernabeu-Mestre J (1994) Health problems and childhood causes of death in Spain 1900–1935. Ann Demogr Hist (Paris): 61–77.

  38. Bernabeu-Mestre J, Esplugues Pellicer JX, Galiana Sanchez ME (2007) Historical background data of Spanish community nutrition: the works of the National School of Health between 1930 and 36. Rev. Esp Salud Publica 81:451–459

    Google Scholar 

  39. GRANDE COVIAN F (1948) Not Available. Rev. Psicol Gen Apl 3:267–306

    Google Scholar 

  40. Culebras JM (2014) Grande Covian and children malnutrition during the Spanish civil war: comments on two classic papers published in “Revista Clinica Espanola” seventy years ago. Nutr Hosp 30:695–698. https://doi.org/10.3305/nh.2014.30.3.7707

    Article  PubMed  Google Scholar 

  41. Grande Covian F, Rof Carballo J, Jimenez Garcia F, Morata Cernuda A (2014) Nutrition and child development I; nutritional status of school children in a peripheral district of Madrid (Rev Clin Esp 1944; XII:87–94). Nutr Hosp 30:699–707. https://doi.org/10.3305/nh.2014.30.3.7708

    Article  CAS  PubMed  Google Scholar 

  42. Hay Marciano https://www.eupedia.com/. 2019.

  43. Melton LJ 3rd, Kanis JA, Johnell O (2005) Potential impact of osteoporosis treatment on hip fracture trends. J Bone Miner Res 20:895–897

    Article  Google Scholar 

  44. Abrahamsen B, Skjodt MK, Vestergaard P (2018) Hip fracture rates and time trends in use of anti-osteoporosis medications in Denmark for the period 2005 to 2015: Missed opportunities in fracture prevention. Bone 120:476–481

    Article  Google Scholar 

  45. Cadarette SM, Solomon DH, Katz JN, Patrick AR, Brookhart MA (2011) Adherence to osteoporosis drugs and fracture prevention: no evidence of healthy adherer bias in a frail cohort of seniors. Osteoporos Int 22:943–954

    Article  CAS  Google Scholar 

  46. Solomon DH, Johnston SS, Boytsov NN, McMorrow D, Lane JM, Krohn KD (2014) Osteoporosis medication use after hip fracture in U.S. patients between 2002 and 2011. J Bone Miner Res 29:1929–1937

    Article  Google Scholar 

  47. [Anonymous]. Ministerio de Sanidad, Servicios Sociales e Igualdad - Statical Site of the NHS - Hospital Discharge Records in the National Health System. CMBD.

  48. Mazzucchelli R, Perez-Fernandez E, Crespi N, Garcia-Vadillo A, Rodriguez Caravaca G, Gil de Miguel A, Carmona L (2017) Second hip fracture: incidence, trends, and predictors. Calcif Tissue Int. https://doi.org/10.1007/s00223-017-0364-2

  49. Morgenstern H (1995) Ecologic studies in epidemiology: concepts, principles, and methods. Annu Rev. Public Health 16:61–81

    Article  CAS  Google Scholar 

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Acknowledgments

The authors thank the staff of the Research Unit of the Spanish Society of Rheumatology for their support in the editing and translation of the manuscript and to my good friend Caligula, who faithfully accompanies me in my research work.

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Authors and Affiliations

  1. Department of Rheumatology, Hospital Universitario Fundación Alcorcón, Madrid, Spain

    Ramón Mazzucchelli

  2. Department of Clinical Research, Hospital Universitario Fundación Alcorcón, Madrid, Spain

    Elia Pérez Fernández

  3. La Rivota Health Center, Alcorcón, Madrid, Spain

    Natalia Crespí Villarías

  4. Department of Allergy, Hospital Universitario Fundación Hospital Alcorcón, Madrid, Spain

    Miguel Ángel Tejedor Alonso

  5. Department of Orthogeriatrics, Hospital Universitario Fundación Alcorcon, Instituto de Investigación del Hospital La Paz, IdiPAZ, Madrid, Spain

    Pilar Sáez López

  6. Department of Rheumatology, Hospital Universitario de la Princesa, Madrid, Spain

    Alberto García-Vadillo

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  1. Ramón Mazzucchelli
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  3. Natalia Crespí Villarías
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Contributions

RM and NCV designed the research. EPF, RM, PS, and NCV analyzed the data. EPF, PS, RM, MATA, PSL, and AGV wrote the paper.

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Correspondence to Ramón Mazzucchelli.

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Mazzucchelli, R., Pérez Fernández, E., Crespí Villarías, N. et al. East-west gradient in hip fracture incidence in Spain: how much can we explain by following the pattern of risk factors?. Arch Osteoporos 14, 115 (2019). https://doi.org/10.1007/s11657-019-0665-3

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