Osteoporosis 2016 | The effect of social deprivation on hip fracture incidence has not changed over 10 years in England: Arti Gauvri Bhimjiyani #osteo2016
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1) The study examined the association between social deprivation and hip fracture rates in England over a 10-year period from 2001-2011. 2) It found that social deprivation had a stronger link to higher hip fracture rates in men compared to women. 3) While hip fracture rates declined in women and increased in men overall during this period, the gaps in rates between more and less deprived areas did not narrow for men and widened somewhat for women.
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Osteoporosis 2016 | The effect of social deprivation on hip fracture incidence has not changed over 10 years in England: Arti Gauvri Bhimjiyani #osteo2016
- 1. The effect of social deprivation on hip fracture incidence has not changed over 10 years in England Arti Bhimjiyani1, Jenny Neuburger2, Yoav Ben-Shlomo3, Celia Gregson1 1Musculoskeletal Research Unit, University of Bristol 2London School of Hygiene and Tropical Medicine, Nuffield Trust London 3School of Social and Community Medicine, University of Bristol
- 2. No conflicts of interest to disclose
- 3. Background • England & Wales: ~65,000 hip fractures per year1 • UK annual hospital costs of incident hip fracture ~£1.1 billion2 • Worsening levels of deprivation are associated with: • Higher rates of hip fracture3 • Poorer outcomes post-hip fracture4 • Secular trends show an increase in hip fracture incidence for men and plateau for women in the UK5 • Unclear how the association between deprivation and incident hip fracture has changed over the last decade 1 National Hip Fracture Database annual report 2015. London: RCP, 2015 4 Thorne K et al. Ost Int. 2016;27(9):2727-37 2 Leal J et al. Ost Int. 2016 Feb;27(2):549-58 5 van der Velde et al. Ost Int. 2016;27(11):3197-3206 3 Quah C et al. JBone Joint SurgBr. 2011;93(6):801-5
- 4. Hypothesis & Aims Hypothesis • Secular changes in hip fracture incidence have not occurred equally across all levels of deprivation i.e. any declines in incidence are likely to be seen predominantly in less deprived people Aims • To determine the association between deprivation and hip fracture incidence, by gender • To examine if secular trends in hip fracture incidence over 10 years differ by deprivation and gender
- 5. Hypothesis & Aims Hypothesis • Secular changes in hip fracture incidence have not occurred equally across all levels of deprivation i.e. any declines in incidence are likely to be seen predominantly in less deprived people Aims • To determine the association between deprivation and hip fracture incidence, by gender • To examine if secular trends in hip fracture incidence over 10 years differ by deprivation and gender
- 6. Data source: Hospital Episode Statistics (HES) • Anonymised, patient-level data extract from the HES Admitted Patient Care database • Routinely collected data from all English NHS hospitals • Time period: April 2001 to March 2012 • Study Population • Male and female English residents aged ≥50 years • Patients admitted with an index hip fracture (i.e. 1st hip fracture), or in-hospital index hip fractures
- 7. HES Exposure: Index of Multiple Deprivation (IMD) 2010 • Based on a classification of 32,482 local areas defined by an individual’s postcode • 7 domains: 1. Education, skills & training 5. Crime 2. Barriers to housing & services 6. Income 3. Health & disability 7.Employment 4. Living environment • Quintiles-based ranking of IMD scores: Q1 – Least deprived . . . Q5 – Most deprived Source: Index of Multiple Deprivation 2010 Neighbourhood Statistics Release
- 8. HES Outcome: Hip Fracture ICD-10 disease codes: • S72.0 (Fracture of Neck of Femur) • S72.1 (Pertrochanteric fracture) • S72.2 (Subtrochanteric fracture)
- 9. HES Outcome: Hip Fracture ICD-10 disease codes: • S72.0 (Fracture of Neck of Femur) • S72.1 (Pertrochanteric fracture) • S72.2 (Subtrochanteric fracture) Mid-year population estimates for England • Years 2001 to 2012 • Stratified by: Age in 5-year intervals Gender IMD 2015 quintile Population Denominator: Office for National Statistics (ONS)
- 10. Statistical Analyses • Annual incidence rates of hip fracture per 100,000 population: Number of index hip fractures x 100,000 by each strata of gender Population count & IMD per year • Age-standardised (direct) hip fracture incidence rates for males and females stratified by IMD quintiles (reference year: 2001) • Poisson regression modelling of the association between IMD & hip fracture incidence • Incident rate ratios (IRRs) (95% confidence interval), adjusted for age, stratified by IMD quintiles & gender • Reference cat. least deprived quintile (Q1) • Formal tests for interaction
- 11. Total Hip Fracture Population: 2001 to 2011 N (%) No. of patients with hip fracture 577,767 Female (%) 433,983 (75) IMD Quintile 1 (Least deprived) 109,265 (18.9) Q2 120,566 (20.9) Q3 122,751 (21.3) Q4 115,080 (19.9) Quintile 5 (Most deprived) 110,105 (19.1) Age (years) mean (SD) 81.6 (9.4)
- 12. 0.9 1 1.1 1.2 1.3 1.4 Q1 Q2 Q3 Q4 Q5 IncidentRateRatios(IRRs) Males Greater deprivation associated with higher incidence in men but less marked for women Poisson regression modelling adjusted for age Formal test for gender x deprivation interaction (adjusted for age) p<0.001 0.9 1 1.1 1.2 1.3 1.4 Q1 Q2 Q3 Q4 Q5 IncidentRateRatios(IRRs) Females
- 13. 0 100200300400500 2001 2003 2005 2007 2009 2011 Year Female age-standardised incidence is declining over time whilst rates have slightly increased for men Females Males 95% CIs have not been shown as very narrow Time x gender interaction (adjusted for age) p<0.001 Annual % increase: 0.81% Annual % decline: 1.18%
- 14. Age-Standardised Incidence Rates by IMD Quintiles for MEN No evidence of time x deprivation interaction (adjusted for age) p=0.61 0 50 100150200250300 2001 2003 2005 2007 2009 2011 Year Q5 Q1 Deprivation Annual % change Q1 +0.90 . . . Q5 +0.78
- 15. 0 100200300400 2001 2003 2005 2007 2009 2011 Year Age-Standardised Incidence Rates by IMD Quintiles for WOMEN Time x deprivation interaction (adjusted for age) p<0.001 Q5 Q1 Deprivation Annual % change Q1 -1.42 . . . Q5 -0.89
- 16. Limitations • We used an area-based measure of deprivation as a proxy for individual deprivation • Quality of HES coding may have changed over time • We lack co-morbidity data • Our results are derived from English data only
- 17. Conclusions • Deprivation is a stronger predictor of adult hip fracture incidence in men than women • Hip fracture incidence has declined in women and increased in men across all strata of deprivation from 2001-2011 • There has been no narrowing of the gap between levels of deprivation for men, with some widening of the gap for women, despite national efforts to reduce hip fracture incidence • Our findings have implications for equity of access to fracture prevention programs nationally
- 18. Acknowledgements Co-authors Celia Gregson, Jenny Neuburger & Yoav Ben-Shlomo Funders Timothy Jones (University of Bristol) Matthew Hurley (ONS)
Editor's Notes
- Good afternoon everyone. My name is Arti Bhimjiyani. I am a second year PhD student based in the Musculoskeletal Research Unit at the University of Bristol. Today I will be presenting analyses conducted as part of my PhD.
- Hip fractures are common. The National Hip Fracture Database reports that around 65,000 hip fractures occur each year in England, Wales and NI And the financial impact of hip fractures to the health service is high. A recent study estimated the annual hospital costs associated with incident hip fractures to be approximately £1.1 billion pounds for the UK A study conducted in Nottingham showed that worsening levels of deprivation were associated with higher rates of hip fracture Furthermore, worsening levels of social deprivation have been associated with increased mortality in England A recent study by Van der Velde and colleagues showed that secular trends in hip fracture incidence increased in men but plateaued in women over a 20-year period in the UK However, it is unclear how the association between deprivation and incident hip fractures has changed over the last decade
- We hypothesised that secular changes in hip fracture incidence have not occurred equally across all levels of deprivation, that is, any declines in incidence are likely to be seen predominantly amongst people who are less deprived The aim of this study was two-fold. Firstly, we aimed to determine the association between area deprivation and hip fracture incidence, by gender. And secondly, to examine if the secular trends in hip fracture incidence over 10 years differ by deprivation and gender
- We hypothesised that secular changes in hip fracture incidence have not occurred equally across all levels of deprivation, that is, any declines in incidence are likely to be seen predominantly amongst people who are less deprived The aim of this study was two-fold. Firstly, we aimed to determine the association between area deprivation and hip fracture incidence, by gender. And secondly, to examine if the secular trends in hip fracture incidence over 10 years differ by deprivation and gender
- We analysed an anonymised, patient-level data extract of routinely collected data from all English hospitals within the National Health Service for the period April 2001 to March 2012 Our study population consisted of index cases of hip fracture, that is the first occurrence of hip fracture, among all English residents aged 50 years and older admitted to hospital with a hip fracture or who sustained a hip fracture during a hospital admission
- We used the Index of Multiple Deprivation (IMD) 2010 to measure an individuals level of socio-economic deprivation The IMD is a measure of deprivation for small areas, of which there were just under 32,500 in England, based on the 2001 population census – shown on the map here, which demonstrates the geographic spread of deprivation in England. Areas in blue are defined as the most deprived and areas in yellow are classified as the least deprived An individual’s local area and hence IMD score and rank is determined by their postcode. The IMD is comprised of 7 domains of deprivation, namely education, skills and training employment barriers to housing and services Living environment crime income and health and disability We categorised patients into five equal groups based on the national IMD ranking of local areas, with quintile 1 being the least deprived and quintile 5 being the most deprived
- We identified our study outcome, that is index cases of hip fracture, using ICD-10 codes for Fracture of the neck of femur Pertrochanteric fracture and Subtrochanteric fracture
- We used mid-year population estimates obtained from the Office for National Statistics (ONS) for the years 2001 through to 2011 as our population denominator data Our denominator data were stratified by age in 5-yearly intervals, gender and IMD quintiles
- We calculated annual incidence rates of hip fracture per 100,000 population as the number of index cases of hip fracture divided by the population count for each strata of gender and IMD quintile multiplied by 100,000 We used direct standardisation methods to calculate age-standardised hip fracture incidence rates for males and females stratified by IMD quintiles using the population of England in 2001 as our reference population We used Poisson regression modelling to determine the association between IMD and hip fracture incidence And calculated incident rate ratios, adjusting for age, and stratified by IMD quintiles and gender Using quintile 1, the least deprived quintile, as the reference category for our analyses We conducted formal tests for interaction between time, gender and deprivation, treating all variables as continuous in our model
- We identified approximately 580,000 hospital admissions with an index hip fracture from 2001 to 2011, of which 75% were in women The mean age of our study population was 82 years
- This is a figure of incident rate ratios on the y axis by quintile of deprivation on the x axis, for males and females Quintile 1, the least deprived quintile, acted as the reference category This figure demonstrates that hip fracture incidence was highest for men in the most deprived versus the least deprived quintile with greater deprivation being associated with an approximately 1.3-fold increase in the rate of incident hip fracture An association between greater deprivation and hip fracture incidence was found in women, albeit less marked than the relationship observed in men We found evidence to suggest that the association between deprivation and hip fracture incidence differed between males and females, i.e. there was a significant gender by deprivation interaction.
- We observed differing trends in age-standardised hip fracture incidence by gender with a decline observed for women at a rate of 1.2% per year whilst rates increased slightly for men at a rate of <1% per year over the 10 years
- Age-standardised hip fracture incidence rates have increased similarly for men across all strata of deprivation from 2001 to 2011 We found no evidence to suggest that the rate of increase over time has differed by levels of deprivation, i.e. no time by deprivation interaction. The increases in hip fracture incidence equate to a 0.9% increase in fracture rate per year amongst the least deprived quintile, and a 0.78% increase per year amongst the most deprived quintile
- Age-standardised hip fracture incidence has declined in women across all strata of deprivation from 2001 to 2011 However, we found evidence to suggest that hip fracture incidence has decreased over time to a greater extent amongst women in the least deprived quintile compared to the most deprived quintile So, the declines in hip fracture incidence equate to a 1.42% decline in fracture rate per year amongst the least deprived quintile, and a 0.89% decline per year amongst the most deprived quintile
- We recognise the following limitations of this study. Firstly, we used an area-based measure of deprivation as a proxy for an individual’s level of deprivation, which may not reflect the heterogeneous nature of deprivation within an area Secondly, the quality of HES coding may have changed over time, which may have influenced the recording of hip fractures over our study period We were unable to obtain population denominator data stratified by level of co-morbidity and therefore we were unable to take account of secular trends in co-morbidity and it’s impact on trends in hip fracture incidence by deprivation We analysed hospital admission data that were collected from English hospitals, which may limit the generalisability of our findings to other study populations
- We conclude from our study findings that deprivation is a stronger predictor of adult hip fracture incidence in men than in women Furthermore, hip fracture incidence has declined in women and increased in men across all strata of deprivation from 2001 to 2011 And finally, our findings suggest that there has been no narrowing of the gap between levels of deprivation for men, with some widening of the gap for women. These trends are seen despite national efforts to reduce hip fracture incidence Our findings have implications for equity of access to fracture prevention programs nationally
- I would like to acknowledge the following people, especially my PhD supervisors Celia Gregson, Jenny Neuburger and Yoav Ben-Shlomo. I would like to thank the National Osteoporosis Society for funding this project and for the opportunity to present our findings. Thank you for listening.