Original articles
Fracture Risk in the U.S. Medicare Population

https://doi.org/10.1016/S0895-4356(98)00167-XGet rights and content

Abstract

Using data from the 5% U.S. Medicare sample, we estimated the actuarial (life table) risk that a person aged 65 will fracture the upper or lower limbs or the pelvis, by age 75, 80, 85, and 90, taking into account the chance of dying in the interval. The actuarial risk of a 65-year old white woman sustaining a fracture by age 90 is 16% for the hip, 9% for distal forearm, 5% for proximal humerus, and 4% for ankle. Black women and white men have substantially lower risks, and the risks for black men are very low. Although hip fractures pose the single greatest risk, the risk of all other fractures combined is greater. White women have particularly high risks for all fractures, because of their longevity as well as their high fracture rates. It is important to adjust for the probability of dying when estimating risks in an elderly population.

Introduction

Although osteoporosis is widely recognized as an important problem of the elderly in Western societies, much of the scientific and public knowledge of the problem is limited to hip fracture. Fractures at other anatomic sites are common 1, 2, 3, but even basic information about the occurrence of many of these fractures is lacking. It has been estimated that in the United States, about 16% of 65-year-old white women will sustain a hip fracture during their remaining lifetime; the corresponding estimate for Colles fracture is 10%, and for vertebral fractures, 28% [4]. Similar risk estimates for other fractures have not been described previously.

Understanding the long-term risk of fracture is important in planning for health care needs and in allocating resources for prevention efforts. For an individual to weigh the risks and benefits of preventive interventions such as hormone replacement therapy and bone resorption retardants, realistic estimates of fracture risks are needed. Given that long-term risk estimates are a simple way of comparing the impact of different diseases, clinicians can use them, together with an individual patient’s own history, to balance the need for particular therapies.

To estimate the probability that a person aged X will develop a disease by age Y, the competing risk of death in the interval should be taken into account. Cumulative risk estimates that assume that everyone of age X survives to age Y overstate the probability of disease by age Y, as some people will not live to be at risk for the whole period.

In this report, we used U.S. Medicare claims to describe the risk for individuals aged 65 of fractures of the upper and lower limbs and of the pelvis by ages 75, 80, 85, and 90 and assessed the importance of taking into account the probability of their dying in the interval.

Section snippets

Methods

Our analysis was based on the U.S. Medicare population aged 65 or more during the period July 1, 1986 to June 30, 1990. We searched the 5% U.S. sample Medicare claims for the years 1986 to 1990 to identify all diagnosis and procedure codes relating to fractures of the proximal humerus, shaft or distal humerus, proximal or shaft of radius/ulna, distal forearm, pelvis (excluding isolated acetabular fracture), hip, shaft or distal femur, patella, proximal or shaft tibia/fibula, and distal

Results

There were 1,421,763 eligible individuals in the study population aged 65 through 89 during the period July 1, 1986 to June 30, 1990. The numbers of enrollees, deaths and fractures by race and gender is given in Table 1. As expected, the hip was by far the most common fracture site. Fractures of the distal forearm, the next most common site, were much less frequent than those of the hip. Except for the hip and ankle, the absolute numbers of fractures occurring among black males was low, and so

Discussion

Because the actuarial risk is not conditional on survival to the upper age, it is a more realistic measure than the cumulative risk. The lower fracture rates in men than women have been documented previously 1, 3. Death rates in men, however, are about twice those in women at age 65, and by age 85, they are still about 60% higher. This analysis demonstrates that the higher male death rates generate even greater differences between the genders in actuarial risks of fracture because fewer men

Acknowledgements

Supported in part by grant AG07146 from the National Institute on Aging.

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