Epidemiology of fractures in the United Kingdom 1988–2012: Variation with age, sex, geography, ethnicity and socioeconomic status

Highlights

• We documented UK fracture incidence, stratifying by age, sex, geographic location, ethnicity and socioeconomic status.

• In men aged 50+ years, the overall rate of fracture was 71.8/10,000 py and in women 50+ years it was 155.4/10,000 py.

• There was heterogeneity in fracture incidence according to geographic location, ethnicity and socioeconomic status.

• These findings may inform public health policy in UK and elsewhere.

Abstract

Summary

Rates of fracture worldwide are changing. Using the Clinical Practice Research Datalink (CPRD), age, and gender, geographical, ethnic and socioeconomic trends in fracture rates across the United Kingdom were studied over a 24-year period 1988–2012. Previously observed patterns in fracture incidence by age and fracture site were evident. New data on the influence of geographic location, ethnic group and socioeconomic status were obtained.

Introduction

With secular changes in age- and sex-specific fracture incidence observed in many populations, and global shifts towards an elderly demography, it is vital for health care planners to have an accurate understanding of fracture incidence nationally. We aimed to present up to date fracture incidence data in the UK, stratified by age, sex, geographic location, ethnicity and socioeconomic status.

Methods

The Clinical Practice Research Datalink (CPRD) contains anonymised electronic health records for approximately 6.9% of the UK population. Information comes from General Practitioners, and covers 11.3 million people from 674 practices across the UK, demonstrated to be representative of the national population. The study population consisted of all permanently registered individuals aged ≥ 18 years. Validated data on fracture incidence were obtained from their medical records, as was information on socioeconomic deprivation, ethnicity and geographic location. Age- and sex-specific fracture incidence rates were calculated.

Results

Fracture incidence rates by age and sex were comparable to those documented in previous studies and demonstrated a bimodal distribution. Substantial geographic heterogeneity in age- and sex adjusted fracture incidence was observed, with rates in Scotland almost 50% greater than those in London and South East England. Lowest rates of fracture were observed in black individuals of both sexes; rates of fragility fracture in white women were 4.7 times greater than in black women. Strong associations between deprivation and fracture risk were observed in hip fracture in men, with a relative risk of 1.3 (95% CI 1.21–1.41) in Index of Multiple Deprivation category 5 (representing the most deprived) compared to category 1.

Conclusions

This study presents robust estimates of fracture incidence across the UK, which will aid decisions regarding allocation of healthcare provision to populations of greatest need. It will also assist the implementation and design of strategies to reduce fracture incidence and its personal and financial impact on individuals and health services.

Introduction

Osteoporosis is characterised by deterioration of bone mass and microarchitecture, resulting in increased bone fragility and propensity to fracture [1]. Worldwide, in the year 2000, there were estimated to be nearly 9 million osteoporotic fractures each year, of which 1.6 million were at the hip, 1.7 million at the forearm and 1.4 million were clinical (symptomatic) vertebral fractures [2]. The US Surgeon General's report of 2004 [3], consistent with data from the UK [4], suggested that almost one in two women and one in five men will experience a fracture in their remaining lifetime from the age of 50 years. The economic and personal costs of osteoporotic fracture are substantial, accounting for 37 billion Euros annually across the 27 countries of the European Union and 1,180,000 quality adjusted life years lost during 2010 [5]. Owing to the ageing population, global costs of osteoporotic fracture are expected to increase by 25% during the period 2010 to 2025 [5]. A similar increase is predicted in the United States, where osteoporosis is the 10th ranked major illness and is among the top 5% highest cost Medicare beneficiaries [3].

There is substantial variability in fracture incidence worldwide [6], and studies have demonstrated differences in fracture risk according to geography [2], [6], [7], ethnicity [7], [8], [9] and socioeconomic status [10], [11], [12]. The largest existing study of fracture epidemiology in England and Wales, published in 2001, sampled 5 million adults from the General Practice Research Database [GPRD, now known as the Clinical Practice Research Datalink (CPRD)] during the period 1988–1998 [4]. In this analysis, it was not possible to stratify fracture incidence according to the geographic region, ethnicity and socioeconomic status; additionally secular changes in age- and sex-adjusted fracture incidence rates have been demonstrated worldwide in recent decades [13]. In this study, we aimed, using CPRD over the period 1988 to 2012, to provide current estimates of fracture incidence stratified by age, sex, geographic region, ethnic group and socioeconomic status.