Emergency department visits for fall-related fractures among older adults in the USA: a retrospective cross-sectional analysis of the National Electronic Injury Surveillance System All Injury Program, 2001-2008.

0.28 MB·English

by  Orces, Carlos H

Open Access Research
Emergency department visits for
fall-related fractures among older
adults in the USA: a retrospective
cross-sectional analysis of the National
Electronic Injury Surveillance System
–
All Injury Program, 2001 2008
Carlos H Orces
Tocite:OrcesCH. ABSTRACT
ARTICLE SUMMARY
Emergencydepartmentvisits Objectives:Todescribethedemographic
forfall-relatedfractures
characteristicsandincidenceofunintentionalfall- Article focus
amongolderadultsinthe
USA:aretrospective relatedfracturesamongolderadultstreatedintheUS ▪ Theaimofthisstudywastodescribethedemo-
cross-sectionalanalysisof hospitalemergencydepartments(EDs). graphic characteristics and incidence of uninten-
theNationalElectronicInjury Design:Retrospectiveobservationalstudy. tional fall-related fracture among persons aged
SurveillanceSystemAllInjury Settings:Hospitals’EDparticipantsintheNational 65yearsoroldertreatedintheUShospitalEDs.
Program,2001–2008.BMJ ElectronicInjurySurveillanceSystemAllInjury
Open2013;3:e001722. Program(NEISS-AIP). Key messages
doi:10.1136/bmjopen-2012- Participants:TheNEISS-AIPwasusedtogenerate ▪ An estimated 4.05 million older adults were
001722 treated in hospital EDs for fall-related fracture
nationalestimatesofhospitalEDvisitsfor
between2001and2008.
unintentionalfall-relatedfractureamongadultsaged
▸ Prepublicationhistoryfor 65yearsorolderbetween2001and2008.Census ▪ Theoldest old, women andlower trunk fractures
thispaperareavailable populationestimateswereusedasthedenominatorto account for the majority of fall-related fractures
online.Toviewthesefiles amongpersonsaged65yearsoroldertreatedin
calculateage-specificandage-adjustedfracturerates
pleasevisitthejournalonline EDs.
per100000persons.
(http://dx.doi.org/10.1136/ ▪ EDs visits and hospitalisations for fall-related
Main outcome measures:Fall-relatedfracturerates
bmjopen-2012-001722). fractureamongolderadultsincreasedintheUSA
andEDdisposition.
duringthestudyperiod.
Received23June2012 Results:Onthebasisof70199cases,anestimated
Revised17December2012 4.05millionolderadultsweretreatedinUShospitalEDs Strength and limitations of this study
Accepted18December2012 forfall-relatedfractureduringthe8-yearperiod.Two- ▪ The present study reports national estimates of
thirdsoftheinjuriesoccurredathomeand69.5%(95% fall-related fracture by gender and body part
Thisfinalarticleisavailable
CI59.7%to77.8%)oftheaffectedindividualswere amongolderadults.
foruseunderthetermsof
white.Fall-relatedfractureratesincreasedgraduallywith ▪ ICD-9-CM diagnosis codes were not available in
theCreativeCommons
AttributionNon-Commercial ageandwereonaveragetwofoldhigheramongwomen. the medical records at the time these data were
2.0Licence;see Ofthosehospitalised,womenandfracturesofthelower collected;therefore,specifictypesofinjuries(eg,
http://bmjopen.bmj.com trunkrepresented75.2%and65.1%oftheadmissions, hipfracture)couldnotbeaccuratelyidentified.
respectively.Theestimatednumberoffall-related
fracturestreatedinEDsincreasedfrom574500in2001
to714800in2008,a24.4%increase.Bygender,anon-
significantupwardtrendinage-adjustedfall-related INTRODUCTION
fracturerateswaspredominantlyseenamongmenatan One-third of people over the age of 65years
annualrateof1.9%(95%CI−0.1%to4.0%),whereas who live in the community fall each year; this
fractureratesamongwomenremainedstableat0.9% proportion increases to 50% by the age of
(95%CI−0.7%to2.5%)peryear. 80years.1 Although not all falls of older
Conclusions:Theoldestold,womenandlowertrunk
DepartmentofMedicine, personsareinjurious,about5%ofthemresult
fracturesaccountforthemajorityoffall-relatedfractures
LaredoMedicalCenter, in a fracture, and other serious injuries occur
amongpersonsaged65yearsoroldertreatedinUS
Laredo,Texas,USA in 5–10% of falls.2 In 2001, an estimated 1.64
hospitalEDs.IncreasingEDvisitsandhospitalisationsfor
million older adults were treated in hospital
Correspondenceto fall-relatedfractureamongolderadultsdeservefurther
emergency departments (EDs) for uninten-
DrCarlosHOrces; research.
[email protected] tionalfall-relatedinjuriesintheUSA.Ofthese,
OrcesCH.BMJOpen2013;3:e001722.doi:10.1136/bmjopen-2012-001722 1
Fall-related fractures among older adults
fractures accounted for 37.8% of women’s and 28.3% of eachcase.Thepresentstudyincludedpersons65yearsor
men’sinjuries.3 older treated in US hospital EDs for unintentional fall-
Between 2001 and 2008, fractures were the most fre- related fractures between 2001 and 2008. National esti-
quent primary diagnosis (63%) among older adults hos- matesareconsideredunstableandpotentiallyunreliableif
pitalised after being treated in hospital EDs for the number of records is based on fewer than 20
fall-related injuries.4 Similarly, a prior study showed that NEISS-AIP cases, national estimates fewer than 1200
fractures accounted for 84% of hospitalisations for fall- (basedonweighteddata)orthecoefficientofvariationof
related injuries among older adults in the USA between the estimate is greater than 30%. The NEISS-AIP public
1988 and 2005. Moreover, hip fracture was the leading use files were downloaded from the Inter-University
diagnosis in both genders, resulting in an estimated ConsortiumforPoliticalandSocialResearch.9
1581600 (47.6%) hospitalisations during the 18-year
study period.5
STATISTICALANALYSIS
About 1–14% of falls in women result in hip fracture
All statistical analyses were performed using SPSS
and over 90% of hip fractures are the result of a fall.6
Complex Sample software, V.17 (SPSS Inc, Chicago,
Although hip fracture rates and subsequent mortality
Illinois, USA) and incorporated population-based sam-
are declining in the USA, information is scarce about
pling weights to obtain unbiased, nationally representa-
the epidemiology of other fall-related fractures nation-
tive estimates from the NEISS-AIP sampling design. The
wide among older adults.7 8 Thus, the aim of this study
sample weight has been adjusted for hospital non-
wastodescribe the demographic characteristics and inci-
response within each NEISS-AIP sample stratum and
dence of unintentional fall-related fracture among
changes in the number of ED visits annually in the sam-
persons aged 65years or older treated in hospital EDs
pling frame of US hospital EDs. Means and proportions
between 2001 and 2008.
were used to describe demographic and clinical charac-
teristics of the study sample. The US Census Bureau
population estimates were used as the denominator to
METHODS
calculatefall-related fracturerates per 100000 persons.10
The National Electronic Injury Surveillance System All
Fracture rates were then standardised by the direct
Injury Program (NEISS-AIP) is designed to provide
method to the US population for the year 2000 to
national incidence estimates of all types and external
account for changes in the age distribution of the popu-
causes of non-fatal injuries and poisonings treated in US
lation over time. Linear regression was used to examine
hospital EDs. Data on injury-related visits were obtained
the statistical significance of trends in fall-related frac-
from a national sample of 66 of 100 NEISS hospitals,
ture rates over the study period. The results are pre-
which were selected as a stratified probability sample of
sented as the annual percentage change in rates and
hospitalsintheUSAwithaminimumofsixbedsand24h
corresponding 95% CI. The annual percentage change
EDs.Dataareweightedbytheinverseoftheprobabilityof
is one way to characterise trends over time in which the
selection to produce national estimates. The sample
rates are assumed to change at a constant percentage of
includes separate strata for very large, large, medium and
the rate of the previous year. All analyses were per-
smallhospitals,definedbythenumberofannualEDvisits
formed by using Joinpoint software, V.3.5.0.11
per hospital. Data obtained on each case include age,
race/ethnicity, gender, principal diagnosis, primary body
part affected, consumer products involved, disposition at RESULTS
ED discharge (ie, hospitalised, transferred, treated and On the basis of 70199 cases, an estimated 5.04 million
released, observation and died), locale where the injury adultswithameanageof80.0(SD8.2)yearsweretreated
occurred, work-relatedness and a narrative description of in US hospital EDs for unintentional fall-related fracture
theinjurycircumstances,also,majorcategoriesofexternal between 2001 and 2008. Women accounted for 75.2%
cause of injury (eg, motor vehicle, falls, cut/pierce, poi- (95%CI74.2% to76.2%) of thesecasesand 69.5% (95%
soningandfire/burn)andofintentofinjury(eg,uninten- CI59.7%to77.8%)oftheaffectedindividualswerewhite.
tional, assault, intentional self-harm and legal Overall,58.7%(95%CI54.0%to63.3%)oftheseinjuries
intervention).Trained,onsitehospitalcoderstookdatafor occurred at home. Moreover, after a fall-related fracture,
injury-related cases from ED records at NEISS hospitals. 50.6% (95% CI 47.7% to 53.5%) of the patients were
The coders coded all data elements, except for cause of treated and released from the ED and 44.2% (95% CI
injury. These coded data and a narrative were electronic- 40.9% to 47.7%) required hospitalisation. Of those hospi-
ally transmitted to Consumer Product Safety Commission talised, women and fractures of the lower trunk (lumbar
(CPSC)headquarters.NEISS-AIPqualityassurancecoders spine, pelvis and hip) represented 75.2% (95% CI 73.9%
atCPSCheadquartersreviewedallofthedataelementsas to 76.5%) and 65.1% (95% CI 62.0% to 68.1%) of the
wellasanarrative(description)foreachcasefromeachof admissions,respectively.
the66NEISS-AIPhospitals.Qualityassurancecodersthen The number, national estimates and fall-related frac-
used the narrative and other data to assign codes for the ture rates according to gender and primary body part
precipitating and direct causes/mechanisms of injury for affected are shown in table 1. In general, lower trunk
2 OrcesCH.BMJOpen2013;3:e001722.doi:10.1136/bmjopen-2012-001722
Fall-related fractures among older adults
Table1 Emergencydepartmentfall-relatedfractureestimatesandincidenceratesaccordingtogenderandbodypart,
NEISS-AIP2001–2008
Cases Menestimates* Rates†(95%CI) Cases Womenestimates Rates(95%CI)
Head‡ 116 5000 4.6(3.2to6.0) 134 7000 4.4(2.9to6.0)
Face 770 56000 45.8(33.7to57.8) 1830 132000 77.3(60.5to94.0)
Neck§ 276 17000 14.1(8.8to19.3) 368 24000 14.4(9.2to19.5)
Uppertrunk¶ 2611 197000 161.0(123.5to198.6) 3975 303000 177.5(133.2to221.8)
Shoulder** 912 68000 55.3(42.7to68.0) 2645 198000 116.1(87.1to145.0)
Elbow 334 23000 18.9(14.3to23.5) 1055 73000 42.9(31.9to54.0)
Upperarm†† 923 66000 53.8(39.7to67.9) 4030 295000 172.8(130.1to215.4)
Lowerarm‡‡ 569 42000 34.4(25.0to43.7) 2852 207000 121.5(87.0to156.0)
Wrist 991 71000 58.2(45.0to71.4) 5530 404000 236.7(185.5to288.0)
Hand 255 17000 14.3(10.3to0.18.3) 671 46000 27.3(21.8to32.7)
Finger 349 25000 20.4(15.4to25.4) 712 52000 30.4(24.5to36.6)
Lowertrunk§§ 6652 470000 382.6(290.6to474to6) 19989 1412000 826.8(622.2to1031.4)
Pubicregion 15 1500 1.2(0.3to2.1) 63 5000 3.1(1.7to4.6)
Knee 338 23000 18.9(14.7to23.3) 1216 88000 51.6(37.8to65.4)
Upperleg¶¶ 748 50000 41.4(28.7to54.1) 2528 175000 102.8(75.5to130.0)
Lowerleg*** 552 38000 31.5(24.3to38.8) 1606 112000 65.5(50.5to80.5)
Ankle 676 47000 38.8(30.6to47.0) 2201 155000 90.9(71.1to110.7)
Foot 264 18000 15.3(11.2to19.3) 1073 75000 44.4(34.1to54.8)
Toe 96 6000 5.6(3.3to7.9) 311 22000 30.4(24.5to36.3)
*NationalestimatesofEDvisitsforfall-relatedfractures.
†Ratesper100000population.
‡Parietalandoccipitalbones.
§Cervicalspine.
¶Thoracicspine,ribsandsternum.
**Clavicle.
††Humerus.
‡‡Ulnaanddistalradius.
§§Lumbarspine,pelvisandhip.
¶¶Femur.
***Fibulaandtibia.
fractures were the most frequently reported injuries in the same period. After age adjustment, fall-related frac-
both genders, representing 37.3% (95% CI 37.2% to ture rates increased from 1618.7 in 2001 to 1789.4/
39.5%) of fall-related fracture visits to EDs in the US 100000 persons in 2008, a 10.5% increase. By gender, a
during the study period. Moreover, wrist and upper non-significant upward trend in age-adjusted fall-related
trunk fractures (thoracic spine, ribs and sternum) fracture rates was seen among men at an annual rate of
accounted for a considerable proportion of fall-related 1.9% (95% CI −0.1% to 4.0%), whereas fracture rates
fractures among women, whereas among men, upper among women remained stable at 0.9% (95% CI −0.7%
trunk fracture was the second most frequent reason for to 2.5%) per year(figure2).
fall-related fractures ED visits, representing an estimated As shown in figure 3, the proportion of patients hospi-
197000 fractures. talised for fall-related fracture increased from 43.5% (95
The incidence of fall-related fracture rates increased CI 42.4% to 44.5%) in 2001 to 48.4% (95 CI 47.4% to
with advancing age and were on average twofold higher 49.3%) in 2008, with a corresponding decrease in the
among women (figure 1). In fact, compared with those proportion of patients released from EDs from 53.4%
in the age group of 65–69years, fracture rates in the age (95 CI 52.3% to 54.5%) to 48.7% (95 CI 47.7% to
group of 85years or older were fourfold higher among 49.7%) during the same period. The proportion of
women and fivefold higher among men. After adjusting patients transferred to other facilities remained stable
for age, fall-related fracture rate varies by race. The over time.
highest rates per 100000 persons were 1268.9 among
non-Hispanic whites, whereas the lowest rates of 876.6
were seen among Asians. Blacks and American Indians DISCUSSION
had rates that were similar but intermediate between In this nationally representative sample, an estimated
those ofwhitesand Asians. 5.04 million older adults were treated for fall-related
The estimated number of fall-related fractures treated fractures in the US hospital EDsbetween 2001 and 2008.
in EDs increased from 574500 in 2001 to 715000 in Fall-related fracture rates increased gradually with advan-
2008, a 24.4% increase. However, the population of cing age and were on average twofold higher among
older adults also increased by 9.8% in the USA during women. The gender differences in fall-related fracture
OrcesCH.BMJOpen2013;3:e001722.doi:10.1136/bmjopen-2012-001722 3
Fall-related fractures among older adults
Figure1 Fall-relatedfracture
ratesand 95%CIamongolder
adultstreatedinUSemergency
departments.
rates were mainly attributed to higher proportions of have a fall-related ED visit for most types of fracture.
upper extremity and lower trunk fractures (lumbar Overall, hospitalisation occurred in 51.3% of older
spine, pelvis and hip) among women. In fact, lower adults with a fall-related fracture ED visit.12 Similarly, a
trunk fractures in women accounted for 28% of all fall- recent study using data from the NEISS-AIP showed that
related fractures among older adults treated in EDs fall-related forearm and wrist fracture rates among
during the 8-year period. The present findings are con- persons 50years or older treated in hospital EDs nation-
sistent with a report from the Healthcare Cost and wide were on average 3.3 higher in women than those
Utilization Project Nationwide Emergency Department rates in men.13 Possible explanations for the marked
Sample on ED injury visits among older adults in which gender differences in fractures are the higher preva-
women were more likely to have ED visits for upper lence of osteopenia and osteoporosis among women
extremity and hip fracturesthan older men. In addition, and the 40–60% higher fall-related injury rates reported
women were two to three times more likely than men to among women.314
Figure2 Trendsinfall-related
fractureratestreatedinUS
emergencydepartments,2001–
2008.
4 OrcesCH.BMJOpen2013;3:e001722.doi:10.1136/bmjopen-2012-001722
Fall-related fractures among older adults
Figure3 Dispositionofolder
adultstreatedinUShospital
emergencydepartmentsfor
fall-relatedfracture.
The racial differences in fall-related fracture rates fracture increased the risk of future fracture of a weight-
found in this study are also consistent with results from bearingbone.21
previous investigations in which white women had the Of interest, 44.2% of patients treated in EDs for fall-
highest fracture rates, whereas black and Asian women related fracture required hospitalisation and the propor-
had the lowest fracture rates.15 16 Although many risk tion of older adults hospitalised for these injuries
factors for fracture have been identified in white increased during the 8-year study period. Although the
women, less is known about risk factors for fracture in present analysis was limited to fall-related fractures, these
non-white women. In a prospective study of 159579 findings are consistent with a recent study that reported
women aged 50–79years enrolled in the Women’s anincreaseby50%intheestimatednumberoffall-related
Health Initiative study, three risk factors common to all hospitalisations among older adults in the USA between
racial groups were older age, positive history of prior 2001 and 2008. Of these, hospitalisations for fractures
fracture after the age of 55years and a positive historyof accounted for 63% of the diagnoses.4 Similarly, fractures
two or more falls.14 17 Among fallers, an increasing were the most common admitting diagnosis among
amount of leisure-time physical activity and wearing persons aged 65yearsorolderhospitalised for fall-related
proper shoes with low, wide heels that cover and stay on injuries in the USA between 1988 and 2005, representing
the foot in the event of a fall have been associated with 84%oftheadmissions.5Moreover,fall-relatedinjuryhospi-
decreased risk of fractures at the foot, distal forearm, talisation rates increased in both genders during the
proximal humerus, pelvis and shaft of the tibia/fibula 18-yearperiod.
compared with fallers who do not fracture.18 Moreover, Overall, the number of fall-related fractures among
among older white women, walking for exercise, redu- older adults treated in EDs increased between 2001 and
cing caffeine intake, quitting smoking, avoiding long- 2008. After age adjustment, a non-significant upward
acting sedatives agents, treating impaired vision and pre- trend in fall-related fracture rates was seen among men.
serving bone mass were reported to reduce the risk of The precise reason for this finding is unknown. However,
hipfractures.19 differences in osteoporosis recommendations for screen-
Several studies have reported that fractures of the hip, ing and prevention between men and women may
spine or wrist are predictors of subsequent fractures.20–23 account for increasing fall-related fracture rates seen
Recently, investigators have demonstrated that besides amongmen.24Theseresultscontrastwithapreviousstudy
typical osteoporotic fractures, prior non-hip and non- among Medicare beneficiaries that reported a significant
spine fractures in both genders are associated with the decrease in hip fracture rates among men and women
incidence of traditional fragility fractures, as well as with between1995and2005.7
fractures of the humerus and tibia/fibula.20 Moreover, TheincreasedproportionofolderAmericanswithphys-
prior rib and upper leg fracture fractures are associated ical limitations (stooping, lifting, reaching, grasping and
with increased risk of subsequent vertebral and hip frac- walking) over time may also partly explain these findings.
ture, respectively. Among women, a history of ankle In fact, data from the Medicare Current Beneficiary
OrcesCH.BMJOpen2013;3:e001722.doi:10.1136/bmjopen-2012-001722 5
Fall-related fractures among older adults
Survey indicate that the age-adjusted proportion of non- in the USA. Increasing ED visits and hospitalisations for
institutionalised adults aged 65years and older with phys- fall-related fracture among older adults deserve further
ical limitations increased from 32.7% in 1992 to 38.4% in research.
2009.25 Similarly, a recent study using data from the
Acknowledgements TheauthorwouldliketothankMrsPatriciaGutierrez
National Health and Nutritional Examination Survey
fromUTHSCLaredocampusforlibrarianassistance.
demonstratedanincreasedprevalenceofself-reporteddis-
Funding Thisresearchreceivednospecificgrantfromanyfundingagencyin
abilityovertimeamongolderAmericansinbasicactivities
thepublic,commercialornot-for-profitsectors.
of daily living, instrumental activities of daily living and
mobility.26Disabilityofthelowerextremitieshasbeenasso- Competinginterests None.
ciated with increased risk for falls among those aged Provenanceandpeerreview Notcommissioned;externallypeerreviewed.
75years or older living in the community and with fall- Datasharingstatement TheNEISS-AIPfilesarepubliclyavailablefor
related hip fracture in women.6 27 Moreover, adequate analysisathttp://www.icpsr.umich.edu/icpsrweb/ICPSR/series/198/studies/
physicalactivityhasbeenassociatedwithareducedriskof 30544?q=neiss&permit%5B0%5D=AVAILABLE&paging.startRow=1.
fractures among fallers, possibly because physical activity
can increase physical functioning, maintain mobility,
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