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Why Are Hip Fracture Rates Falling?

In a recent issue of the Journal, Kannus et al. reported that the age-adjusted incidence of hip fractures in Finland fell by 17% in women and by 6% in men between 1997 and 2004, reversing the steady increase in rates observed among Finnish women and men between 1970 and 1997. The authors speculated that the recent decline might be related to healthier aging and improved functionality among the elderly in recent years. If so, this would be evidence for the “compression of morbidity” (i.e., the notion that a greater delay in the onset of disability relative to the time of death will reduce the proportion of one’s life spent in ill health). However, other perspectives suggest that the burden of frailty has been rising in Scandinavia, and fracture rates are still rising in some locales and subsets of the population. Moreover, ecological data can support many potential explanations for any decrease in a complex phenomenon such as hip fracture. Thus, Canadian investigators attributed an analogous decline in hip fracture incidence between 1992 and 2000 to widespread implementation of an osteoporosis screening and treatment program in the Province of Ontario that increased BMD testing >10-fold and use of antiresorptive therapy almost 20-fold. However, earlier work by our group showed that hip fracture incidence rates in Rochester, MN, rose dramatically in the early decades of the last century, only to decline in women beginning around 1950 and in men around 1980. This pattern has been observed in a number of geographic regions, with timing of the shift varying by decades. These diverse international patterns, as well as discrepancies in secular trends by race, sex, and age, might help identify novel public health measures. It would be equally important to know if the trends reflect changes in personal behaviors such as tobacco use, unexpected beneficial effects of medications for other conditions, or reductions in the comorbid conditions that contribute to hip fracture risk. To help constrain potential explanations, these authors are encouraged to further update their analysis to isolate any specific subsets (i.e., age group, sex, geographic subregion, and type of fracture) responsible for the reversal of hip fracture trends in Finland. As Kannus et al. pointed out, population aging could still counter the effect of the reduction in hip fracture incidence observed thus far, and much more must be known to devise effective interventions for this important public health problem. REFERENCES