title: Understanding Mortality of Femoral Fractures Following Low-Impact Trauma in Persons With and Without Care Need.
abstract: OBJECTIVE
  Persons with osteoporotic fracture history are subject to an increased risk for subsequent fractures and mortality. The aim of this retrospective study was to investigate the impact of a previous osteoporotic low-impact (fragility) index fracture (eg, forearm, lower leg) on mortality of a subsequent femoral fracture.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Claims data of a German health insurance agency including >1.2 million insurants aged 65 years or older and observed between 2004 and 2009.
  
  
  METHODS
  A multistate model was developed handling index fractures and care need as time-dependent exposures, while age was chosen as the underlying time scale. Excess risks were expressed as differences in cause-specific hazards. Nelson-Aalen estimates were used for their nonparametric estimation. Time-simultaneous statistical inference was based on confidence bands provided by wild bootstrap resampling.
  
  
  RESULTS
  Excess femoral fracture risk increased with progressive age and was highest in persons with care need. It was observed starting from an age of 79 years in women and 85 years in men onward. A prior index fracture increased mortality after a femoral fracture by increasing femoral fracture risk, while leaving the hazard of death after a subsequent femoral fracture unchanged.
  
  
  CONCLUSIONS
  The results indicated that increased mortality of a subsequent femoral fracture is not triggered by an intrinsically increased mortality hazard but an increased femoral fracture incidence.
authors: Department of Mathematics and Economics, Institute of Statistics, Ulm University, Ulm, Germany.
authors: Tobias
authors: T
authors: Bluhmki
authors: Department of Medicine, Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany.
authors: Raphael Simon
authors: RS
authors: Peter
authors: Department for Geriatric Rehabilitation, Robert Bosch Krankenhaus, Stuttgart, Germany.
authors: Kilian
authors: K
authors: Rapp
authors: Department of Health Economics and Health Services Research, University Medical Center, Hamburg, Germany.
authors: Hans-Helmut
authors: HH
authors: König
authors: Department for Geriatric Rehabilitation, Robert Bosch Krankenhaus, Stuttgart, Germany.
authors: Clemens
authors: C
authors: Becker
authors: Department of Health Economics and Health Services Research, University Medical Center, Hamburg, Germany.
authors: Ivonne
authors: I
authors: Lindlbauer
authors: Department of Medicine, Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany.
authors: Dietrich
authors: D
authors: Rothenbacher
authors: Department of Mathematics and Economics, Institute of Statistics, Ulm University, Ulm, Germany.
authors: Jan
authors: J
authors: Beyersmann
authors: Department of Medicine, Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany. Electronic address: gisela.buechele@uni-ulm.de.
authors: Gisela
authors: G
authors: Büchele
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005264:Femoral Fractures / Q000209:etiology* / Q000401:mortality*; D005858:Germany / Q000453:epidemiology; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D018570:Risk Assessment / Q000706:statistics & numerical data; D014947:Wounds and Injuries
keywords: Osteoporotic fracture; excess mortality; multistate model; subsequent femoral fracture; wild bootstrap