Abstract

Femur fracture affects the elderly with high morbidity and mortality. The purpose of the present study was to analyze the profile of the assistance given to the elderly who have femoral fractures, relating to their socioeconomic and demographic conditions, in the state of Paraná between the years 2008 to 2013. These relationships were obtained through factor analysis and the development and analysis of the following rates: PAE - the potential of primary health care to the elderly, whose variable was represented by the contribution of the elderly to the municipal GDP, PAP - the potential of the primary health care to the population, represented by GDP per capita and TE - treatment efficiency represented by the annual rate of fractures and annual rate of death per residence. The municipalities were classified according to the rate variation range. In relation to PAE, 10 municipalities were classified with low potential of care for the elderly, 357 with moderate potential and 32 had low potential. In relation to PAE, 12 municipalities were classified with low potential of primary care for the elderly, 303 with moderate potential and 84 had low potential. In relation to TE, 109 municipalities showed high treatment efficiency, 110 with moderate efficiency and 180 had low efficiency. Our conclusion was that the performance of the economy exerts significant influence on femoral fracture morbidity in the elderly.

Key words
Femoral fractures; Aging; Socioeconomic conditions

Introduction

Brazil has been undergoing important demographic changes and there has been an acceleration in the aging of the population. In 2000, 5.61% of the population in the country was made up of people who were 65 years old or older and this number increased in 2010. The prediction is that it will reach 11.3% in 2025¹1. Instituto Brasileiro de Geografia e Estatística (IBGE). Projeções e estimativas da população do Brasil e das Unidades da Federação. 2016. [acessado 2016 Dez 30]. Disponível em: http://www.ibge.gov.br/apps/populacao/projecao/
http://www.ibge.gov.br/apps/populacao/pr... . The southern region has the most amount of elderly people (14.4%) in the country and in the state of Paraná this number represents 11.21% of the population²2. Instituto Paranaense de Desenvolvimento Econômico e Social (IPARDES). Caracterização do Território. Caderno Estatístico. 2015 [acessado 2016 Ago 7]. Disponível em: http://www.ipardes.pr.gov.br/index.php?pg_conteudo=1&cod_conteudo=30
http://www.ipardes.pr.gov.br/index.php?p... . This new scenery has raised concerns and as a result, it has been the focus of public policies due to the related morbidities for this age group, which is proving costly for the health system³3. Kernkamp CL, Costa CKF, Massuda EM, Silva ES, Yamaguchi MU, Bernuci MP. Perfil de morbidade e gastos hospitalares com idosos no Paraná, Brasil, entre 2008 e 2012. Cad Saúde Pública 2016; 32(7):1-13..

Femoral fractures have immerged as one of the main health problems associated with an aging population⁴4. Soares DS, Mello LM, Silva AS, Martinez EZ, Nunes AA. Femoral fractures in elderly Brazilians: a spatial and temporal analysis from 2008 to 2012. Cad Saúde Pública 2014; 30(12):2669-2678.^–66. Franco LG, Kindermann AL, Tramujas L, Kock KS. Factors associated with mortality among elderly people hospitalized due to femoral fractures. Rev Bras Ortop 2016; 51(5):509-514.. It is responsible for the high rates of morbidity and mortality⁷7. Karademir G, Bilgin Y, Erşen A, Polat G, Buget MI, Demirel M, Balcı HI. Hip fractures in patients older than 75 years old: Retrospective analysis for prognostic factors. Int J Surg 2015; 24(Pt A):101-104.^,88. Rosso F, Dettoni F, Bonasia DE, Olivero F, Mattei L, Bruzzone M, Marmotti A, Rossi R. Prognostic factors for mortality after hip fracture: Operation within 48 hours is mandatory. Injury 2016; 47(Supl. 4):S91-S97.. It has a negative effect on the quality of life of the elderly⁹9. Moloney GB, Pan T, Van Eck CF, Patel D, Tarkin I. Geriatric distal femur fracture: Are we underestimating the rate of local and systemic complications? Injury 2016; 47(8):1732-1736.^–1111. Khow KS, Shibu P, Yu SC, Chehade MJ, Visvanathan R. Epidemiology and Postoperative Outcomes of Atypical Femoral Fractures in Older Adults: A Systematic Review. J Nutr Health Aging 2017; 21(1):83-91.. Although changes in the bone density due to osteoporosis¹²12. Zhu L, Jiang X, Sun Y, Shu W. Effect of hormone therapy on the risk of bone fractures: a systematic review and meta-analysis of randomized controlled trials. Menopause 2016; 23(4):461-470.^–1414. Lucato P, Trevisan C, Stubbs B, Zanforlini BM, Solmi M, Luchini C, Girotti G, Pizzato S, Manzato E, Sergi G, Giannini S, Fusaro M, Veronese N. Nephrolithiasis, bone mineral density, osteoporosis, and fractures: a systematic review and comparative meta-analysis. Osteoporos Int 2016; 27(11):3155-3164. have been associated with incidents of fractures of the femur for the older people, little is known about the profile of morbidity during the different conditions.

Amongst the studies that have associated ethnic and demographic factors to fractures, particularly for older people, only a few have analyzed aspects connected to social and economic issues¹⁵15. Benetou V, Orfanos P, Feskanich D, Michaëlsson K, Pettersson-Kymmer U, Ahmed LA, Peasey A, Wolk A, Brenner H, Bobak M, Wilsgaard T, Schöttker B, Saum KU, Bellavia A, Grodstein F, Klinaki E, Valanou E, Papatesta EM, Boffetta P, Trichopoulou A. Education, marital status, and risk of hip fractures in older men and women: the CHANCES project. Osteoporos Int 2015; 26(6):1733-1746.^–1818. Oliveira CM, Alves SM, Pina MF. Marked socioeconomic inequalities in hip fracture incidence rates during the Bone and Joint Decade (2000-2010) in Portugal: age and sex temporal trends in a population based study. J Epidemiol Community Health 2016; 70(8):755-763. and even fewer have evaluated the influence of income¹⁹19. Oliveira CM, Economou T, Bailey T, Mendonça D, Pina MF. The interactions between municipal socioeconomic status and age on hip fracture risk. Osteoporos Int 2015; 26(2):489-498.^,2020. Kristensen PK, Thillemann TM, Pedersen AB, Søballe K, Johnsen SP. Socioeconomic inequality in clinical outcome among hip fracture patients: a nationwide cohort study. Osteoporos Int 2016; 28(4):1233-1243.. Evidence of the positive effects of wealth on the offer of services and the availability of infrastructure in health²¹21. Bassani DG, Corsi DJ, Gaffey MF, Barros AJ. Local distributions of wealth to describe health inequalities in India: a new approach for analyzing nationally representative household survey data, 1992-2008. PLoS One 2014; 30; 9(10).^–2323. Mullachery P, Silver D, Macinko J. Changes in health care inequity in Brazil between 2008 and 2013. Int J Equity Health 2016; 17;15(1):140., reinforces the interference of socioeconomic development in the profile of morbidities.

In this way, we understood that health care outcomes are determined by different life cycles and constructed by one's social, economic and environment conditions impacting on a person's quality of life particularly when the individual reaches senescence²⁴24. Geib LT. Social determinants of health in the elderly. Cien Saude Colet. 2012; 17(1):123-33.^–2727. RUBIN L. Social Determinats of Health. In: Rubin L, Merrick j, Greydanus DE, Patel DR, organizadores. Health Care for People with Intellectual and Developmental Disabilities across the Lifespan. Suiça: Springer, 2016, p. 1919-1932, 2016.. Therefore, the purpose of this study was to analyze the profile of morbidity for femoral fractures affecting the elderly and its relationship with socioeconomic and demographic conditions in the state of Paraná between the years 2008 to 2013.

Methods

This was a quantitative study that was also retrospective and inter-disciplinary. The population in the study was made up of data on older people being 60 years old or older victims of femoral fractures resulting in a hospital admission between January 2008 and December 2013 on the Brazilian National Health System (SUS) in the municipalities of the state of Paraná. We obtained approval from the ethics committee on research at the Centro Universitário de Maringá under number 1.359.807.

The information was collected from the a public database through the program TabNet (version 3.6 of TAB for Windows), available from the SUS Information Technology Department – DATASUS²⁸28. Brasil. Ministério da Saúde. Portal da Saúde – DATASUS. Informações de Saúde. Tabnet [Internet]. 2008-2013 [acessado 2015 Maio 04]. Disponível em: http://www2.datasus.gov.br/DATASUS/index.php
http://www2.datasus.gov.br/DATASUS/index... (http://www2.datasus.gov.br/DATASUS/index.php), which refers to hospital admissions (SIH) of elderly people on SUS. The following data was collected: age of the elderly people, year of hospital admission, classification in accordance with the code for the International Classification of Disease (ICD 10)²⁸28. Brasil. Ministério da Saúde. Portal da Saúde – DATASUS. Informações de Saúde. Tabnet [Internet]. 2008-2013 [acessado 2015 Maio 04]. Disponível em: http://www2.datasus.gov.br/DATASUS/index.php
http://www2.datasus.gov.br/DATASUS/index... , the number of deaths per residence and the number of femoral fractures per area of residence.

The data referring to the Human Development Index (HDI), the Municipal Human Development Index (MHDI), the Gross Domestic Product (GDP) and the GDP per capita, were obtained from the Instituto Paranaense de Desenvolvimento Econômico e Social – IPARDES²⁹29. Instituto Paranaense de Desenvolvimento Econômico e Social (IPARDES). Indicadores [Internet]. 2008-2013 [acessado 2015 Out 13]. Disponível em: http://www.ipardes.gov.br/index.php?pg_conteudo=1&cod_noticia=701.
http://www.ipardes.gov.br/index.php?pg_c... (http://www.ipardes.gov.br/) and the Instituto Brasileiro de Geografia e Estatística – IBGE³⁰30. Instituto Brasileiro de Geografia e Estatística – IBGE. [Internet] Histórico Infográgico [acessado 2016 Ago 07]. Disponível em: http://ibge.gov.br/cidadesat/painel/historico.php?lang=&codmun=412627&search=parana|saudade-do-iguacu|infograficos:-historico
http://ibge.gov.br/cidadesat/painel/hist... – (http://www.ibge.gov.br/home/) from 399 municipalities in the state of Paraná. For this study, the GDP of the municipalities was divided by the number of elderly people resident in each one of them in order to fully understand the effect of the differences in the proportion of the elderly. In this way, the level of wealth in the municipalities represented by their GDP was obtained in such a way that so as to take into account the elderly population.

Typology of the municipalities do state do Paraná

For the construction of the typology of the homogenous groups in the municipalities, the multivariate Factor Analysis technique was primarily used (AF). The main purpose of this step was to obtain the factor scores. AF identifies the relatively small factor number that can be used to represent the relationships between many variables that are inter-related. The mathematical model is similar to the multiple regression equation; where every variable is expressed as a linear combination of non-observed factors:

Where:

A_ij = factor load;

F₁, F₂,…, F_m = common factors;

ε₁, ε₁,…, ε_p = errors or specific factors.

Although it is possible that all of the variables contribute to a determined factor, only a sub-group from them will actually characterize it. Thus the factor model assumes that the variables can be grouped by their correlations to which they belong, being the same group that is highly co-related to each other. Subsequently and based of the factor scores, we calculated the three rates: potential of care to elderly people (PAE), potential of care to the population (PAP) and efficiency of the treatment (TE). For the calculation of the index, we used the following expression:

Based on the index that we created, the municipalities were classified in one of three groups. In Chart 1 the interval variation of the index for each group has been presented.

In this case, the higher the value of the obtained index, the better the classification of the municipality in relation to PAE and PAP. For the TE index, the best efficiency is shown by the lowest values. Three groups of municipalities were set out.

Characterization of the municipal groups

The description of the homogenous groups consisted of frequency tables and descriptive measures such as averages, standart deviation. The data was analyzed using the program Statistical Analysis Software (SAS, version 9.4) based on a database that was developed using the Excel³²32. Stokes ME, Davis CS, Koch GG. Categorical data analysis using SAS system. USA: SAS Institute Inc. 2000. application.

Grouping of the municipalities

Based on the matrix data whose columns contain information of: the per capita GDP (pp2008, pp2009, pp2010, pp2011, pp2012 e pp2013), municipal GDP (pm2008, pm2009, pm2010, pm2011, pm2012 e pm2013), annual rate of fractures (%), (TFLR), the annual rate of deaths (%), (TOLR) and the survival rate (TSOB) per residency for the years 2008 to 2013 carried out the AF. We adopted the Kaiser criteria to choose the factors to retain (eigenvalue higher than 1) for choices of the factor numbers.

The AF model showed good adjustments (KMO = 0.75) and it was possible to identify three factors which explained 85.52% of the variance total for the data. In Table 1, it is possible to evaluate the three retained factors. The first eigenvalue (λ₁ = 7,11) explained 47.40% of the total variance and this is related to the PAE shown in the municipal GDP. The second eigenvalue (λ₂ = 3.94) explained 26.32% of the variation total as shown in the PAP results and this was represented by the per capita GDP in the municipality. The third eigenvalue (λ₂ = 1.77) explained the 11.80% of the total variance shown in the TE results as it was represented by the TFLR per 1000 as well as by the TOLR per 1000 and TSOB per 100%.

Results

In relation to the PAE, the municipalities were placed into three groups. The first was made up of municipalities (n = 10) that showed a high level of PEA (PAE ≥ 10). The second by municipalities (n = 357) which was moderate (5 ≤ PAI < 10) and the third (n = 32) by those being low (PAE < 5) (Figure 1).

For the PAP, three groups were also considered. The first one was made up of municipalities (n = 12) that showed a high level of PAP (PAP ≥ 20). The second by municipalities (n = 303) which were moderate (10 ≤ PAP < 20) and the third (n = 84) by those being low PAP (PAP < 10) (Figure 2).

For the TE, three groups were considered. The first was made up of municipalities (n = 109) that showed a high level of TE (TE ≥ 20). The second by municipalities (n = 110) which were moderate (10 ≤ TE < 20) and the third (n = 180) by those being low (TE < 10) (Figure 3).

Discussion

The PAE retained the municipal GDP as the main explanatory variable. The GDP represents the economic activity of the municipalities and it reflects, therefore, the production of goods and services for each of them in monetary terms²⁹29. Instituto Paranaense de Desenvolvimento Econômico e Social (IPARDES). Indicadores [Internet]. 2008-2013 [acessado 2015 Out 13]. Disponível em: http://www.ipardes.gov.br/index.php?pg_conteudo=1&cod_noticia=701.
http://www.ipardes.gov.br/index.php?pg_c... . It is one of the most used indicators in the area of economics to measure economic activity in a region, such as the higher the GDP, higher is the generated wealth of the municipality, state or country. Theoretically, there is the assumption that the municipal GDP represents the resources that the municipality has and can be used in investments and actions directed towards the elderly³⁰30. Instituto Brasileiro de Geografia e Estatística – IBGE. [Internet] Histórico Infográgico [acessado 2016 Ago 07]. Disponível em: http://ibge.gov.br/cidadesat/painel/historico.php?lang=&codmun=412627&search=parana|saudade-do-iguacu|infograficos:-historico
http://ibge.gov.br/cidadesat/painel/hist... .

In group I, there is a list of the most developed municipalities in terms of economic activity, showing the highest demographic density and it represented, in its majority, the highest values of the municipal GDP in the state. These municipalities occupy primary positions in the state ranking: 1^st Curitiba, 2^nd São José dos Pinhais, 3^rd Londrina, 4^th Araucária, 5^th Maringá, 6^th Ponta Grossa, 7^th Foz do Iguaçú, 8^th Cascavel, 9^th Paranaguá and 10^th Pinhais³³33. Instituto Brasileiro de Geografia e Estatística – IBGE [Internet]. Produto Interno Bruto dos Municípios [acessado 2016 Dez 30]. Disponível em: http://www.ibge.gov.br/home/estatistica/economia/pibmunicipios/2010_2013/default.shtm
http://www.ibge.gov.br/home/estatistica/... . The most populous municipalities have better infrastructure and are less dependent on the state or the union because they have a greater capacity to generate their own income³⁴34. Barbosa OC, Nascimento SP, Dalmas JC. Uma Análise das condições de saúde nos municípios paranaense. Rev. Economia & Região 2015; 1(2):47-71..

In group II for the moderate PAE, we observed that the majority of the municipalities are situated around those with the most amount of economic activity. The supposition is that the population take advantage of the infrastructure and services in the exiting health system in the municipalities of group I which has favorable repercussions on the state of the health of the elderly population in group II³⁵35. Kernkamp CL, Costa CKF, Massuda EM, Silva ES, Yamaguchi, MU, Bernuci, MP. Perfil de morbidade e gastos hospitalares com idosos no Paraná, Brasil, entre 2008 e 2012. Cad Saúde Pública 2016; 32(7):1-14.^,3636. Bortolon PC, Andrade CLT, Andrade CAF. O perfil das internações do SUS para fratura osteoporótica de fêmur em idosos no Brasil: uma descrição do triênio 2006-2008. Cad Saúde Pública 2011: 27(4):733-42..

The association between health and income was discussed in a Preston³⁷37. Preston SH. The Changing Relation between Mortality and Level of Economic. Development Population Studies 1975: 29(2):231-48. article that identified a strong correlation between life expectancy and the per capita national income, showing a positive relationship between the variables. The richest countries have higher life expectancy in comparison to the poorest ones. This shows the benefits of economic growth on health ³⁸38. Pelegrini ML, Castro JD. Expectativa de vida e gastos públicos em saúde. Análise Econômica 2012; 30(n. especial):97-107.^–4040. Hajebi, E, Javad, RM. Effect of Income Inequality on Health Status in a Selection of Middle and Low Income Countries. Equilibrium. Quarterly Journal of Economics and Economic Policy 2014; 9(3):133-152..

In addition to wealth, access to basic goods for investment in infrastructure and the surrounding areas which includes: the provision of clean water, sanitation, electricity, pavements, communication lines, urban planning, transport, and markets are essentials for promotion of a healthy life style⁴¹41. Carvalho, AI. Determinantes sociais, econômicos e ambientais da saúde. In: Fundação Oswaldo Cruz, organizador. A saúde no Brasil em 2030 - prospecção estratégica do sistema de saúde brasileiro: população e perfil sanitário. Rio de Janeiro: Fiocruz/Ipea/Ministério da Saúde/Secretaria de Assuntos Estratégicos da Presidência da República, 2013. v. 2, p. 19-38.. Data shows that the actions of SUS do not have a direct relationship with the low income of the municipality and its mico-regions²²22. Cielo ID, Schmidr CM, Wenningkamp KR. Políticas Públicas de Saúde no Brasil: Uma Avaliação do IDSUS no Estado do Paraná. DRD – Desenvolvimento Regional em Debate 2015; 5(1):211-220.. It was notable that the low level of development of a population does not necessarily reflect the scarcity of financial resources. If this were the case, all of the areas of need in the municipality would no longer be in need due to economic growth⁴²42. Rosado PL, Rossato MV, Lima JE. Análise do Desenvolvimento Socioeconômico das Microrregiões de Minas Gerais. Revista Econômica do Nordeste 2009: 40(2). p.297-310.^,4343. Organization for Economic Co-operation and Development - OECD. Growing Unequal? Income distribution and poverty in OECD countries. Geneva: OECD 2008..

According to the results that were found referring to PAE, income constitutes an important explanatory factor as a socioeconomic variable in femoral fractures. In spite of not being able to attribute this just to any direct relationship, the supposition is that growth and economic performance contribute in a decisive way, to the well-being and health of the elderly. This may occur in a tangible way in the construction of physical structures through the facilitation of access to various environments or through consolidated primary health which takes the form of the provision of information, explanations and empowerment amongst other things. These are all essential for facilitating access to these universal actions.

An elevated GDP provides the possibility for the widening of investments in health on the part of the municipalities, which is legally backed by the Constitutional amendment 29 of 13 September 2000 which establishes the co-participation of the Union, states and municipalities in financing SUS. The participation of the Union is connected to the performance of the GDP and the municipalities allocate a part of their tax receipts that come from the property tax for public actions and services in health⁴⁴44. Brasil. Ministério da Saúde (MS). Gestão Financeira do Sistema Único de Saúde - Manual Básico. Brasília: MS; 2003..

The positioning of the municipalities in the different groups of the PAP, manifets their economic activity and inter-relations (GDP) as well as the number of their inhabitants. This being the case, a greater population relative to the generation of wealth, spreads itself and puts the large and richest municipalities in an inferior position in the groups⁴⁵45. van Deurzen I, van Oorschot W, van Ingen E (2014) The Link between Inequality and Population Health in Low and Middle Income Countries: Policy Myth or Social Reality? Plows One 2014; 9(12):1-22.. Going beyond a certain level of the per capita GDP, the way of the distribution of wealth has become more important for explaining the health situation of the population⁴⁶46. Buss PM, Pellegrini Filho A. Iniquidades em saúde no Brasil, nossa mais grave doença: comentários sobre o documento de referência e os trabalhos da Comissão Nacional sobre Determinantes Sociais da Saúde. Cad Saúde Pública 2006; 22(9):2005-2008.. This finding came from Preston³⁷37. Preston SH. The Changing Relation between Mortality and Level of Economic. Development Population Studies 1975: 29(2):231-48. affirming that at higher levels of income generation that supersedes certain limits, there is little correspondence between life expectancy and the national income⁴⁷47. Jakubowska A, Horváthová. Economic Growth and Health: a Comparative Study of the EU Countries, Economics and Sociology 2016 (3):158-168.^–4949. Husain, MJ. Revisiting the Preston Curve: An Analysis of the Joint Evolution of Income and Life Expectancy in the 20th Century [Internet], USA: Keele Univesity, 2011. [acessado 2015 Out 13]. Disponível em: https://www.keele.ac.uk/media/keeleuniversity/ri/risocsci/docs/economics/workingpapers/LeY_KeeleEconWP_JamiHusain.pdf
https://www.keele.ac.uk/media/keeleunive... .

The social cohesion and political participation policies are factors that have impacts on the health situation of the population. Major income inequalities cause low levels of social cohesion and low political participation which results in less investment in human capital and social support networks. These are considered primordial elements for the promotion and protection of health⁴⁶46. Buss PM, Pellegrini Filho A. Iniquidades em saúde no Brasil, nossa mais grave doença: comentários sobre o documento de referência e os trabalhos da Comissão Nacional sobre Determinantes Sociais da Saúde. Cad Saúde Pública 2006; 22(9):2005-2008.. In this way, the association between democratic governance and health suggests that the political situation of the societies can be an important determinant for the health of the population⁵⁰50. Krueger PM, Dovel, K, Denney, JT. Democracy and Self-Rated Health across 67 Countries: A Multilevel Analysis. Soc Sci Med. 2015 Oct; 143: 137–144..

The municipalities with moderate TE in addition to having a greater proportion of elderly people probably receive people from neighboring metropolitan cities that are small for health treatment. In these localities we find a greater concentration of elderly people in absolute numbers (above 80 years old)³³33. Instituto Brasileiro de Geografia e Estatística – IBGE [Internet]. Produto Interno Bruto dos Municípios [acessado 2016 Dez 30]. Disponível em: http://www.ibge.gov.br/home/estatistica/economia/pibmunicipios/2010_2013/default.shtm
http://www.ibge.gov.br/home/estatistica/... . Population longevity increase the femur fractures ⁵¹51. Stolnicki B, Oliveira LG. Para que a primeira fratura seja a última. Rev. Bras Ortop. 2016; 51(2):121-126. and the higher the age, the higher the risk of fractures in elderly people.

Conclusion

The profile of assistance given to the femoral fractures in Paraná for elderly is associated with the production of wealth, represented by the municipal older people GDP and by the per capita GDP. This has led us to the conclusion that economic factors play a significant role in the health of the population particularly for elderly people. In relation to the efficiency of the treatment of femoral fractures, indicates that the presence of long-lived elderly people carry on some influence on this factor.

References

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