1. Bridging the Gap Between Clinical and Community Research: Assessing the Association between Fracture Rates in Children and Neighborhood Factors Leticia Ryan, MD 1,2, Jichuan Wang, PhD 2, Mark Guagliardo, PhD 2, Jennifer Marsh, PhD 2, Steven Singer, MD 2, Joseph Wright, MD,MPH 1,2,3, Stephen Teach, MD, MPH 1,2, James Chamberlain, MD 1,2 1 Division of Emergency Medicine, 2 Center for Clinical and Community Research, 3 Child Health Advocacy Institute, Children’s National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC

2. Background: Pediatric bone fractures –Are increasing in incidence 1 Person-level factors –Are associated with increased risk –Relate to lower bone mineral density physical inactivity 2 /obesity 3 poor nutrition 4 poor vitamin D status 5 –May not account for all population variation in risk

3. Background Neighborhood factors –Have been found for many diseases including adult hip fracture. 6 –No published studies have evaluated the role of neighborhood factors in childhood fractures.

4. Study Overview OBJECTIVE: –to evaluate the relationship between fracture rates in children and neighborhood factors HYPOTHESIS: –Certain neighborhood factors will be either positively or negatively associated with local fracture rates.

5. Design/Methods Retrospective cohort study with IRB approval Billing records used to identify fracture visits: –ages 0-17 –residence in Washington DC –evaluated for bone fracture in the Children’s National Medical Center Emergency Department between January 1, 2003 and December 31, 2006

6. Design/Methods Addresses converted to point locations using Geographical Information Systems (GIS) software Chart review of multiple fracture visits for an individual subject to exclude: –Visits of patients with bone mineralization disorders –Follow up visits for the same fracture event

7. Design/Methods Unit of Analysis: census block group (CBG) –areas of DC with > 80% catchment at our facility –minimum CBG population of 250 Fracture rate estimations: Fracture rates calculated for each CBG using year 2000 census data

8. Design/Methods Neighborhood factor analysis: –Variables extracted from year 2000 census data –Correlation matrix searched to identify clusters of variables –Each cluster represented as a linear combination of its constituent variables (factor) –Factor scores served as predictor variables in regression models of fracture rate with control for race, sex and age within the CBGs

9. Results FRACTURE VISITS PRESENT IN STUDY CBGs 3462 (80%) FRACTURE VISITS AFTER CHART REVIEW 3900 (90%) FRACTURE VISITS MAPPED 4081 (94%) FRACTURE VISITS IDENTIFIED 4343 INITIAL: 361 CENSUS BLOCK GROUPS FINAL: 349 CENSUS BLOCK GROUPS (97%)

10. Results NEIGHBORHOOD FACTOR ODDS RATIO95% CONFIDENCE INTERVAL F1- RACE/EDUCATION1.2711.139-1.418 F2- UNEMPLOY/POVERTY0.9470.891-1.007 F3- IMMIGRANTS0.9570.900-1.018 F4- RENTALS1.0210.968-1.077 F5- LARGE FAMILIES1.1141.056-1.176 F6- CROWDING1.0400.976-1.109 F7- SENIORS0.9070.856-0.963

11. Fracture Cases and Relationship to Factor 1- Race/Education WASHINGTON DC

12. Discussion A race and education factor was significantly associated with increased fracture risk. This factor correlated to neighborhoods with long term blue collar African American residents with lower education levels. –? Vitamin D insufficiency –? Lower dietary intake of calcium –? obesity

13. Conclusions These preliminary results demonstrate that neighborhood factors are associated with risk patterns for bone fracture in children. This is an essential first step in the development of targeted community-based strategies for fracture prevention.

14. Future direction Because forearm fractures may represent a particular fracture location reflecting bone health deficit, future analysis will focus on the subgroup of approximately 1000 children with isolated forearm fracture. Additionally, we are conducting a case-control study to evaluate person-level risk factors for childhood fracture related to bone health.

15. Acknowledgements Primary Mentorship: James Chamberlain, MD Division Chief, Division of Emergency Medicine Children’s National Medical Center This study is funded in part by:  National Institutes of Health National Center for Research Resources (1K23 RR024467-01)  Children’s Research Institute Children’s National Medical Center Research Advisory Council Grant

16. Selected References 1. Khosla S, et al. Incidence of childhood distal forearm fractures over 30 years: a population-based study. JAMA. 2003; 290: 1479-1485. 2. McKay HA, et al. Augmented trochanteric bone mineral density after modified physical education classes: a randomized school-based exercise intervention study in prepubescent and early pubescent children. J Pediatr 2000; 136: 156-162. 3. Goulding A, et al. Bone mineral density and body composition in boys with distal forearm fractures: a dual-energy x-ray absorptiometry study. J Pediatr 2001; 139: 509-515. 4. Ma D, Jones G. The association between bone mineral density, metacarpal morphometry, and upper limb fractures in children: a population-based case- control study. J Clin Endocrinol Metab. 2003; 88: 1486-1491. 5. Valimaki VV, et al. Vitamin D status as a determinant of peak bone mass in young Finnish men. J Clin Endocrinol Metab 2004; 89: 76-80. 6. Reimers A, Laflamme L. Hip fractures among the elderly. J Trauma. 2007; 62: 365-369.