Hip fractures in the winter – Using the National Hip Fracture Database to examine seasonal variation in incidence and mortality
Introduction
Each year around 66,000 people in England, Wales and Northern Ireland will suffer a hip fracture [1], making this the commonest reason for an older person to need emergency anaesthesia and surgery and is the commonest cause of accidental death.
This high incidence combined with a an average length of stay of three weeks [2] means that at any one time over 3600 hospital beds are occupied by people recovering from hip fracture; an annual NHS bed occupancy of 1.3 million bed days. Hip fracture is associated with total hospital costs of over £1 billion per year; equivalent to about 1% of the whole NHS budget [3].
The NHFD has overseen a progressive improvement in mortality after hip fracture; from 10.9% in 2007 [4] to 6.1% in 2019 [1] (Fig. 1). Improvements in anaesthetic, surgical and multidisciplinary care mean that almost all patients are now offered surgery, and that even patients in the highest anaesthetic risk categories face a mortality of less than 1% on the day of surgery [5]. However, recovery after surgery and rehabilitation often prove challenging as the average patient is an 80 years old, with at least one significant medical or psychiatric problem. This is a group of people who were at increased risk of dying even before they sustained a hip fracture. The physiological and psychological stress of surgery and inpatient care mean that up to a third of patients can be expected to die within a year of hip fracture, a third of these during their time in hospital [1].
We have previously identified significant seasonal variation in the incidence of hip fracture [6], and in this study we set out to examine how this variation might affect trauma services in the winter months, and whether increased pressures on the service are reflected in an increased risk of patients dying at this challenging time of the year.
Section snippets
Methodology
This prospective cohort study used data that had been collected by the national clinical audit of hip fracture care in England, Wales and Northern Ireland; the National Hip Fracture Database (NHFD). The NHFD captures over 95% of all patients over 60 years of age who present with hip fracture to all 175 trauma units in these countries.
These patients’ demographic data, fracture type, assessment, medical and surgical care and outcomes are collected and submitted by the clinical staff who provide
Results
During the seven years from April 2011 to March 2018 the NHFD has published data for 450,764 over-60 year old patients who presented with hip fracture; over 95% of all hip fracture cases in England, Wales, and Northern Ireland.
The NHFD recorded a gradual increase in the total number of hip fractures presenting each year over this period; from 60,442 in the year from April 2011, to 66,949 in the year from April 2018. In spite of this, the annual number of deaths in the 30 days after hip fracture
Discussion
The public health impact of these findings is significant. An 8% increase in hip fractures during the winter months would equate with 1250 additional people presenting with hip fracture each year.
The variability in hip fractures during the year can only be fully understood through examination of the mechanism of fractures and the falls causing the injury. Our work does not have direct access to such information, but the reasons that might underlie seasonality of hip fracture have been discussed
Declaration of Competing Interest
The first author is clinical lead for the NHFD, but this analysis was performed independently by his clinical colleagues – only using data that was already in the public domain on www.nhfd.co.uk.
Acknowledgements
This work was entirely based on the data made freely available on the NHFD website. We are particularly grateful to Tim Bunning at Crown Informatics for his development of that website – so that it could provide both the stimulus and the data for this work.
References (28)
- et al.
The seasonality of hip fracture and its relationship with weather conditions in New South Wales
Aust J Public Health
(1995) - et al.
Epidemiology of hip fracture in the elderly in Spain
Bone
(2008) - et al.
Seasonal variation of proximal femoral fractures in the United Kingdom
Injury
(2003) - et al.
Seasonal variation of hip fracture at 3 latitudes
Injury
(2000) - (2019)
- (2017)
- et al.
Impact of hip fracture on hospital care costs: a population based study
Osteoporos Int
(2015) - et al.
The impact of a national clinician-led audit initiative on care and mortality after hip fracture in England: an external evaluation using time trends in non-audit data
Med Care
(2015) - et al.
Understanding mortality rates after hip fracture repair using ASA physical status in the National Hip Fracture Database
Anaesthesia
(2017) - et al.
Diurnal and seasonal patterns in presentations with hip fracture – data from the national hip fracture database
Age Ageing
(2016)