Elsevier

Injury

Volume 51, Issue 4, April 2020, Pages 1011-1014
Injury

Hip fractures in the winter – Using the National Hip Fracture Database to examine seasonal variation in incidence and mortality

https://doi.org/10.1016/j.injury.2020.02.088Get rights and content

Highlights

  • Data describing the care and outcome for nearly half a million patients are freely available on the National Hip Fracture Database website www.nhfd.co.uk.

  • The incidence of hip fracture shows marked seasonal variation, with a winter peak that is 8% higher than the summer.

  • Patients presenting in January have a risk of dying in the following 30 days that is 30% higher than for those presenting in July

  • A typical trauma unit can expect to see several additional cases of hip fracture and two additional deaths in the winter months.

Abstract

We set out to examine the implications of seasonal variation in hip fracture for trauma services and for the frail older people who typically suffer this injury.

Since 2007 the National Hip Fracture Database (NHFD) has been reporting data for all over-60 year old patients presenting in England, Wales and Northern Ireland. We analysed published NHFD data for the 450,764 people who presented during the seven years from April 2011 to March 2018.

We found marked seasonal variation in the number of people presenting: 8% more people presenting in the winter months (December-February) than in the summer (June-August).

The total number of people dying within 30 days of hip fracture was 30.5% higher among those presenting in these winter months. In total 33,649 people (7.5%) died within 30 days of hip fracture, but this figure varied significantly (p < 0.001, Chi2 test); ranging from 6.7% in July to 8.7% (30% higher) in January.

The public health impact of these findings is significant. An 8% increase in hip fracture numbers during the winter would equate with 1250 additional fractures during these months each year. Patients average over 20 days in hospital, so these additional cases will compound the stresses on hospital services over the Christmas and New Year holiday period. Such factors must be taken into consideration when organising trauma services if we are to try and avoid the additional 325 deaths that we found to occur each winter.

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.

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