Are hip fracture rates falling or rising over time? Using routine data to understand

the Epidemiology.

Scottish Faculty of Public Health Annual Conference, Aviemore. 10th November 2011

Gordon McLarenConsultant in Public Health Medicine, NHS Fife

Bryan Archibald, Senior Information Analyst, NHS Fife

Hip Fractures: Background

• Ageing population

• Hip fractures as a marker condition

• Importance of bone health and falls

• Balance of treatment as well as prevention

• Different findings from Scottish Hip Fracture Audit, Local Hospital Activity Data and ISD

The Problem and a way forward

Problem• Conflicting views from different sources about trends in

hip fractures (numbers and rates) in Fife• What is the correct picture?• How do trends compare across Scotland?• The need for an agreed, consistent approach to

understand the epidemiology of hip fractures

Potential Solution• Feasibility of using routine data to study epidemiology

Other sources of information

1. Scottish Hip Fracture Audit (SHFA) – link from ISD website. Focus on clinical practice http://www.shfa.scot.nhs.uk/

2. Scottish Clinical Indicators on the web (up to 2009): Focus on clinical outcomes not epidemiology: http://www.indicators.scot.nhs.uk/TrendsJuly09/Hip.html

3. ISD Acute Hospital Activity (episodes and incidences by diagnostic code) – from ISD Website. http://www.isdscotland.org/Health-Topics/Hospital-Care/Diagnoses/

4. NICE Guideline 124: The management of hip fracture in adults. June 2011

Scottish Hip Fracture Audit – now subsumed into wider programme

Aim of SHFA Data collection• SHFA included all patients aged 50 or over who

sustained a hip fracture, regardless of pathology or mechanism of injury. …”

• Data available up to 2008• Collection of new data suspended after 2008

when the resource was transferred to an audit of Musculoskeletal Access (MSK)

SHFA

SHFA and epidemiology

• the SHFA is a clinical audit system of the care of most hip fracture cases, not a register of all cases

• The SHFA is hospital-based not population-based.

• (e.g. ?what is the denominator population for a hospital?)

• main focus of SHFA is on health care – focussed on orthopaedics - and clinical outcomes, not epidemiology

ISD Acute Activity – by Diagnosis

• Population based numbers & rates, recent trends for episodes and incidence are already provided:

• Incidence based on: first occurrence of diagnosis with a 10 year look-back period.

• Fractures of Femur (ICD10 – S72) i.e. not only hip fracture.

• Figures hard to find – see http://www.isdscotland.org/Health-Topics/Hospital-Care/Diagnoses/

Proposed new approach

Methods

• ISD SMR01 dataset • Hip fractures admitted to hospital for residents of NHS

Boards (treated anywhere)– ICD9 code 820 and ICD10 codes S72.0 - S72.2, in any

diagnostic position– Episodes grouped into continuous inpatient stays

• 12 month follow-up period applied from the date of discharge from hospital– If the patient is readmitted within 12 months, admission classed

as related to initial admission. – A patient will not be counted more than once in any specific

year.• Agreement with local Geriatrician and Orthopaedic

surgeon in Fife• Analysis by NHS Board and Scotland

S72 – Fracture of Femur

S72.0 to S72.2 – Hip Fracture

Copyright: Caryln Iverson and NIH, USA

Definitions

ICD-9 820 Fracture Neck of FemurandICD-10 Code Description• S72.0 Fracture of neck of femur• S72.1 Pertrochanteric fracture• S72.2 Subtrochanteric fracture

Diagnostic position on SMR01 record• Any diagnostic position• Though NHS ISD uses first diagnostic position in Clinical

Outcomes indicators

Results

Scotland

Fife

Selected mainland Health Boards

Hip Fracture Incidence: Scotland. 65 and over. 1986 - 2009

YEAR NUMBER RATE (per 1000)

1986 4,460 6.00

1987 4,441 5.90

1988 4,862 6.43

1989 5,123 6.71

1990 5,063 6.62

1991 5,192 6.74

1992 5,319 6.87

1993 5,537 7.14

1994 5,423 6.98

1995 5,527 7.07

1996 5,652 7.20

1997 5,669 7.18

1998 6,028 7.61

1999 6,202 7.80

2000 5,991 7.49

2001 5,967 7.39

2002 6,083 7.48

2003 6,008 7.34

2004 5,903 7.14

2005 6,227 7.47

2006 5,921 7.07

2007 6,107 7.22

2008 6,202 7.24

2009 6,266 7.21

Highest rate

Numbers remain fairly steady since 1999

Summary

Scotland

• Hip Fracture rates rose from 6.0 in 1986 to 7.80 per 1000 in 1999 in over 65s, then slowly fell to 7.21 per 1000.

• Despite the ageing population the number of hip fractures has remained fairly stable since 1999, due to the reduction in fracture rate

Hip Fracture Incidence; 65 and over; SCOTLAND

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Hip

Fra

ctur

es

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

Hip Fracture Rate per 1000

Hip Fractures Rate per 1000

Source: ISD SMR01

Hip Fracture Incidence; 65 and over; FIFE

0

50

100

150

200

250

300

350

400

450

500

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Hip

Fra

ctur

es

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

Hip Fracture Rate per 1000

Hip Fractures Rate per 1000

Source: ISD SMR01

Hip Fracture Incidence; 65 and over; GG & C

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Hip

Fra

ctur

es

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

Hip Fracture Rate per 1000

Hip Fractures Rate per 1000

Source: ISD SMR01

Source: ISD SMR01

Hip Fracture Incidence; 65 and over; LOTHIAN

0

200

400

600

800

1,000

1,200

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Hip

Fra

ctur

es

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

Hip Fracture Rate per 1000

Hip Fractures Rate per 1000

Source: ISD SMR01

Hip Fracture Incidence; 65 and over; TAYSIDE

0

100

200

300

400

500

600

700

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Hip

Fra

ctur

es

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

Hip Fracture Rate per 1000

Hip Fractures Rate per 1000

Hip Fracture Incidence; 65 and over; FORTH VALLEY

0

50

100

150

200

250

300

350

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Hip

Fra

ctur

es

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

Hip Fracture Rate per 1000

Hip Fractures Rate per 1000

Source: ISD SMR01

Changes over time

Source: SMR01 Mainland NHS Boards only

1987-89 1997-99 2007-09 1987-89 1997-99 2007-09A & A 5.99 7.19 7.34 5 4 9BORDERS 5.91 6.06 6.25 3 2 1D & G 5.35 6.01 6.29 2 1 2FIFE 6.41 7.43 6.68 7 6 4FORTH VALLEY 5.93 7.65 6.53 4 8 3GG & C 6.47 7.82 7.75 8 10 12GRAMPIAN 7.19 7.98 7.22 12 11 6HIGHLAND 6.57 7.66 7.27 10 9 8LANARKSHIRE 5.06 7.01 7.14 1 3 5LOTHIAN 6.79 8.12 7.43 11 12 10SCOTLAND 6.35 7.53 7.23 6 7 7TAYSIDE 6.52 7.37 7.45 9 5 11

Rate per 1000 Rank (Lo to Hi)

Summary (NHS Boards)

• GG&C, Lothian NHS Boards have tended to have higher hip fracture rates over all time periods

• Borders and D&G have tended to have the lowest rates over three time periods

• The relative position of A&A, GG&C, Lanarkshire and Tayside NHS Boards has fallen (increased rates) by two or more places between 1997/99 and 2007/9.

• Fife, Forth Valley, Grampian and Lothian NHS Boards have improved relative position by 2 or more places since 1997/99

Possible Explanations

Not known, but reasons could include: • Focus on Falls and Fracture Prevention• Focus on Osteoporosis and Bone Health and

Bone health treatments• Less smoking, more physical activity?• Cohort effect in over 65 population? (fitter, less

likely to fall, less likely to fracture)• Data related issues?• Other factors?• A combination of factors

Conclusions

• Analysis shows value of using routine hospital activity data to describe the epidemiology of this key condition

• Analysis reminds us of the importance of prevention across the population

• Varying historic trends in mainland NHS Boards merit further consideration

• This approach should be considered for use on the ISD website

Comments and Discussion

• Do you agree with the approach?

• Are the results valid?

• What lies behind the trends shown?

• Do you think this type of analysis should be made more easily available?

• Any other comments?