1. Are hip fracture rates falling or rising over time? Using routine data to understand the Epidemiology. Scottish Faculty of Public Health Annual Conference, Aviemore. 10 th November 2011 Gordon McLaren Consultant in Public Health Medicine, NHS Fife Bryan Archibald, Senior Information Analyst, NHS Fife

2. 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

3. 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

4. Other sources of information 1.Scottish Hip Fracture Audit (SHFA) – link from ISD website. Focus on clinical practice http://www.shfa.scot.nhs.uk/ 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.htm l http://www.indicators.scot.nhs.uk/TrendsJuly09/Hip.htm l 3.ISD Acute Hospital Activity (episodes and incidences by diagnostic code) – from ISD Website. http://www.isdscotland.org/Health-Topics/Hospital- Care/Diagnoses/ http://www.isdscotland.org/Health-Topics/Hospital- Care/Diagnoses/ 4.NICE Guideline 124: The management of hip fracture in adults. June 2011

5. 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)

6. SHFA

7. 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

8. 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/ http://www.isdscotland.org/Health- Topics/Hospital-Care/Diagnoses/

10. Proposed new approach

11. 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

12. S72 – Fracture of Femur S72.0 to S72.2 – Hip Fracture Copyright: Caryln Iverson and NIH, USA

13. Definitions ICD-9 820 Fracture Neck of Femur and ICD-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

14. Results Scotland Fife Selected mainland Health Boards

15. Hip Fracture Incidence: Scotland. 65 and over. 1986 - 2009 Highest rate Numbers remain fairly steady since 1999

16. 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

17. Source: ISD SMR01

23. Changes over time Source: SMR01 Mainland NHS Boards only

24. 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

25. 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

26. 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

27. 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?