Abstract
Introduction
This study examined seasonal variations in hip fracture rates using nation-wide, population-based data from Taiwan, a subtropical island with fairly uniform weather conditions (mean ambient temperature difference of 11.3°C between peak summer and peak winter months).
Methods
All inpatients aged 45+ years included in the National Health Insurance Database between 1997 and 2003 and bearing an ICD diagnosis code 820 (fracture neck of femur) were included (n=102,792 cases).
Results
Auto-regressive integrated moving average (ARIMA) modeling showed significant seasonality and an association of monthly hip fracture admission rates with ambient temperature among both sexes and all three age groups, 45–64, 65–74, and 75+ years. Crude rates show a significant trough during May–August (late spring and summer), followed by a sharp increase in September, and a discernible peak during November–February (late autumn and winter). Adjusted for seasonality, trend, and month, hip fracture rates are significantly reduced among males (b=−0.280, p<0.001) and females (b=−0.341, p<0.001) with increases in the mean ambient temperature. The protective effect of temperature intensifies with age (b=−0.010, −0.241 and −2.263 among the groups aged 45–64, 65–74, and 75+ years, respectively). January (mid-winter) is independently associated with 0.339, 0.663 and 8.153 more hip fractures, respectively, among the three age groups, beyond the temperature effect noted above, and May (late spring) is associated with 0.168, 1.364, and 7.255 fewer fractures. Hours of sunshine and atmospheric pressure were not significant predictors.
Conclusions
Based on our ARIMA regression coefficients for temperature, January, and May, we estimate that 32.1% of total hip fractures in January (the peak incidence month) are attributable to the season effect among seniors aged 75+ years, 17.2% among those aged 65–74 years, and 11.5% among those aged 45–64 years. We find that in a sub-tropical climate the effects of winter on hip fracture propensity is significant and increases with age. The policy implications are discussed.
Similar content being viewed by others
References
Chang KP, Center JR, Nguyen TV, Eisman JA (2004) Incidence of hip and other osteoporotic fractures in elderly men and women: dubbo osteoporosis epidemiology study. J Bone Miner Res 19:532–536
Braithwaite RS, Col NF, Wong JB (2003) Estimating hip fracture morbidity, mortality and costs. J Am Geriatr Soc 51:364–370
Delmas PD, Fraser M (1999) Strong bones in later life: luxury or necessity? Bull World Health Organ 77:416–422
Maggi S, Kelsey JL, Litvak J, Heyse SP (1991) Incidence of hip fractures in the elderly: a cross-national analysis. Osteoporos Int 1:232–241
US Department of Health and Human Services (1984) Detail diagnosis and surgical procedures for patients discharged from short stay hospitals. Washington, D.C.
Gullberg B, Johnell O, Kanis JA (1997) World-wide projections for hip fracture. Osteoporos Int 7:407–413
Population Reference Bureau (2004) The 2003 World Population Data Sheet. Accessed on August 8, 2005 at http://www.prb.org/pdf04/04WorldDataSheet_Eng.pdf
World Health Organization (2004) Prevention and management of osteoporosis. Report of the WHO Scientific Group held in Geneva April 7–10, 2000, published by the WHO Executive Board, 114 Session, April 13, 2004
Bhattoa HP, Bettembuk P, Ganacharya S, Balogh A (2004) Prevalence and seasonal variation of hypovitaminosis D and its relationship to bone metabolism in community dwelling postmenopausal Hungarian women. Osteoporos Int 15:447–451
Kim JH, Moon SJ (2000) Time spent outdoors and seasonal variation in serum concentrations of 25-hydroxyvitamin D in Korean women. Int J Food Sci Nutr 51:439–451
Muenier P (1996) Prevention of hip fractures by correcting calcium and vitamin D insufficiencies in elderly people. Scand J Rheumatol Suppl 103:75–78
Dukas L, Staehelin HB, Schacht E, Bischoff HA (2005) Better functional ability in community dwelling elderly is related to D-hormone serum levels and to daily calcium intake. J Nutr Health Aging 9:347–351
Bischoff HA, Staehelin HB, Dick W, Akos R, Knecht M, Salis C, Nebiker M, Theiler R, Pfiefer M, Begerow B, Lew RA, Conzelmann M (2003) Effects of vitamin D and calcium supplementation on falls: a randomized controlled trial. J Bone Miner Res 18:1342
Jacobsen SJ, Goldberg J, Miles TP, Brody JA, Stiers W, Rimm AA (1991) Seasonal variation in the incidence of hip fracture among white persons aged 65 years and older in the United States, 1984–1987. Am J Epidemiol 133:996–1004
Mirchandani S, Aharonoff GB, Hiebert R, Capla EL, Zuckerman JD, Koval KJ (2005) The effects of weather and seasonality on hip fracture incidence in older adults. Orthopedics 28:149–155
Chesser TJ, Howlett I, Ward AJ, Pounsford JC (2002) The influence of outside temperature and season on the incidence of hip fractures in patients over the age of 65. Age Ageing 31:343–348
Stewart IM (1955) Fractures of neck of femur; incidence and implications. Br Med J 4915:698–701
Parker MJ, Martin S (1994) Falls, hip fractures and the weather. Eur J Epidemiol 10:441–442
Holmberg S, Thorngren KG (1987) Statistical analysis of femoral neck fractures based on 3053 cases. Clin Orthop Relat Res 218:32–41
Levy AR, Bensimon DR, Mayo NE, Leighton HG (1998) Inclement weather and the risk of hip fracture. Epidemiology 9:172–177
Lau EM, Gillespie BG, Valenti L, O’Connell D (1995) The seasonality of hip fracture and its relationship with weather conditions in New South Wales. Aust J Public Health 19:76–80
Tenias JM, Mifsut Miedes D (2004) Hip fracture incidence: trends, seasonality and geographic distribution in a Health District in the Autonomous Community of Valencia, Spain (1994–2000). Rev Esp Salud Publica 78:539–546
Pedrazzoni M, Alfano FS, Malvi C, Ostanello F, Passeri M (1993) Seasonal variation in the incidence of hip fractures in Emilia-Romagna and Parma. Bone 14[Suppl 1]:S57–S63
Douglas S, Bunyan A, Chiu KH, Twaddle B, Maffulli N (2000) Seasonal variation of hip fracture at three latitudes. Injury 31:11–19
Chiu KY, Ng TP, Chow SP (1996) Seasonal variation of fractures of the hip in elderly persons. Injury 27:333–336
Rowe SM, Yoon TR, Ryang DH (1993) An epidemiological study of hip fracture in Honam, Korea. Int Orthop 17:139–143
Baudoin C, Fardellone P, Potard V, Sebert JL (1993) Fractures of the proximal femur in Picardy, France, in 1987. Osteoporos Int 3:43–49
Pettifor Jm, Moodley GP, Hough FS, Koch H, Chen T, Lu Z, Holick MF (1996) The effect of season and latitude on in vitro vitamin D formation by sunlight in South Africa. S Afr Med J 86:1270–1272
Ladizesky M, Lu Z, Oliveri B, San Roman B, Diaz S, Holick MF, Mautalen C (1995) Solar ultra violet radiation and photoproduction of vitamin D3 in central and southern areas of Argentina. J Bone Miner Res 10:545–549
Vieth R, Ladak Y, Walfish PG (2003) Age related changes in the 25-hydroxyvitamin D versus parathyroid hormone relationship suggest a different reason why older adults need more vitamin D. J Clin Endocrinol Metab 88:185–191
MacLaughlin J, Holick MF (1985) Aging decreases the capacity of human skin to produce vitamin D3. J Clin Invest 76:1536–1538
Rodriguez J, Herrara A, Canales V, Serrano S (1987) Epidemiologic factors, morbidity and mortality after femoral neck fractures in the elderly. A comparative study: internal fixation vs. hemiarthroplasty. Acta Orthop Belg 53:472–479
Jacobsen SJ, Sargent DJ, Atkinson EJ, O’Fallon WM, Melton LJ 3rd (1995) Population-based study of the contribution of weather to hip fracture seasonality. Am J Epidemiol 141:79–83
Riley MW, Cochran DJ (1984) Dexterity performance and reduced ambient temperature. Hum Factors 26:207–214
Tourism Bureau, Ministry of Transportation and Communications, Taiwan (2005) The 2003 World Population Data Sheet. Accessed on August 20, 2005 at http://www.taiwantourism.org/
Koutkia P, Lu Z, Chen TC, Holick MF (2001) Treatment of vitamin D deficiency due to Crohn’s disease with tanning bed ultraviolet radiation. Gastroenterology 121:1485–1488
Matsuoka LY, Wortsman J, Hollis BW (1990) Suntanning and cutaneous synthesis of vitamin D3. J Lab Clin Med 116:87–90
Acknowledgements
We acknowledge with thanks the assistance of Yu-Chih Tung, PhD, Assistant Professor, Ming-Chuan University, Department of Health Care Information and Management, Taipei, Taiwan, for statistical assistance in running the ARIMA models. This study is based in part on data from the National Health Insurance Research Database provided by the Bureau of National Health Insurance, Department of Health, Taiwan and managed by the National Health Research Institutes. The Interpretations and conclusions contained herein do not represent those of the Bureau of National Health Insurance, Department of Health, or the National Health Research Institutes.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Lin, H.C., **rasagar, S. Seasonality of hip fractures and estimates of season-attributable effects: a multivariate ARIMA analysis of population-based data. Osteoporos Int 17, 795–806 (2006). https://doi.org/10.1007/s00198-005-0060-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00198-005-0060-3