Hip fractures in Italy: 2000–2005 extension study
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- Piscitelli, P., Gimigliano, F., Gatto, S. et al. Osteoporos Int (2010) 21: 1323. doi:10.1007/s00198-009-1084-x
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A total of 507,671 people ≥65 experienced hip fractures between 2000 and 2005. In 2005, 94,471 people ≥65 were hospitalized due to hip fractures, corresponding to a 28.5% increase over 6 years. Most fractures occurred in patients ≥75 (82.9%; n = 420,890; +16% across 6 years), particularly in women (78.2%; n = 396,967).
We aimed to analyze incidence and costs of hip fractures in Italy over the last 6 years.
We analyzed the national hospitalization and DRG databases concerning fractures occurred in people ≥65 between 2000 and 2005.
A total of 507,671 people ≥65 experienced hip fractures across 6 years, resulting in about 120,000 deaths. In year 2005 94,471 people aged ≥65 were hospitalized due to hip fractures, corresponding to a 28.5% increase over 6 years. The majority of hip fractures occurred in patients ≥75 (82.9%; n = 420,890; +16% across 6 years) and particularly in women (78.2%; n = 396,967). Among women, 84.2% of fractures (n = 334,223; +28.0% over 6 years) were experienced by patients ≥75, which is known to be the age group with the highest prevalence of osteoporosis, accounting for 68.6% of the overall observed increase in the total number of fractures. Hip fractures in men ≥75 increased by 33.1% (up to 16,540). Hospitalization costs increased across the six examined years (+36.1%) reaching 467 million euros in 2005, while rehabilitation costs rose up to 531 million in the same year.
Hip fractures of the elderly are increasing and represent a major health problem in industrialized countries such as Italy.
Demographic trends of the last 50 years have increased life expectancy and changed the age profile of populations in developed countries. Italy has one of the highest life expectancies in the world: according to the Italian National Institute for Statistics (ISTAT), life expectancy at birth increased at a rate of 4 months/year from 1950 to 2005, reaching 77.8 years for men and 86.9 years for women [1, 2], but it is estimated to rise up to 78.4 and 87.4 years, respectively, by 2010 [1, 2]. In Italy, 18% of the population is actually over 65 years of age ; within the next decade, this age group may exceed 22% of the population . Moreover, 4% of this group is already ≥80 years of age . For these reasons, Italy represents an interesting international case study for determining social and economic burden of aging-related diseases, because of the increasing weight of older age groups within the general population (resulting in the inversion of the age pyramid), which is a general phenomenon observed in all industrialized countries.
Therefore, observations made in Italy could be relevant for many other industrialized countries facing similar problems of aging of the population. Increased life expectancy is associated with a greater frailty of elderly people and a higher prevalence of chronic and degenerative diseases. Osteoporosis and its complications—especially hip fractures—represent a challenge for health professionals and decision makers in the twenty-first century. The World Health Organization considers osteoporosis to be second only to cardiovascular diseases as a critical health problem , and in our previous study, we have shown that incidence and costs of hip fractures in Italy are already comparable to those of acute myocardial infarction . Furthermore, hip fractures have a 5% acute mortality rate and 15–25% 1-year mortality [6, 7]. Once hip fracture has occurred, the ability to walk is completely lost in 20% of cases, and only 30–40% of patients recover a degree of autonomy comparable to the period before the fracture [8–11]. The main Epidemiological Study on the Prevalence of Osteoporosis in Italy (ESOPO) reported a high prevalence of osteoporosis: 23% among all women, with age-specific rates ranging from 9% (40- to 49-year-olds) to 45% (70- to 79-year-olds), and almost 15% in men aged ≥60 years [12, 13]. According to these percentages, about four million of Italian women and 800,000 men are thought to be affected by osteoporosis , although an overestimation of these prevalence data cannot be excluded because the ESOPO study was conducted by using QUS measurements and not DEXA [13–15]. It is known that osteoporosis is a condition that enhances the risk of fracture, especially vertebral and hip fractures . Each year in Italy, almost 18,000 elderly people become completely disabled as a consequence of hip fractures, resulting in inestimable human suffering and substantial social costs . Despite these observations, no detailed data were available about the incidence and costs of hip fractures in the elderly Italian population before our first analyses carried out in 2005–2006 [4, 17, 18], demonstrating a worrisome lack of appreciation concerning the severity of this pathology. In this extension study, we aimed to determine the burden of hip fractures in the Italian elderly population and its trend across 6 years.
Materials and methods
Information concerning all hospitalizations occurring in Italian public and private care setting are registered in hospital discharge records, which are collected at the Italian Ministry of Health (national hospitalization database, SDO). These information are anonymous and include patient’s age, diagnosis, procedures performed, and length of the hospitalization. This study is an extension of our previously published work addressing (with the same methodology) the incidence and costs of hip fractures compared to acute myocardial infarction in the Italian population in a 4-year survey (1999–2002). The present manuscript focuses on the number of hospitalizations for hip fracture in Italy, their incidence, and the direct cost of hospitalization and rehabilitation during the years 2000 through 2005. Actually, it does overlap with previously published data by 3 years (2000 to 2002) and the number of hip fractures (and their costs) shown in the current study are consistent with the previously published figures. We assumed that almost all hip fractures occurred in the elderly result in hospitalization. Therefore, in order to determine the incidence of hip fractures in the Italian population aged ≥65 years old, we analyzed the national hospitalization database (SDO) maintained at the Italian Ministry of Health. The study period (from year 2000 to 2005) was chosen because it reflects the most recently available nationwide clinical (hospitalization records) and demographic data. Population data were obtained from the National Institute for Statistics (ISTAT) for each of the considered years .
Cost parameters used in DRGs analysis
DRG rate (Euros)
Max hospitalization length (days)
Number of hospitalizations following hip fractures in Italy in patients ≥65 years old, by age categories and sex between the years 2000 and 2005
Considering all 6 years together, 82.9% of total hip fractures occurred in patients 75 years of age or older (n = 420,890 fractures), with women accounting for 78.2% of all fractures (n = 396,967). Among women, 84.2% of hip fractures (n = 334,223) were experienced by patients ≥75 years of age (Table 2). The number of fractures in this subgroup of women increased by 28.0% over 6 years and accounted for 68.6% of the overall observed increase in the total number of hip fractures between 2000 and 2005 (Table 2). In the same period, hip fractures in men passed from 16,037 cases in year 2000 to 20,909 in year 2005, with an increase of 30.3% over 6 years. Hip fractures occurred in men aged ≥75 years increased by 33.1% reaching a total of 16,540 cases in 2005 vs. 12,426 fractures of year 2000 (Table 2). Breakdown by age and gender confirmed the marked increase with age and the predominance of women. The incidence of hip fractures observed among women was three or four times higher than that of men in the two older age groups, with a progressive increase between 2000 and 2005 for both genders, particularly in the oldest age group.
Number of hip fractures per 10,000 inhabitants by age categories and sex between the years 2000 and 2005
45–64 years old
65–74 years old
≥75 years old
Direct costs (million Euros) sustained for hospitalizations due to hip fractures in all the adult Italian population (≥45 years old) and in the elderly (≥65 years old)
Adults aged >45 years old (million Euros)
Elderly people aged >65 years old (million Euros)
Direct costs sustained for hospitalizations and rehabilitation following hip fractures in people aged ≥65 years old, from year 2000 to 2005
Patients (n) and costs (€) Year 2000
Patients (n) and costs (€) Year 2001
Patients (n) and costs (€) Year 2002
Patients (n) and costs (€) Year 2003
Patients (n) and costs (€) Year 2004
Patients (n) and costs (€) Year 2005
Hospitalizations due to hip fractures
Overall hospitalizations direct costs
Pts (n.) discharged from the hospital (95% of pts.) undergoing rehabilit.
Istitutionalizations following hospital discharge (18.2% of total pts.)
In-hospital rehabilit. after institutionalization (63% of institutionalized pts.)
In-hospital rehabilitation (13.5% of total pts.)
Institutionalizations after in-hospital rehabilitation (10% in-hospital pts.)
Home-based rehabilitation (63.3% of total pts.)
Ambulatorial rehabilitation within 6 months (13.2% of total pts.)
In-hospital rehabilit. post ambulatory rehabilit. (40% of ambulatorial pts.)
Overall rehabilitation costs €
Overall direct costs estimation €
This Italian study is of special interest because it has been carried out analyzing the national hospitalization database; thus, the data reported should be regarded as estimates closely reflecting the real situation. We believe that hospitalizations due to hip fractures registered in the national database at the Ministry of Health represent the best possible surrogate of fractures true incidence. The analysis of hospitalization records is a methodology that have been used in recent years by several authors from different countries (Switzerland, France, Germany, Austria, Italy), in order to closely determine the incidence of hip fractures and cardiovascular diseases [5, 19, 25–30]. Moreover, a British study has found an excellent accuracy and reliability of the clinical indicators related to hip fractures hospitalization records . However, it should be considered that a small proportion of hospitalizations (possibly 3–5%) may represent readmissions for the same persons, and a very small number of hip fractures may not result in hospitalization. It is also important to point out the assumption that in this analysis, all hip fractures were considered, independently of underlying osteoporosis or not, and no osteoporosis attribution rates were applied because it still does not exist a specific codification for osteoporotic fractures. On the other hand, the most frequent underlying cause of hip fractures in the elderly (which represent the majority of cases recorded in the hospitalization database) is osteoporosis, and almost 83% of hip fractures were found to have been experienced by patients 75 years of age or older, in accordance with the higher prevalence of osteoporosis in this age group . It must be pointed out also that we included in the analysis also the ICD9-CM codes 821, which comprises fractures of the femoral shaft (and other not defined hip fractures), whereby 821.0 are closed fractures and 821.1 are open fractures (generally high energy trauma fractures). However, their number in the elderly population represented a small percentage of all hip fractures computed (about 7–8% each year), and patients with osteoporosis may also break after a high-energy trauma.
Our findings seem to be consistent with IOF estimations concerning the overall incidence and costs of hip fractures in Italy  and provides further detailed information regarding the costs specifically generated by elderly people. Furthermore, these results are consistent with the national hospitalization database analyses of the surgical interventions following hip fractures we had already performed  and with data from other European [27, 33–39] and non-European countries [40, 41], where an increasing trend of hip fractures incidence and costs was shown for many industrialized countries. On the opposite, some previously published studies concerning Sweden , Switzerland [30, 43], Australia , and Canada  have found a reversal in hip fractures incidence, mainly for women. These differences can be explained considering the higher incidence of hip fractures among oldest age groups in those countries where effective preventive strategies have not yet been fully implemented, especially for nursing home residents, whose risk of fractures is two- or threefold higher than community dwelling elderly people . Actually, some authors have suggested that the decrease in secular hip fractures trend observed in some countries may be attributable to the reduction of hip fractures in nursing homes .
In line with the commonly accepted approach in health economics, we used DRGs in order to calculate direct costs of hip fractures, for the reason that this method enabled us to accurately measure the financial consequences of hospitalizations. A 15% average reduction for each DRG was adopted in order to overcome the differences between the regions in cutting the national rate-list values. Another main contribution of this manuscript is the attempt (on the basis of the available national literature) of quantifying rehabilitation costs, which were found to be higher than direct hospitalization costs (Table 5). However, there are still many differences between the Italian regions concerning the post-acute treatments, with Northern Italy having a higher number of people institutionalized after hip fracture and more patients staying at home in Southern Italy, according to the data provided by the Italian Society of Rehabilitative Medicine.
Although our study was primarily focused on determining the number of hospitalizations and direct costs following hip fractures, a full evaluation of the problem would also require to consider the burden—in terms of health and economic resources—of mortality and disability. The average yearly mortality rate for hip fractures is currently 15–25% [5, 6, 20, 21], and we have computed that no less than 120,000 people died in Italy because of hip fractures from year 2000 to 2005. It has also been estimated that each year 18,000 patients become disabled as a consequence of hip fracture, generating yearly costs (financial aid provided by the State) of 80–100 million Euros . Furthermore, long-term costs related to hip fractures occurred in previous years should also be considered for a detailed cost analysis, as assessed in other European studies . Indirect costs related to hip fractures are not easily assessable, although the International Osteoporosis Foundation (IOF) has estimated them to account for 20% of overall direct costs . In this perspective, total costs generated by hip fractures in the elderly Italian population are now estimated to exceed 1.3 billion Euros/year. Our study confirms the findings of our previous analyses [5, 17, 18] and highlights the high social impact of hip fractures in elderly people. However, the large database of the Italian hospital records offers the opportunity of new studies concerning the differences across hip fracture types, such as between neck and trochanter fractures, which could be of particular interest especially for orthopedic surgeons.
According to our estimations, overall direct costs (due both to hospitalizations and rehabilitation) sustained in Italy for hip fractures in the elderly are now close to one billion Euros/year, showing a continuous increasing trend from 2000 to 2005. This study shows that in the Italian population aged ≥65, hospitalizations following hip fracture and their related costs are growing progressively, representing a serious medical and public health problem. Italy, such as all industrialized countries where the number of elderly people is still increasing, should, therefore, adopt adequate preventive strategies aimed to reduce the risk of hip fractures (i.e., osteoporosis prevention and fall prevention), especially in the oldest age groups.
We thank Dr. L. Lispi and D. Del Gigante (General Direction for Planning Affairs, Italian Ministry of Health) for their help in the analysis of national hospitalization data. Many thanks to the CERSUM research group on osteoporosis (Euro Mediterranean Scientific Biomedical Institute, ISBEM/IFC CNR, Brindisi).
Conflicts of interest
AD, AM, SG, PM, MM, EQ, FC, FF, GC, MLB, GC, AG, GG, RG, GI have received research grant and funding for consulting/speaking by Merck, Sanofi-Aventis, Novartis, Stroder-Servier, Procter & Gamble, Ely Lilly, Roche, Glaxo; PP has received once funding for consulting/speaking by Sanofi-Aventis; FG, AM, GC, MC, LDP, MB, ES, OB, BF: no disclosures.