Osteoporosis International

, Volume 17, Issue 6, pp 795–806 | Cite as

Seasonality of hip fractures and estimates of season-attributable effects: a multivariate ARIMA analysis of population-based data

Original Article

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.

Keywords

ARIMA Hip fracture Seasonality Weather 

Notes

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.

References

  1. 1.
    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 19:532–536PubMedCrossRefGoogle Scholar
  2. 2.
    Braithwaite RS, Col NF, Wong JB (2003) Estimating hip fracture morbidity, mortality and costs. J Am Geriatr Soc 51:364–370PubMedCrossRefGoogle Scholar
  3. 3.
    Delmas PD, Fraser M (1999) Strong bones in later life: luxury or necessity? Bull World Health Organ 77:416–422PubMedGoogle Scholar
  4. 4.
    Maggi S, Kelsey JL, Litvak J, Heyse SP (1991) Incidence of hip fractures in the elderly: a cross-national analysis. Osteoporos Int 1:232–241PubMedCrossRefGoogle Scholar
  5. 5.
    US Department of Health and Human Services (1984) Detail diagnosis and surgical procedures for patients discharged from short stay hospitals. Washington, D.C.Google Scholar
  6. 6.
    Gullberg B, Johnell O, Kanis JA (1997) World-wide projections for hip fracture. Osteoporos Int 7:407–413PubMedCrossRefGoogle Scholar
  7. 7.
    Population Reference Bureau (2004) The 2003 World Population Data Sheet. Accessed on August 8, 2005 at http://www.prb.org/pdf04/04WorldDataSheet_Eng.pdf
  8. 8.
    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, 2004Google Scholar
  9. 9.
    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 15:447–451PubMedCrossRefGoogle Scholar
  10. 10.
    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 51:439–451PubMedCrossRefGoogle Scholar
  11. 11.
    Muenier P (1996) Prevention of hip fractures by correcting calcium and vitamin D insufficiencies in elderly people. Scand J Rheumatol Suppl 103:75–78Google Scholar
  12. 12.
    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 9:347–351PubMedGoogle Scholar
  13. 13.
    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 18:1342CrossRefGoogle Scholar
  14. 14.
    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 133:996–1004PubMedGoogle Scholar
  15. 15.
    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 28:149–155PubMedGoogle Scholar
  16. 16.
    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 31:343–348PubMedCrossRefGoogle Scholar
  17. 17.
    Stewart IM (1955) Fractures of neck of femur; incidence and implications. Br Med J 4915:698–701CrossRefGoogle Scholar
  18. 18.
    Parker MJ, Martin S (1994) Falls, hip fractures and the weather. Eur J Epidemiol 10:441–442PubMedCrossRefGoogle Scholar
  19. 19.
    Holmberg S, Thorngren KG (1987) Statistical analysis of femoral neck fractures based on 3053 cases. Clin Orthop Relat Res 218:32–41PubMedGoogle Scholar
  20. 20.
    Levy AR, Bensimon DR, Mayo NE, Leighton HG (1998) Inclement weather and the risk of hip fracture. Epidemiology 9:172–177PubMedCrossRefGoogle Scholar
  21. 21.
    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 19:76–80PubMedCrossRefGoogle Scholar
  22. 22.
    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 78:539–546PubMedCrossRefGoogle Scholar
  23. 23.
    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–S63PubMedCrossRefGoogle Scholar
  24. 24.
    Douglas S, Bunyan A, Chiu KH, Twaddle B, Maffulli N (2000) Seasonal variation of hip fracture at three latitudes. Injury 31:11–19PubMedCrossRefGoogle Scholar
  25. 25.
    Chiu KY, Ng TP, Chow SP (1996) Seasonal variation of fractures of the hip in elderly persons. Injury 27:333–336PubMedCrossRefGoogle Scholar
  26. 26.
    Rowe SM, Yoon TR, Ryang DH (1993) An epidemiological study of hip fracture in Honam, Korea. Int Orthop 17:139–143PubMedGoogle Scholar
  27. 27.
    Baudoin C, Fardellone P, Potard V, Sebert JL (1993) Fractures of the proximal femur in Picardy, France, in 1987. Osteoporos Int 3:43–49PubMedCrossRefGoogle Scholar
  28. 28.
    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 86:1270–1272PubMedGoogle Scholar
  29. 29.
    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 10:545–549PubMedCrossRefGoogle Scholar
  30. 30.
    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 88:185–191PubMedCrossRefGoogle Scholar
  31. 31.
    MacLaughlin J, Holick MF (1985) Aging decreases the capacity of human skin to produce vitamin D3. J Clin Invest 76:1536–1538PubMedCrossRefGoogle Scholar
  32. 32.
    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 53:472–479PubMedGoogle Scholar
  33. 33.
    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 141:79–83PubMedGoogle Scholar
  34. 34.
    Riley MW, Cochran DJ (1984) Dexterity performance and reduced ambient temperature. Hum Factors 26:207–214PubMedGoogle Scholar
  35. 35.
    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/
  36. 36.
    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 121:1485–1488PubMedCrossRefGoogle Scholar
  37. 37.
    Matsuoka LY, Wortsman J, Hollis BW (1990) Suntanning and cutaneous synthesis of vitamin D3. J Lab Clin Med 116:87–90PubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2006

Authors and Affiliations

  1. 1.School of Health Care AdministrationTaipei Medical UniversityTaipeiTaiwan
  2. 2.Department of Health Services Policy and Management, Arnold School of Public HealthUniversity of South CarolinaColumbiaUSA

Personalised recommendations