Traditionally, the mortality rate at 1-year post hip fracture was quoted as approximately 30% of all hip fractures. There have been recent improvements in hip fracture care in the main driven by national hip fracture registries with reductions in 30-d mortality rates reported.

To address recent 1-year post hip fracture mortality rates in the literature.

Systematic literature review, national hip fracture registries/databases, local studies on hip fracture mortality, 5 years limitation (2013-2017), cohorts > 100, studies in English. Outcome measure: Mortality rate at 1-year post hip fracture.

Recent 1-year mortality rates were reviewed using the literature from 8 National Registries and 36 different countries. Recently published 1-year mortality rates appear lower than traditional figures and may represent a downward trend.

There appears to be a consistent worldwide reduction in mortality at 1-year post hip fracture compared to previously published research. Globally, those which suffer hip fractures may currently be benefiting from the results of approximately 30 years of national registries, rigorous audit processes and international collaboration. The previously quoted mortality rates of 10% at 1-mo and 30% at 1-year may be outdated.

Hip fracture care continues to improve secondary to international audit and optimization of hip fracture management. Hip fractures are exceedingly common presentations to global emergency departments with approximately 3600 in Ireland per year[1], approximately 65000 in the United Kingdom[2], approximately 620000 in the European Union[3], approximately 300000 in the United States[4] and roughly 2 million worldwide[5]. This global figure is modest projected to increase threefold by 2050[6].

There is significant cost associated with hip fractures regarding: (A) financial cost to the health service providing care; and (B) morbidity and mortality cost to the patient. Recent research estimates the year 1 hospital cost secondary to an index hip fracture to be £14000 (€15900/$18750) per patient[7]. The annual cost of treatment in the European Union and the United States has been recently reported as €32 billion and $20 billion respectively[8].

The literature describes that after suffering a hip fracture, the patient will experience a reduction in overall functional status, social independence, mobility and increasing scores in depressive symptoms[9-10]. Due to the high prevalence of hip fractures and the disadvantage to both the patient and the local health service responsible for care, optimisation and the standardisation of hip fracture management has been targeted to reduce morbidity, mortality and financial expense. This optimisation and standardization, in the form of a national registry, has been shown previously to improve the quality of care and outcomes of hip fracture patients[11].

The earliest hip fracture registry established is “RIKSHÖFT”, the Swedish national hip fracture registry, set up in 1988, following on from the successful local implementation of national knee and hip arthroplasty registers in the 1970s[12]. In 1993, the Scottish Hip Fracture Audit (SHFA) implemented a registry that reported annually until 2008, after which, the audit was stepped down to capture “snapshot” data only. Following audit and the recognition of deterioration in outcomes post step down[13], the SHFA was re-implemented in May 2016 and year round data collection was re-instituted[14]. In 1995, the European Commission funded the initiation of the Standardised Audit of Hip Fracture in Europe due to the triumphs in outcomes secondary to the “RIKSHÖFT” audit in Sweden[15]. The Danish orthopaedic community established the Danish Hip Fracture Database in 2003[5] whilst the Norwegian community set up their database, the “NOREPOS”, in 2005[16].

In 2007, an important milestone was reached regarding the initiation of the largest and fastest growing national hip fracture registry by the United Kingdom. After publishing the “Blue Book”, which set quality standards established by the British Orthopaedic Association and the British Geriatrics Society, the National Hip Fracture Database (NFHD) began to collect and publish data annually regarding hip fractures[3]. In 2010, a European Union program, named euroHOPE (Healthcare Outcomes, Performance, Efficiency), was created to compare healthcare performance regarding hip fracture treatment across 7 European countries[17]. The fragility fracture network was then established in 2011, a global network, with a mission to optimize the multidisciplinary management of patients with fragility fracture globally and prevent secondary fracture[18]. This was followed by the foundation of the Irish Hip Fracture Database in 2012[1] and more recently the Australian and New Zealand Hip Fracture Registries in 2016[19]. Several countries are currently piloting their own national hip registries following the achievements published by the registries described above including Greece, Malta, Nederlands, Slovenia, Spain, Lebanon and Argentina.

Traditionally, orthopaedic trainees are taught that the mortality rates in this fragile population were approximately 10% at 30 d and approximately 30% at 1 year[20]. These figures are important at: (A) a patient level with regards to family discussions surrounding realistic expectations and prognosis following hip fracture; and (B) at a hospital and national level with regards to the optimisation of care and distribution of finite resources.

In 2015, following a review of 471590 patients which suffered a hip fracture in the United Kingdom between 2003-2011, it was concluded that “the launch of a national clinician-led audit initiative was associated with substantial improvements in care and survival of older people”[21]. This group reported significant reductions in 30-d mortality.

Following review of the recent literature emanating from the national registries, it was noted that whilst 87.5% of the national registries publish annual data on in-patient mortality and 62.5% publish annually on 30-d mortality, only 12.5% (1 registry) published mortality rate at 1-year post hip fracture. In order to explore whether there have been any recent global reductions in 1-year mortality post fracture, a systematic literature review was undertaken.

A review of the available literature on (A) national hip fracture registries/databases and (B) local hip fracture studies which included 1-year mortality data was conducted using Pubmed and Google Scholar. The following keywords were used: “hip fracture”, “mortality”, “year”, “death”, “outcomes”, “registry”, “registries”, “database” and “databases”. The inclusion criteria were those studies published within the last 5 years (2013-2017), studies including a cohort > 100 and those in the English language. The most recent national registry reports were obtained and personal contact to authors of the Swedish and Danish reports via e-mail was required as these are reported in local language only.

The mortality at 1 year post hip fracture has traditionally been reported as 30%[20] and more recently described as “around a third within a year”[60], whilst the 2017 NFHD annual report suggests “up to a third die within a year following a hip fracture”[2]. There have been significant developments with regards to data collection in the areas of casemix, surgical/anaesthetic practice, process and outcomes of hip fracture care by the national registries. However, only 1 of the 8 national registries is publishing data regarding mortality at 1-year post hip fracture. There is therefore a void in the published literature on this topic.

After reviewing the recent hip fracture related mortality literature, it was found that the mean 1-year mortality rate in Europe was 23.3% (22 studies), whilst in Asia was 17.9% (10 studies). The figures for the United States and Australia were 21% and 24.9% respectively. The figure in South America was 26.8%, however, this originated from small studies. On analysis of data from all 36 studies (n = 229851 patients), the mean 1-year global mortality rate was 22% (SD 7.2%, median 22.8%).

These results are at odds with those reported previously and may suggest a consistent global improvement in longer-term survival following hip fracture. Best practice guidelines have been developed by way of continuous optimization through the auditing process of the national registries and continue to be developed, refined or discarded based on continuous audit cycle. The improvement in longer term survival post hip fracture may be secondary to worldwide adoption of current best practice in the care and secondary prevention of hip fracture.

This is the first study that has reviewed recent worldwide-published data on 1-year mortality rates including data collected from 229851 patients. Although the literature review included studies within the last 5 years, it is worth noting that the vast majority (83%) of the local studies (30/36) were published within the last 3 years (2015-2017). It is also worth noting that the most recent papers on this topic (published in 2018) confirm that the changing trend in 1-year mortality continues to be observed[61-63]. Cancio et al[64] this year published a 1-year mortality rate of 22% for a large hip fracture cohort (n = 30552), which is similar to our findings described above.

Whilst this article reports a decreasing trend in mortality at 1-year post hip fracture, it is important to recognize limitations of this study. A potential source of error is the use of data from all 36 studies to ascertain a mean mortality rate as some of the studies included patients < 60 years of age. However, limiting the inclusion criteria to those studies that include patients > 60 years only, the mortality rate is 21.8% (SD 7.6%, median 23.6%) which is a similar finding. Another limitation is equal weighting to mortality rates despite wide variation in cohort numbers. Limiting the inclusion criteria to those studies which include > 10001 patients only (n = 7), the mean mortality rate is 20.7% (SD 2.4%, median 20.5%) which also is a similar finding.

It is also worth noting that as an index hip fracture outcome measure, mortality is an imperfect quality indicator and is affected by both patient age and casemix (multiple comorbidities typically). Therefore, it is the trend in mortality rate data over time that is more useful as a quality indicator.

Osteoporosis currently causes approximately 9 million fractures annually around the world[65]. As alluded to in the introduction, hip fractures are increasing with excess of 6 million per year predicted in 2050. The greatest increases are expected in Asia[66]. The World Health Organisation predicts that between 2000 and 2050, the proportion of those aged > 60 will double in numbers from 11 to 22% or 605 million to 2 billion people[67]. It is important that this expected rise is planned for and this literature review suggests that as a global orthopaedic and orthogeriatric community, vast strides are being made in the optimisation of care with hip fracture patients to mitigate for the impending surge in hip fracture incidence. The reduction in 1-year mortality provides feedback that following adoption of hip fracture management standards of care, it is not simply improvements in early mortality with deferral of mortality outside of the acute window (30 d) but longer-term survival at 1-year post hip fracture. The United Kingdom National Hip Fracture Database website publishes monthly on overall performance measures including national average 30-d mortality. The most recent figure was 5.7% (July, 2018)[68] with almost month-to-month reductions since initially published in April 2012. These findings are very positive. Another recent positive development in hip fracture care is the increasing involvement of orthogeriatricians in the care of these fragile patients and their corresponding impact on mortality reduction[60].

The data collected by the national registries allow us as a community to tackle a complex international problem to minimise morbidity, mortality and costs associated with hip fractures. These registries continue to be optimised and it has been recently suggested that (1) simplicity; (2) continuous collection of all cases as routine practice; (3) definition of variables collected; and (4) a common set of variables collected will fulfil the criteria of a model registry which should allow direct national and international comparison and further improvements in care delivered[3].

In conclusion, globally, those which suffer hip fractures may currently be benefiting from 30 years of national registries, rigorous audit processes and international collaboration. This literature review suggests a decrease in trends in mortality at 1-year post hip fracture compared to previous research on this topic. Further improvements in hip fracture care quality indicators are expected by the authors in light of increased involvement of the orthogeriatric subspeciality and the continuous refinement process of the national registries. The results of 7 novel national pilot registries are anticipated.