To the Editor: Hip fracture is a condition associated with high economic and social costs, whose incidence is rising worldwide.1 Moreover, the incidence of hip fracture increases with age. One of six persons aged 90 and older will suffer from this condition, making it one of the leading causes of disability in the elderly population.2,3 Other authors have studied the mortality and the disability and institutionalization rates associated with hip fracture in nonagenarians,4–6 but data about its consequences in centenarians are scarce and derive from small retrospective studies.7,8
An observational study based on data from the Minimum Basic Data Set (MBDS) from the Spanish National Surveillance System for Hospital Data, a database including more than 95% of hospitals in Spain, was conducted. Hospital diagnoses are coded according to the International Classification of Diseases, Ninth Revision, Clinical Modification, and grouped according to the Diagnosis Group Relationship (DGR).
This study was conducted using data corresponding to persons aged 100 and older who were admitted to the hospital during 2005 regardless of the cause. The main variables in this study were age, sex, main diagnosis, destination upon discharge, hospital stay (days), and DGR. Each case was allocated a unique identification number to identify subjects who were repeatedly admitted.
The total frequency of admissions due to any type of hip fracture was calculated in the whole population studied and segregated according to sex. The incidence of hip fracture, the global and per-sex in-hospital mortality rates, and the costs associated with hip fracture were calculated in this age group according to the pertinent DGRs corresponding to 2004 (codes 210.00, 211.00, 236.00, 558.00, 560.00, 731.00, 818.00).
One hundred sixty-two patients (28 male and 134 female) were admitted to the hospital with hip fracture in Spain during 2005 (Table 1). The average age of admitted patients was 101.2 (range 100–107). For the 1,552 centenarians admitted to the hospital, hip fracture was the leading cause of hospitalization, followed by congestive heart failure and pneumonia. According to data from the official statistics, 4,302 persons aged 100 and older (3,286 women and 1,016 men) were living in Spain in 2005. On this basis, the global incidence of hip fracture in centenarians during 2005 was 3.8% (3,765/100,000); the incidence was 4.1% (4,078/100,000) in women and 2.8% (2,756/100,000) in men.
|Type of Fracture||Subtype of Fracture||International Classification of|
Diseases, Ninth Revision,
Clinical Modification Code
|Base of the neck||820.03||7||4.3|
|Unspecified femoral neck fracture||820.8||10||6.2|
One hundred seventeen patients (72.2%) were discharged to home, 14 (8.64%) were transferred to another hospital or to a sociosanitary institution, and 28 (17.3%) died during their hospital stay, 26 of them (16%) within 1 month. The total hospital stay due to hip fracture was 2,040 days; the average stay at the first acute care hospital (regardless of possible transfers) was 12.6 days. The direct cost of hospitalization due to hip fracture in centenarians was 1,030,046.9€; the average cost per case was 6,358.31€, which corresponds to 505.03€ per day of hospital stay. All of this involves an average cost of 239.43€ per centenarian in Spain during 2005 (1€=1.245$).
A study conducted in Spain with data corresponding to 2000 to 2002 reported an incidence of 511 cases of hip fracture per 100,000 persons aged 65 and older.9 In the present study, a seven times higher incidence of hip fracture was estimated in centenarians, which evidences a remarkable rise, than any other age group, even institutionalized persons. Such a high incidence agrees with an earlier estimation based on data from persons aged 95 and older between 1996 and 1999.10 In-hospital mortality was found to be higher than 17% for centenarians, as found in earlier studies,9 which evidences the high mortality risk of this condition for extremely old people, for whom it seems to be a major cause of death. The total cost of hip fracture in centenarians could seem low because there are few centenarians living in Spain, but the per capita cost is not low; it might actually be one of the highest costs of hospital care for persons of this age group. In addition, the indirect costs associated with this condition, mainly derived from formal and informal care of survivors and subsequent complications and dependency, are probably the highest ones.
In summary, hip fracture is a major cause of hospitalization and mortality in centenarians and is associated with high costs. All of this supports the need to study the possible benefits of treating osteoporosis and fall risk during the last decades of life.