Survival after hip fracture in the elderly population of Croatia

Survival after hip fracture in the elderly population of Croatia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Survival after hip fracture in the elderly population of Croatia Gordan Sarajlić, Branko Kolarić, Petra Čukelj, Mario Šekerija, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8639446/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Aims To determine the incidence of hip fracture in elderly people (≥ 65) in Croatia, and to analyse survival by sex, age group, residence and fracture type. Methods To identify individual patients with hip fracture and data on death, we used the Hospital Discharge Database for the period of calendar year 2018 and the Cause of Death Database for the period from 1 January 2018 to 31 December 2020. Incidence of hip fracture was estimated and reported as annual incidence per 100,000 people for 2018, further stratified by age, sex and region of residence. Survival analysis was performed with the Kaplan-Meier method. Survivor function was calculated and presented at various follow-up times. Results 5052 hip fracture cases among the elderly in 2018 were identified. The overall crude incidence of hip fracture in 2018 was 607/100,000 (355/100,000 in males and 778/100,000 in females). Higher incidence was estimated in females across all age groups. Males had a shorter median survival time than females (538 days versus 1036 days). Log-rank test confirmed the significance of difference in survivorship between the sexes, as well as between different age groups and between patients residing in different regions. Survivorship between patients who have suffered different types of femur fracture did not differ significantly. Conclusion Elderly females are more affected by hip fracture in terms of incidence, while men have shorter survival. Results for Croatia are in line with the current knowledge. As hip fracture remains a major public concern, additional efforts need to be put in prevention. Femur fracture survival Figures Figure 1 Figure 2 INTRODUCTION Femur fractures are a common cause of morbidity and mortality in elderly people (≥ 65 years of age). They are usually the result of a fall, with the proximal femur being especially fragile, even in the absence of great force. According to the Global Burden of Disease Study ( 1 ), in 2019 there were an estimated 14.2 million cases of hip fractures in the world, which is an increase of 92.7% compared to 1990. Of those, 6.6 million fractures (47%) occurred in people over 70 years of age, which is an increase of 188% for hip fractures in this age group from 1990. Due to aging population we can expect further increase of the number of hip fractures and related societal costs ( 2 ). Fractures of the proximal part of the femur manifest as either femoral neck, trochanteric area, or subtrochanteric area fractures, and are often referred to as hip fractures. Since hip fracture is a serious clinical event that requires hospitalization, this diagnosis is generally accurately coded in hospital systems, using the ICD-10 codes S72.0, S72.1 and S72.2 ( 3 , 4 , 5 , 6 ). Excess mortality after hip fracture in the elderly population is a recognized phenomenon ( 7 ), and is the result of many different factors: the trauma of the injury itself, complications of a subsequent surgery, existing comorbidities and complications that come with a prolonged period of immobility. The results of studies investigating 1-year post-fracture mortality range from 15%-40%, depending on the source ( 3 , 8 ). A recent review on post-fracture mortality rates ( 9 ) stated that those figures might be outdated; due to optimization in registration and follow-up of patients, 1-year mortality rate could be around 22%. In recently conducted survival studies where hip fracture patients were aged 50 years and above ( 10 , 11 ), it was found that survival rates were lower among men and in older age groups. Differences in survival rates pertaining to sex diminished over time, but only after a long follow-up period had elapsed. Results on survival difference based on the type of fracture were not conclusive, with one study ( 11 ) reporting no difference, and the other lower survival for trochanteric fracture ( 10 ). Around 40% of all hospitalizations due to injuries in Croatia are recorded in elderly people, and the proportion is even more pronounced for femur fractures; 84% of them occur in people older than 65. Femur fractures also represent more than a third (37%) off all injury-related hospital discharges in Croatia in this age group ( 12 ). Croatian routine mortality and morbidity statistics show that femur fracture is not only the most common cause of injury-related hospitalizations, but also the most common cause among all injury-related deaths. Latest mortality data for 2020 report 652 deaths as a direct consequence of a femur fracture, 98% of which happened in people over 65 years of age ( 13 ). To our knowledge, no survival analysis was done on routinely collected data on hospital discharges and mortality related to hip fractures in Croatia. The results of the EUROSTAT "Morbidity Statistics" project for Croatia report of a total of 3 981 incident femur fractures (crude rate 121.3/100,000) in the elderly people in 2017 ( 16 ); but no further analysis was performed on the data. Given the public health burden that hip fractures present in the elderly population, and aging population that will only increase the size of the problem, our aim is to present data on incidence of hip fracture in the ≥ 65 age group in Croatia and analyse their survival to the extent to which validated national data are available at this moment. The results could inform public health policies and clinical practice guidelines. MATERIALS AND METHODS The study was conducted as a retrospective, population-based cohort study of individuals aged ≥ 65 years using linked secondary health data stemming from hospital discharges in Croatia during 2018 and national mortality records from 1 January 2018 to 31 December 2020. A unique, national level identifier allowed for linking of individual patient data across the different databases, which are integral parts of The National Public Health Information System within the Croatian Institute of Public Health. The study population comprised of all individuals who were hospitalized in Croatian health-care institutions in 2018 with hip fracture (ICD-10 codes: S72.0, S72.1 and S72.2) coded as the leading or as any other discharge diagnosis, aged ≥ 65 years at admission. Taking into account the severity of hip fracture and need for intervention and treatment, patients diagnosed with hip fracture are always admitted to hospital, even if only a conservative treatment approach is pursued. Therefore, the hospital discharges stand as a valuable principal source of information for hip fracture cases in Croatia. The hospital admission date was chosen as an adequate proxy for exposure, i.e. incident hip fracture. Each individual was counted only once in case they had more than one hospital discharge related to hip fracture in the year of observation. Individuals discharged from rehabilitation and physical therapy wards, as well as individuals discharged from day hospitals were not included, as these hospitalizations are unlikely to represent incident hip fracture cases. The possible cases were analysed in more detail to account for their eligibility. Efforts were made to address potential case ascertainment bias that arises when using secondary data from hospital discharges. The following cases were also not included: cases with ICD-10 diagnosis from T group coded as the leading discharge diagnosis (representing hospitalizations due to complications of orthopaedic prosthetic devices and other post-surgical complications, and not incident hip fractures) cases with ICD-10 diagnosis from Z group coded as the leading discharge diagnosis (representing hospitalizations due to orthopaedic follow-up care and palliative care, and not incident hip fractures) cases with ICD-10 diagnosis from C group coded as the leading discharge diagnosis (most probably representing patients with a pathological fracture due to the underlying malignant disease, not representative of the study population) All cases were followed until death or until end of the study (31 December 2020). This constitutes up to 3 years following the hip fracture admission date. The variables of interest were complete for every individual case: sex, date of birth, hospital admission date, hospital discharge date, leading discharge diagnosis, other discharge diagnoses (if fitting the criteria of ICD-10 codes S72.0-S72.2) and county of residence. Date of death was ascertained for all cases that have deceased in the study period. Statistical software STATA 16.1 (Copyright 1985–2019 StataCorp LLC) was used for data analysis. Baseline descriptive data of the study population was calculated and reported based on the scale of the respective variables. For continuous variables, means with standard deviations or medians with interquartile ranges were calculated, depending on whether normality of distribution was confirmed (verified using Shapiro-Wilk test). Descriptive statistics for categorical variables was reported using frequencies. Incidence of hip fracture for the 2018 population aged ≥ 65 years was calculated and reported as annual incidence per 100,000 people. We then proceeded to calculate crude rates for the total male and female population and for the male and female population further stratified according to defined age groups (65–69, 70–74, 75–79, 80–84 and ≥ 85), as well as crude rates stratified by NUTS2 regions of Croatia. Incidence was calculated by dividing the respective number of incident cases by the corresponding population sizes. As the denominator in these calculations, official mid-2018 population estimates of the Croatian Bureau of Statistics were used. Survival analysis was performed with the Kaplan-Meier method. Kaplan-Meier curves were computed in order to ascertain survival estimates for the study population and to compare survival over time since hip fracture by sex, age group and fracture type. For the purposes of survival analysis, survival time was defined as the time from hospital admission date (entry to the study) until the date of death (outcome of interest; failure). All-cause death outcomes were included in the analysis. In cases when individuals did not experience the outcome of interest, they were followed-up until the end of the study period and were labelled as censored. Differences in the survival between different groups were assessed using the log-rank test. RESULTS According to the mid-year population estimates for 2018 for Croatia, the elderly population consisted of 337,148 males (41%) and 495,464 females (59%). Among these, we identified 5052 incident hip fractures using hospital discharge records (mean age 81.53 (SD = 7.28)) in 2018. Of all the incident hip fractures, 3856 (76.3%) were suffered by females and 1196 (23.7%) were suffered by males. There was a statistically significant difference between the mean values of age at which males and females experienced fracture (79.87 years and 82.05 years, two-sample t-test, p < 0.001). As shown in Table 1 , most of the hip fractures occurred in older age groups. More than 50% of all fractures were suffered by women aged 80 and older. In the 65–69 age group, there were about twice as many females with hip fracture as males, while in the 70–74 age group, the female-male ratio was about 3. In the oldest age group, the female to male patient ratio was 4. Fracture of neck of femur and pertrochanteric fracture were equally represented and together accounted for almost all hip fractures types suffered, while subtrochanteric fractures accounted for a considerably smaller fraction. Table 1 Demographic and clinical characteristics of elderly patients with hip fracture in Croatia, 2018 (N = 5052) Characteristic Total study population N = 5052 (100%) N % Age group (years) 65–69 383 7.6% 70–74 484 9.6% 75–79 945 18.7% 80–84 1360 26.9% ≥ 85 1880 37.2% total 5052 100.0% Sex Male 1196 23.7% Female 3856 76.3% total 5052 100.0% Type of fracture Fracture of neck of femur 2342 46.4% Pertrochanteric fracture 2328 46.1% Subtrochanteric fracture 382 7.5% total 5052 100.0% Region of residence Adriatic Croatia 1824 36.1% City of Zagreb 903 17.9% Northern Croatia 806 16.0% Pannonian Croatia 1519 30.0% total 5052 100.0% The incidence of hip fractures in the elderly population is more than twice as high in females, 778 per 100,000 versus males (355 per 100,000) (Fig. 1 ). The highest calculated incidence was in females and males aged ≥ 85 years. Incidence increases with age and the difference in the incidence between males and females increases in parallel. Stratified by NUTS2 regions, the incidence in Pannonian Croatia was the highest (681 per 100,000), followed by Adriatic Croatia (612 per 100,000) and the City of Zagreb region (586 per 100,000). Northern Croatia had the lowest incidence in 2018, calculated at 513 per 100,000. Of the study population, 50% died during the follow-up period. The number and distribution of patients that have died in the study period is detailed in Table 2 were the proportions shown are calculated out of the complete number of the patients that have died (2508 hip fracture patients). More deaths were observed in older groups. Within the first week of follow-up, 3% of the patients have died and by 3 months, 24%. One year after fracture, 37% of all the patients have died and by 2 years, 45%. Table 2 Number and proportion of elderly patients with hip fracture in 2018 that have deceased during the study period, Croatia, 2018–2020 (N = 2508) Age groups (years) Number (proportion) all patients male female 7 days after fracture 30 days after fracture 90 days after fracture 180 days after fracture 1 year after fracture 2 years after fracture 65–69 99 (3.9%) 51 (2.0%) 48 (1.9%) 3 (0.1%) 9 (0.4%) 30 (1.2%) 46 (1.8%) 59 (2.4%) 80 (3.2%) 70–74 152 (6.1%) 64 (2.6%) 88 (3.5%) 10 (0.4%) 29 (1.1%) 59 (2.4%) 81 (3.2%) 98 (3.9%) 134 (5.3%) 75–79 358 (14.2%) 116 (4.6%) 242 (9.6%) 18 (0.7%) 77 (3.1%) 147 (5.8%) 201 (8.0%) 246 (9.8%) 316 (12.6%) 80–84 666 (26.6%) 192 (7.7%) 474 (18.9%) 48 (0.9%) 168 (6.7%) 331 (13.2%) 417 (16.3%) 497 (19.8%) 616 (24.6%) ≥ 85 1233 (49.2%) 271 (10.8%) 962 (38.4%) 88 (3.5%) 321 (12.8%) 637 (25.4%) 804 (32.1%) 942 (37.5%) 1130 (45.1%) total 2508 (100.0%) 694 (27.7%) 1814 (72.3%) 167 (6.7%) 604 (24.1%) 1204 (48%) 1549 (61.4%) 1842 (73.4%) 2276 (90.8%) Among 5,052 patients, 8 displayed a survival time of zero days. Due to data quality concerns, we removed these 8 cases and performed the survival analysis based on the remaining 5,044 patients. Every patient had a single observation in the survival dataset and there were no subjects with delayed entry. The median survival time for the study population was 949 days (538 days for males, 1036 days for females). Survival at 7 days, 30 days, 90 days, 180 days, 1 year, 2 year and 3 years following hip fracture are shown in Table 3 . One month after fracture, 90% of female participants and 81% of the male participants were still alive. As more time elapsed after fracture, this difference in survival between males and females was more pronounced. Table 3 Proportion of surviving elderly patients with hip fracture (based on Kaplan-Meier survivor function estimate) at various follow-up times, 2018–2020 (N = 5052) 7 days 30 days 90 days 180 days 1 year 2 years 3 years All patients (5052) 97% 88% 76% 67% 64% 55% 45% Sex male 95% 81% 68% 61% 54% 46% - female 97% 90% 79% 72% 67% 58% 47% Age 65–69 99% 98% 92% 88% 85% 79% - 70–74 98% 94% 88% 83% 80% 72% 66% 75–79 98% 92% 85% 79% 74% 67% 53% 80–84 97% 88% 76% 69% 64% 55% 48% ≥ 85 96% 83% 66% 57% 50% 40% - A log-rank test was performed to assess the difference of survival functions between different groups of hip fracture patients. Survivorship between males and females who have suffered hip fracture differs significantly as females had almost double the survival time of males (p < 0.001). A statistically significant difference in survivorship was also found between different age groups (p < 0.001) and a test for trends confirmed that more deaths occur in older age groups (p < 0.001). Survivorship between patients residing in different regions also differs significantly (p = 0.036). The lowest median survival time was found for residents of Northern Croatia, while the highest was found for residents of the City of Zagreb. Survivorship between patients who have suffered different types of femur fracture did not differ significantly (p = 0.3848). The Kaplan-Meier curves present the survival of studied patients based on selected population characteristics (Fig. 2 ). DISCUSSION This was the first comprehensive study to evaluate the epidemiology and survival of elderly patients with hip fracture in Croatia. The overall crude incidence of hip fracture in elderly was 607/100,000, with a rate of 355/100 000 in males and 778/100 000 in females. The results show that hip fracture in this population is more frequent in females and in older are groups, which is supported by previous studies ( 2 , 5 , 11 , 17 ). Higher incidence in females across all age groups in this study support this. The age of males at hip fracture was significantly lower than that of females, which is also supported by results from recent survival studies ( 10 , 11 ). This can be partially explained by the simple fact that females, on average, live longer than males. There is also some indication that younger elderly males may possibly be more at risks, or be more active beyond their abilities. Hip fracture incidence across NUTS regions of the country slightly vary, possibly due to different age structure of the underlying populations, but no conclusions can be drawn as part of this analysis. The representation of different fracture types is difficult to compare with other studies as coding conventions for discharge diagnoses vary between countries and their respective systems. The higher number of observed deaths in females during the study period reflects the fact that incidence of hip fracture is substantially higher in women, rather than the fact that risk of mortality following hip fracture is higher, as female sex is a proven protective factor against mortality following hip fracture ( 10 ). Females in this study had almost double the survival time of males. The calculated survivor functions where consistently higher in females across the entire study period. The significant difference in survival between sexes showing men as having shorter survival after hip fracture is already well-established ( 10 ), as well as the fact that older individuals with hip fracture will have significantly shorter survival. The results showing that survivorship between patients who have suffered different types of femur fracture does not differ significantly is also supported by results from previous studies ( 10 , 18 ). The results of this study can be considered representative for all elderly people as the cohort was comprised of all Croatian elderly people that suffered hip fracture. Although comprehensive, this study does have some limitations. Only the hip-fracture patients who were identified through the hospital discharge database were included. Some cases could have been missed because they never reached hospital care and diagnosis (due to death or other reasons). However, it is unlikely that observing these missing hip fracture cases would have significantly altered the results. Furthermore, there is a number of factors that affect survivorship after hip fracture, besides age and sex that were not accounted for in this analysis (eg. type of treatment, time from fracture to treatment, comorbidities, osteoporosis and use of medications). No interpretation for competing risks is provided as part of this study. In conclusion, women aged ≥ 65 are more frequently affected by hip fracture, while men in the same age group have shorter survival after hip fracture. This is in line with the current knowledge on hip fracture. As hip fracture remains a major public concern, additional efforts in prevention of falls and education of the elderly about risk factors need to be undertaken. The difference in survivorship of patients based on the region of residence warrants further investigation, but more likely from a new perspective that would correspond to the gravitation of patients and hospital coverage areas, rather than the place of residence. Declarations Ethical approval This study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of the Croatian Institute of Public Health (approval number 030-02/22-02/5). Consent to participate The study was based on already available data of Croatian public health databases and registries, so obtaining consent to participate and publish was not necessary. There are no specific requirements to comply by in local law pertaining to secondary use of health data. Consent to publish Not applicable. Data Availability Statement The data analysed for this manuscript is part of routinely collected datasets gathered for national level public health monitoring and reporting. The data are available on request and can be provided by the Croatian Institute of Public Health (https://www.hzjz.hr/kako-se-prijaviti-za-pristup-zdravstvenim-podacima/). Competing interests No funding was received for conducting this study or for the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose. The authors have no conflicts of interest to declare that are relevant to the content of this article. The first author is an alumnus of The ECDC Fellowship Programme, Field Epidemiology path (EPIET), European Centre for Disease Prevention and Control (ECDC), Solna, Sweden. The author was a fellow of the ECDC Fellowship Programme, supported financially by the European Centre for Disease Prevention and Control. The views and opinions expressed herein do not state or reflect those of ECDC. ECDC is not responsible for the data and information collation and analysis and cannot be held liable for conclusions or opinions drawn. References Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2019 (GBD 2019). Seattle, United States of America: Institute for Health Metrics and Evaluation (IHME); 2016. Veronese N, Maggi S. Epidemiology and social costs of hip fracture. Injury. 2018;49(8):1458–60. Giversen IM. Time trends of mortality after first hip fractures. Osteoporos Int. 2007;18(6):721–32. Lystad RP, Cameron CM, Mitchell RJ. 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Epidemiology of hip fractures: Systematic literature review of German data and an overview of the international literature. Z Gerontol Geriatr. 2019;52(1):10–6. Maharlouei N, Jafarzadeh F, Rezaianzadeh A, Janfada M, Mesbahi A, Namazi H, et al. Survival analysis of patients with hip fracture, Shiraz, Iran. Arch Osteoporos. 2020;15(1):33. Yong EL, Ganesan G, Kramer MS, Howe TS, Koh JSB, Thu WP, et al. Risk Factors and Trends Associated With Mortality Among Adults With Hip Fracture in Singapore. JAMA Netw Open. 2020;3(2):e1919706. In-patient Statistics Form database [Internet]. Croatia: CIPH. 2017–20 [cited 23 September 2022]. Erceg M, Miler Knežević A. Izvješće o umrlim osobama u Hrvatskoj u 2020. godini [Report on deceased persons in Croatia in 2020]. Zagreb (Croatia): CIPH; 2021 Sept. p. 12. Popis stanovništva, kućanstava i stanova u Republici Hrvatskoj. 2011 [National population census of Croatia 2011][Internet]. Zagreb (Croatia): Državni zavod za statistiku; 2012. Popis stanovništva, kućanstava i stanova u Republici Hrvatskoj. 2021 [National population census of Croatia 2021][Internet]. Zagreb (Croatia): Državni zavod za statistiku; 2022. Capak K. Rezultati projekta EUROSTAT ‘Morbidity Statistics’, Rezultati za Hrvatsku [Results of the EUROSTAT ‘Morbidity Statistics’ project, Results for Croatia]. Zagreb (Croatia): CIPH; 2022. p. 67. Maggi S, Kelsey JL, Litvak J, Heyse SP. Incidence of hip fractures in the elderly: a cross-national analysis. Osteoporos Int. 1991;1(4):232–41. Kilci O, Un C, Sacan O, Gamli M, Baskan S, Baydar M, et al. Postoperative Mortality after Hip Fracture Surgery: A 3 Years Follow Up. PLoS ONE. 2016;11(10):e0162097. Additional Declarations No competing interests reported. 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Health","correspondingAuthor":false,"prefix":"","firstName":"Zvjezdana","middleName":"Lovrić","lastName":"Makarić","suffix":""},{"id":591409215,"identity":"b2830133-096e-474c-b2bc-948165f73753","order_by":11,"name":"Ivana Brkić Biloš","email":"","orcid":"","institution":"Croatian Institute of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Ivana","middleName":"Brkić","lastName":"Biloš","suffix":""}],"badges":[],"createdAt":"2026-01-19 12:25:53","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8639446/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8639446/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102861763,"identity":"4314050d-1e3a-466f-8cbc-d9003bdcccd6","added_by":"auto","created_at":"2026-02-17 16:12:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":35372,"visible":true,"origin":"","legend":"\u003cp\u003eIncidence of hip fracture per 100,000 population by sex and age groups, Croatia. 2018 (N=5052)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8639446/v1/6033f65b463a575022830881.png"},{"id":102861762,"identity":"6dbbe498-60fa-42f6-82be-a39cdd4eaa6d","added_by":"auto","created_at":"2026-02-17 16:12:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":992164,"visible":true,"origin":"","legend":"\u003cp\u003eSurvival in 5052 elderly patients up to 3 years following hip fracture by sex, age group, hip fracture type and region of residence­­, Croatia. 2018 (N=5052)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8639446/v1/3886c884ff89cc456e6b43d7.png"},{"id":103056577,"identity":"352fcc19-d403-49eb-aea0-a5f6590cdbe9","added_by":"auto","created_at":"2026-02-20 09:16:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2016867,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8639446/v1/85cd24c5-6cf3-489c-8aeb-5ff8e297a64c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Survival after hip fracture in the elderly population of Croatia","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eFemur fractures are a common cause of morbidity and mortality in elderly people (\u0026ge;\u0026thinsp;65 years of age). They are usually the result of a fall, with the proximal femur being especially fragile, even in the absence of great force. According to the Global Burden of Disease Study (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), in 2019 there were an estimated 14.2\u0026nbsp;million cases of hip fractures in the world, which is an increase of 92.7% compared to 1990. Of those, 6.6\u0026nbsp;million fractures (47%) occurred in people over 70 years of age, which is an increase of 188% for hip fractures in this age group from 1990. Due to aging population we can expect further increase of the number of hip fractures and related societal costs (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFractures of the proximal part of the femur manifest as either femoral neck, trochanteric area, or subtrochanteric area fractures, and are often referred to as hip fractures. Since hip fracture is a serious clinical event that requires hospitalization, this diagnosis is generally accurately coded in hospital systems, using the ICD-10 codes S72.0, S72.1 and S72.2 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eExcess mortality after hip fracture in the elderly population is a recognized phenomenon (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), and is the result of many different factors: the trauma of the injury itself, complications of a subsequent surgery, existing comorbidities and complications that come with a prolonged period of immobility. The results of studies investigating 1-year post-fracture mortality range from 15%-40%, depending on the source (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). A recent review on post-fracture mortality rates (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) stated that those figures might be outdated; due to optimization in registration and follow-up of patients, 1-year mortality rate could be around 22%.\u003c/p\u003e \u003cp\u003eIn recently conducted survival studies where hip fracture patients were aged 50 years and above (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), it was found that survival rates were lower among men and in older age groups. Differences in survival rates pertaining to sex diminished over time, but only after a long follow-up period had elapsed. Results on survival difference based on the type of fracture were not conclusive, with one study (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) reporting no difference, and the other lower survival for trochanteric fracture (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAround 40% of all hospitalizations due to injuries in Croatia are recorded in elderly people, and the proportion is even more pronounced for femur fractures; 84% of them occur in people older than 65. Femur fractures also represent more than a third (37%) off all injury-related hospital discharges in Croatia in this age group (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCroatian routine mortality and morbidity statistics show that femur fracture is not only the most common cause of injury-related hospitalizations, but also the most common cause among all injury-related deaths. Latest mortality data for 2020 report 652 deaths as a direct consequence of a femur fracture, 98% of which happened in people over 65 years of age (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo our knowledge, no survival analysis was done on routinely collected data on hospital discharges and mortality related to hip fractures in Croatia. The results of the EUROSTAT \"Morbidity Statistics\" project for Croatia report of a total of 3 981 incident femur fractures (crude rate 121.3/100,000) in the elderly people in 2017 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e); but no further analysis was performed on the data.\u003c/p\u003e \u003cp\u003eGiven the public health burden that hip fractures present in the elderly population, and aging population that will only increase the size of the problem, our aim is to present data on incidence of hip fracture in the \u0026ge;\u0026thinsp;65 age group in Croatia and analyse their survival to the extent to which validated national data are available at this moment. The results could inform public health policies and clinical practice guidelines.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eThe study was conducted as a retrospective, population-based cohort study of individuals aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years using linked secondary health data stemming from hospital discharges in Croatia during 2018 and national mortality records from 1 January 2018 to 31 December 2020. A unique, national level identifier allowed for linking of individual patient data across the different databases, which are integral parts of The National Public Health Information System within the Croatian Institute of Public Health.\u003c/p\u003e \u003cp\u003eThe study population comprised of all individuals who were hospitalized in Croatian health-care institutions in 2018 with hip fracture (ICD-10 codes: S72.0, S72.1 and S72.2) coded as the leading or as any other discharge diagnosis, aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years at admission. Taking into account the severity of hip fracture and need for intervention and treatment, patients diagnosed with hip fracture are always admitted to hospital, even if only a conservative treatment approach is pursued. Therefore, the hospital discharges stand as a valuable principal source of information for hip fracture cases in Croatia. The hospital admission date was chosen as an adequate proxy for exposure, i.e. incident hip fracture. Each individual was counted only once in case they had more than one hospital discharge related to hip fracture in the year of observation. Individuals discharged from rehabilitation and physical therapy wards, as well as individuals discharged from day hospitals were not included, as these hospitalizations are unlikely to represent incident hip fracture cases. The possible cases were analysed in more detail to account for their eligibility. Efforts were made to address potential case ascertainment bias that arises when using secondary data from hospital discharges.\u003c/p\u003e \u003cp\u003eThe following cases were also not included:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ecases with ICD-10 diagnosis from T group coded as the leading discharge diagnosis (representing hospitalizations due to complications of orthopaedic prosthetic devices and other post-surgical complications, and not incident hip fractures)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ecases with ICD-10 diagnosis from Z group coded as the leading discharge diagnosis (representing hospitalizations due to orthopaedic follow-up care and palliative care, and not incident hip fractures)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ecases with ICD-10 diagnosis from C group coded as the leading discharge diagnosis (most probably representing patients with a pathological fracture due to the underlying malignant disease, not representative of the study population)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eAll cases were followed until death or until end of the study (31 December 2020). This constitutes up to 3 years following the hip fracture admission date.\u003c/p\u003e \u003cp\u003eThe variables of interest were complete for every individual case: sex, date of birth, hospital admission date, hospital discharge date, leading discharge diagnosis, other discharge diagnoses (if fitting the criteria of ICD-10 codes S72.0-S72.2) and county of residence. Date of death was ascertained for all cases that have deceased in the study period.\u003c/p\u003e \u003cp\u003eStatistical software STATA 16.1 (Copyright 1985\u0026ndash;2019 StataCorp LLC) was used for data analysis.\u003c/p\u003e \u003cp\u003eBaseline descriptive data of the study population was calculated and reported based on the scale of the respective variables. For continuous variables, means with standard deviations or medians with interquartile ranges were calculated, depending on whether normality of distribution was confirmed (verified using Shapiro-Wilk test). Descriptive statistics for categorical variables was reported using frequencies.\u003c/p\u003e \u003cp\u003eIncidence of hip fracture for the 2018 population aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years was calculated and reported as annual incidence per 100,000 people. We then proceeded to calculate crude rates for the total male and female population and for the male and female population further stratified according to defined age groups (65\u0026ndash;69, 70\u0026ndash;74, 75\u0026ndash;79, 80\u0026ndash;84 and \u0026ge;\u0026thinsp;85), as well as crude rates stratified by NUTS2 regions of Croatia. Incidence was calculated by dividing the respective number of incident cases by the corresponding population sizes. As the denominator in these calculations, official mid-2018 population estimates of the Croatian Bureau of Statistics were used.\u003c/p\u003e \u003cp\u003eSurvival analysis was performed with the Kaplan-Meier method. Kaplan-Meier curves were computed in order to ascertain survival estimates for the study population and to compare survival over time since hip fracture by sex, age group and fracture type. For the purposes of survival analysis, survival time was defined as the time from hospital admission date (entry to the study) until the date of death (outcome of interest; failure). All-cause death outcomes were included in the analysis. In cases when individuals did not experience the outcome of interest, they were followed-up until the end of the study period and were labelled as censored. Differences in the survival between different groups were assessed using the log-rank test.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eAccording to the mid-year population estimates for 2018 for Croatia, the elderly population consisted of 337,148 males (41%) and 495,464 females (59%). Among these, we identified 5052 incident hip fractures using hospital discharge records (mean age 81.53 (SD\u0026thinsp;=\u0026thinsp;7.28)) in 2018. Of all the incident hip fractures, 3856 (76.3%) were suffered by females and 1196 (23.7%) were suffered by males. There was a statistically significant difference between the mean values of age at which males and females experienced fracture (79.87 years and 82.05 years, two-sample t-test, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). As shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, most of the hip fractures occurred in older age groups. More than 50% of all fractures were suffered by women aged 80 and older. In the 65\u0026ndash;69 age group, there were about twice as many females with hip fracture as males, while in the 70\u0026ndash;74 age group, the female-male ratio was about 3. In the oldest age group, the female to male patient ratio was 4. Fracture of neck of femur and pertrochanteric fracture were equally represented and together accounted for almost all hip fractures types suffered, while subtrochanteric fractures accounted for a considerably smaller fraction.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and clinical characteristics of elderly patients with hip fracture in Croatia, 2018 (N\u0026thinsp;=\u0026thinsp;5052)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eTotal study population\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;5052 (100%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eAge group (years)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e65\u0026ndash;69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e383\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e70\u0026ndash;74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e484\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e75\u0026ndash;79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e945\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e80\u0026ndash;84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1360\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1880\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3856\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eType of fracture\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFracture of neck of femur\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2342\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePertrochanteric fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2328\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubtrochanteric fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e382\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eRegion of residence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdriatic Croatia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1824\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCity of Zagreb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e903\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorthern Croatia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e806\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePannonian Croatia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1519\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe incidence of hip fractures in the elderly population is more than twice as high in females, 778 per 100,000 versus males (355 per 100,000) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The highest calculated incidence was in females and males aged\u0026thinsp;\u0026ge;\u0026thinsp;85 years. Incidence increases with age and the difference in the incidence between males and females increases in parallel.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eStratified by NUTS2 regions, the incidence in Pannonian Croatia was the highest (681 per 100,000), followed by Adriatic Croatia (612 per 100,000) and the City of Zagreb region (586 per 100,000). Northern Croatia had the lowest incidence in 2018, calculated at 513 per 100,000.\u003c/p\u003e \u003cp\u003eOf the study population, 50% died during the follow-up period. The number and distribution of patients that have died in the study period is detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e were the proportions shown are calculated out of the complete number of the patients that have died (2508 hip fracture patients). More deaths were observed in older groups. Within the first week of follow-up, 3% of the patients have died and by 3 months, 24%. One year after fracture, 37% of all the patients have died and by 2 years, 45%.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumber and proportion of elderly patients with hip fracture in 2018 that have deceased during the study period, Croatia, 2018\u0026ndash;2020 (N\u0026thinsp;=\u0026thinsp;2508)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge groups (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"9\" nameend=\"c10\" namest=\"c2\"\u003e \u003cp\u003eNumber (proportion)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eall patients\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003emale\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003efemale\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e7 days after fracture\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e30 days after fracture\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e90 days after fracture\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e180 days after fracture\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e1 year after fracture\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e2 years after fracture\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e65\u0026ndash;69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e99 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003cp\u003e(2.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3 (0.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e46 (1.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e59 (2.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e80 (3.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e70\u0026ndash;74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e152 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e88 (3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e29 (1.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e59 (2.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e81 (3.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e98 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e134 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e75\u0026ndash;79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e358 (14.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e116 (4.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e242 (9.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e77 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e147 (5.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e201 (8.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e246 (9.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e316 (12.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e80\u0026ndash;84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e666 (26.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e192 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e474 (18.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e48 (0.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e168 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e331 (13.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e417 (16.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e497\u003c/p\u003e \u003cp\u003e(19.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e616 (24.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1233 (49.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e271 (10.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e962 (38.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e88 (3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e321 (12.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e637 (25.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e804 (32.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e942 (37.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1130 (45.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2508 (100.0%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e694 (27.7%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1814 (72.3%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e167 (6.7%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e604 (24.1%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e1204 (48%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e1549 (61.4%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e1842 (73.4%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e2276 (90.8%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmong 5,052 patients, 8 displayed a survival time of zero days. Due to data quality concerns, we removed these 8 cases and performed the survival analysis based on the remaining 5,044 patients. Every patient had a single observation in the survival dataset and there were no subjects with delayed entry. The median survival time for the study population was 949 days (538 days for males, 1036 days for females). Survival at 7 days, 30 days, 90 days, 180 days, 1 year, 2 year and 3 years following hip fracture are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. One month after fracture, 90% of female participants and 81% of the male participants were still alive. As more time elapsed after fracture, this difference in survival between males and females was more pronounced.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eProportion of surviving elderly patients with hip fracture (based on Kaplan-Meier survivor function estimate) at various follow-up times, 2018\u0026ndash;2020 (N\u0026thinsp;=\u0026thinsp;5052)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 days\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 days\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e90 days\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e180 days\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3 years\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(5052)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e76%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e67%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e64%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e55%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e45%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e61%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e54%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e46%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e72%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e67%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e58%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e47%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65\u0026ndash;69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e98%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e92%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e88%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e85%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e79%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70\u0026ndash;74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e88%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e83%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e80%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e72%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e66%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75\u0026ndash;79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e85%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e79%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e74%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e67%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e53%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80\u0026ndash;84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e76%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e69%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e64%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e55%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e48%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e66%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e57%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e40%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA log-rank test was performed to assess the difference of survival functions between different groups of hip fracture patients. Survivorship between males and females who have suffered hip fracture differs significantly as females had almost double the survival time of males (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A statistically significant difference in survivorship was also found between different age groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and a test for trends confirmed that more deaths occur in older age groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Survivorship between patients residing in different regions also differs significantly (p\u0026thinsp;=\u0026thinsp;0.036). The lowest median survival time was found for residents of Northern Croatia, while the highest was found for residents of the City of Zagreb. Survivorship between patients who have suffered different types of femur fracture did not differ significantly (p\u0026thinsp;=\u0026thinsp;0.3848).\u003c/p\u003e \u003cp\u003eThe Kaplan-Meier curves present the survival of studied patients based on selected population characteristics (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis was the first comprehensive study to evaluate the epidemiology and survival of elderly patients with hip fracture in Croatia. The overall crude incidence of hip fracture in elderly was 607/100,000, with a rate of 355/100 000 in males and 778/100 000 in females. The results show that hip fracture in this population is more frequent in females and in older are groups, which is supported by previous studies (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Higher incidence in females across all age groups in this study support this. The age of males at hip fracture was significantly lower than that of females, which is also supported by results from recent survival studies (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This can be partially explained by the simple fact that females, on average, live longer than males. There is also some indication that younger elderly males may possibly be more at risks, or be more active beyond their abilities.\u003c/p\u003e \u003cp\u003eHip fracture incidence across NUTS regions of the country slightly vary, possibly due to different age structure of the underlying populations, but no conclusions can be drawn as part of this analysis. The representation of different fracture types is difficult to compare with other studies as coding conventions for discharge diagnoses vary between countries and their respective systems.\u003c/p\u003e \u003cp\u003eThe higher number of observed deaths in females during the study period reflects the fact that incidence of hip fracture is substantially higher in women, rather than the fact that risk of mortality following hip fracture is higher, as female sex is a proven protective factor against mortality following hip fracture (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Females in this study had almost double the survival time of males. The calculated survivor functions where consistently higher in females across the entire study period. The significant difference in survival between sexes showing men as having shorter survival after hip fracture is already well-established (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), as well as the fact that older individuals with hip fracture will have significantly shorter survival. The results showing that survivorship between patients who have suffered different types of femur fracture does not differ significantly is also supported by results from previous studies (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe results of this study can be considered representative for all elderly people as the cohort was comprised of all Croatian elderly people that suffered hip fracture. Although comprehensive, this study does have some limitations. Only the hip-fracture patients who were identified through the hospital discharge database were included. Some cases could have been missed because they never reached hospital care and diagnosis (due to death or other reasons). However, it is unlikely that observing these missing hip fracture cases would have significantly altered the results. Furthermore, there is a number of factors that affect survivorship after hip fracture, besides age and sex that were not accounted for in this analysis (eg. type of treatment, time from fracture to treatment, comorbidities, osteoporosis and use of medications). No interpretation for competing risks is provided as part of this study.\u003c/p\u003e \u003cp\u003eIn conclusion, women aged\u0026thinsp;\u0026ge;\u0026thinsp;65 are more frequently affected by hip fracture, while men in the same age group have shorter survival after hip fracture. This is in line with the current knowledge on hip fracture. As hip fracture remains a major public concern, additional efforts in prevention of falls and education of the elderly about risk factors need to be undertaken. The difference in survivorship of patients based on the region of residence warrants further investigation, but more likely from a new perspective that would correspond to the gravitation of patients and hospital coverage areas, rather than the place of residence.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of the Croatian Institute of Public Health (approval number 030-02/22-02/5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was based on already available data of Croatian public health databases and registries, so obtaining consent to participate and publish was not necessary. There are no specific requirements to comply by in local law pertaining to secondary use of health data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data analysed for this manuscript is part of routinely collected datasets gathered for national level public health monitoring and reporting. The data are available on request and can be provided by the Croatian Institute of Public Health (https://www.hzjz.hr/kako-se-prijaviti-za-pristup-zdravstvenim-podacima/). \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for conducting this study or for the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose. The authors have no conflicts of interest to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The first author is an alumnus of The ECDC Fellowship Programme, Field Epidemiology path (EPIET), European Centre for Disease Prevention and Control (ECDC), Solna, Sweden. The author was a fellow of the ECDC Fellowship Programme, supported financially by the European Centre for Disease Prevention and Control. The views and opinions expressed herein do not state or reflect those of ECDC. ECDC is not responsible for the data and information collation and analysis and cannot be held liable for conclusions or opinions drawn.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGlobal Burden of Disease Collaborative Network. Global Burden of Disease Study 2019 (GBD 2019). Seattle, United States of America: Institute for Health Metrics and Evaluation (IHME); 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeronese N, Maggi S. Epidemiology and social costs of hip fracture. Injury. 2018;49(8):1458\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiversen IM. Time trends of mortality after first hip fractures. Osteoporos Int. 2007;18(6):721\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLystad RP, Cameron CM, Mitchell RJ. Mortality risk among older Australians hospitalised with hip fracture: a population-based matched cohort study. Arch Osteoporos. 2017;12(1):67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilk R, Skrzypek M, Kowalska M, Koczy B, Zag\u0026oacute;rski P, Pluskiewicz W. The 13-year observation of hip fracture in Poland-worrying trend and prognosis for the future. Aging Clin Exp Res. 2018;30(1):61\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSing CW, Lin TC, Bartholomew S, Bell JS, Bennett C, Beyene K, et al. Global epidemiology of hip fractures: a study protocol using a common analytical platform among multiple countries. BMJ Open. 2021;11(7):e047258.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbrahamsen B, van Staa T, Ariely R, Olson M, Cooper C. Excess mortality following hip fracture: a systematic epidemiological review. Osteoporos Int. 2009;20(10):1633\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuh YS, Kim YB, Choi HS, Yoon HK, Seo GW, Lee BI. Postoperative Mortality and the Associated Factors in Elderly Patients with Hip Fracture. J Korean Orthop Association. 2012;47:445.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRapp K, B\u0026uuml;chele G, Dreinh\u0026ouml;fer K, B\u0026uuml;cking B, Becker C, Benzinger P. Epidemiology of hip fractures: Systematic literature review of German data and an overview of the international literature. Z Gerontol Geriatr. 2019;52(1):10\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaharlouei N, Jafarzadeh F, Rezaianzadeh A, Janfada M, Mesbahi A, Namazi H, et al. Survival analysis of patients with hip fracture, Shiraz, Iran. Arch Osteoporos. 2020;15(1):33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYong EL, Ganesan G, Kramer MS, Howe TS, Koh JSB, Thu WP, et al. Risk Factors and Trends Associated With Mortality Among Adults With Hip Fracture in Singapore. JAMA Netw Open. 2020;3(2):e1919706.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIn-patient Statistics Form database [Internet]. Croatia: CIPH. 2017\u0026ndash;20 [cited 23 September 2022].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErceg M, Miler Knežević A. Izvješće o umrlim osobama u Hrvatskoj u 2020. godini [Report on deceased persons in Croatia in 2020]. Zagreb (Croatia): CIPH; 2021 Sept. p. 12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePopis stanovništva, kućanstava i stanova u Republici Hrvatskoj. 2011 [National population census of Croatia 2011][Internet]. Zagreb (Croatia): Državni zavod za statistiku; 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePopis stanovništva, kućanstava i stanova u Republici Hrvatskoj. 2021 [National population census of Croatia 2021][Internet]. Zagreb (Croatia): Državni zavod za statistiku; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCapak K. Rezultati projekta EUROSTAT \u0026lsquo;Morbidity Statistics\u0026rsquo;, Rezultati za Hrvatsku [Results of the EUROSTAT \u0026lsquo;Morbidity Statistics\u0026rsquo; project, Results for Croatia]. Zagreb (Croatia): CIPH; 2022. p. 67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaggi S, Kelsey JL, Litvak J, Heyse SP. Incidence of hip fractures in the elderly: a cross-national analysis. Osteoporos Int. 1991;1(4):232\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKilci O, Un C, Sacan O, Gamli M, Baskan S, Baydar M, et al. Postoperative Mortality after Hip Fracture Surgery: A 3 Years Follow Up. PLoS ONE. 2016;11(10):e0162097.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Femur fracture, survival","lastPublishedDoi":"10.21203/rs.3.rs-8639446/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8639446/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eAims\u003c/h2\u003e \u003cp\u003eTo determine the incidence of hip fracture in elderly people (\u0026ge;\u0026thinsp;65) in Croatia, and to analyse survival by sex, age group, residence and fracture type.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eTo identify individual patients with hip fracture and data on death, we used the Hospital Discharge Database for the period of calendar year 2018 and the Cause of Death Database for the period from 1 January 2018 to 31 December 2020. Incidence of hip fracture was estimated and reported as annual incidence per 100,000 people for 2018, further stratified by age, sex and region of residence. Survival analysis was performed with the Kaplan-Meier method. Survivor function was calculated and presented at various follow-up times.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e5052 hip fracture cases among the elderly in 2018 were identified. The overall crude incidence of hip fracture in 2018 was 607/100,000 (355/100,000 in males and 778/100,000 in females). Higher incidence was estimated in females across all age groups. Males had a shorter median survival time than females (538 days versus 1036 days). Log-rank test confirmed the significance of difference in survivorship between the sexes, as well as between different age groups and between patients residing in different regions. Survivorship between patients who have suffered different types of femur fracture did not differ significantly.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eElderly females are more affected by hip fracture in terms of incidence, while men have shorter survival. Results for Croatia are in line with the current knowledge. As hip fracture remains a major public concern, additional efforts need to be put in prevention.\u003c/p\u003e","manuscriptTitle":"Survival after hip fracture in the elderly population of Croatia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-17 16:12:54","doi":"10.21203/rs.3.rs-8639446/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-17T13:09:44+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-01T14:11:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-26T10:15:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"297156611520847785755299371005145983183","date":"2026-02-18T11:38:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"98156451597264492979283446541303114432","date":"2026-02-14T15:41:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"167561796617834667540687476577250180156","date":"2026-02-14T10:38:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"190239411649200982337311451069112821775","date":"2026-02-12T12:52:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-12T10:30:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-30T16:28:25+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-29T14:22:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-29T13:15:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2026-01-29T12:48:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"61cb726f-fafd-4768-bac0-fd783175e701","owner":[],"postedDate":"February 17th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-27T21:38:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-17 16:12:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8639446","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8639446","identity":"rs-8639446","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}