Association Between Long‑Term Exposure to Air Pollution and the Rate of Mortality After Hip Fracture Surgery in Patients Older Than 60 Years: Nationwide Cohort Study in Taiwan

Abstract

Background: To enhance postoperative patient survival, particularly in older adults, understanding the predictors of mortality following hip fracture becomes paramount. Air pollution, a prominent global environmental issue, has been linked to heightened morbidity and mortality across a spectrum of diseases. Nevertheless, the precise impact of air pollution on hip fracture outcomes remains elusive.

Objective: This retrospective study aims to comprehensively investigate the profound influence of a decade-long exposure to 12 diverse air pollutants on the risk of post-hip fracture mortality among older Taiwanese patients (older than 60 years). We hypothesized that enduring long-term exposure to air pollution would significantly elevate the 1-year mortality rate following hip fracture surgery.

Methods: From Taiwan's National Health Insurance Research Database, we obtained the data of patients who underwent hip fracture surgery between July 1, 2003, and December 31, 2013. Using patients' insurance registration data, we estimated their cumulative exposure levels to sulfur dioxide (SO₂), carbon dioxide (CO₂), carbon monoxide (CO), ozone (O₃), particulate matter having a size of <10 μm (PM₁₀), particulate matter having a size of <2.5 μm (PM_2.5), nitrogen oxides (NO_X), nitrogen monoxide (NO), nitrogen dioxide (NO₂), total hydrocarbons (THC), nonmethane hydrocarbons (NMHC), and methane (CH₄). We quantified the dose-response relationship between these air pollutants and the risk of mortality by calculating hazard ratios associated with a 1 SD increase in exposure levels over a decade.

Results: Long-term exposure to SO₂, CO, PM₁₀, PM_2.5, NO_X, NO, NO₂, THC, NMHC, and CH₄ demonstrated significant associations with heightened all-cause mortality risk within 1 year post hip fracture surgery among older adults. For older adults, each 1 SD increment in the average exposure levels of SO₂, CO, PM₁₀, PM_2.5, NO_X, NO, NO₂, THC, NMHC, and CH₄ corresponded to a substantial escalation in mortality risk, with increments of 14%, 49%, 18%, 12%, 41%, 33%, 38%, 20%, 9%, and 26%, respectively. We further noted a 35% reduction in the hazard ratio for O₃ exposure suggesting a potential protective effect, along with a trend of potentially protective effects of CO₂.

Conclusions: This comprehensive nationwide retrospective study, grounded in a population-based approach, demonstrated that long-term exposure to specific air pollutants significantly increased the risk of all-cause mortality within 1 year after hip fracture surgery in older Taiwanese adults. A reduction in the levels of SO₂, CO, PM₁₀, PM_2.5, NO_X, NO, NO₂, THC, NMHC, and CH₄ may reduce the risk of mortality after hip fracture surgery. This study provides robust evidence and highlights the substantial impact of air pollution on the outcomes of hip fractures.

Keywords: air pollution; environmental hazard; exposure; hazard; hip fracture; morbidity; mortality; older adult.