Geographical variation in surgical care and mortality following hip fracture in England: a cohort study using the National Hip Fracture Database (NHFD)

Anjali Shah, Sam Hawley*, Dominic Inman, Cyrus Cooper, Elizabeth Fagan, Antony Johansen, Andrew Judge

*Corresponding author for this work

Research output: Contribution to journalArticle (Academic Journal)peer-review

3 Citations (Scopus)
34 Downloads (Pure)


We describe variation across geographical regions of England in operations undertaken following presentation of hip fracture and in 30-day mortality. Some significant geographic variation in 30-day mortality was observed particularly for patients with trochanteric hip fractures and warrants further investigation of other aspects of post-hip fracture care

Mortality after hip fracture has improved considerably in the UK over recent decades. Our aim here was to describe geographical variation in type of operation performed and 30-day mortality amongst patients in England with hip fracture.

The National Hip Fracture Database was used to carry out a prospective cohort study of nearly all over-60 year olds with hip fracture in England. These data were linked to Hospital Episode Statistics (HES), allowing us to explore regional variation in the operations performed for three fracture types (intracapsular, trochanteric and subtrochanteric), and use logistic regression models adjusted for demographic and clinical factors to describe associated 30-day mortality.

NHFD recorded data for 64,211 patients who underwent surgery in England during 2017. Most had an intracapsular (59%) or trochanteric fracture (35%), and we found significant geographical variation across regions of England in use of total hip replacement (THR) (ranging from 10.1 to 17.4%) for intracapsular fracture and in intermedullary nailing (ranging from 14.9 to 27.0%) of trochanteric fracture. Some geographical variation in mortality amongst intracapsular fracture patients was found, with slightly higher mortality in the East of England (adjusted odds ratio [aOR]: 1.22, 95% CI: 1.02–1.46). Trochanteric fractures showed slightly more variation, with higher 30-day mortality (aOR: 1.40, 95%CI: 1.05–1.88) in the East of England and significantly lower mortality in the North East (aOR: 0.65, 95%CI: 0.46–0.93).

We have identified regional differences in operation type and 30-day mortality amongst hip fracture patients in England. The relationship between surgical approach and mortality has been explored, but the extent to which differential mortality reflects variation in approach to medical assessment, anaesthesia and other aspects of care warrants further investigation.v
Original languageEnglish
Pages (from-to)1989-1998
Number of pages10
JournalOsteoporosis International
Issue number10
Early online date25 Mar 2021
Publication statusPublished - Oct 2021

Bibliographical note

Funding Information:
This work was performed as part of a Royal College of Physicians (RCP) audit programme commissioned by the HealthCare Quality Improvement Partnership (HQIP). This study was also supported by the NIHR Biomedical Research Centre (BRC) at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol, and from the Oxford NIHR Musculoskeletal BRC, Nuffield Orthopaedic Centre, and University of Oxford. The funding source had no role in the design and conduct of the study, in the collection, analysis and interpretation of the data, or in the preparation, review or approval of the manuscript.

Publisher Copyright:
© 2021, International Osteoporosis Foundation and National Osteoporosis Foundation.


  • hip fracture
  • surgery
  • geographical variation
  • mortality
  • epidemiology


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