Regionalization of Hip Fracture Care in Five High-Income Countries

Objective: To describe differences in regionalization of hip fracture care and the volume-outcome relationship in five countries. Study Setting and Design: We conducted a population-based cross-sectional cohort study in Canada, Israel, the Netherlands, Taiwan, and the United States. Within each country, we stratified patients into quintiles based upon the volume of hip fractures in the hospital where they were treated. We measured regionalization by the proportion of acute-care hospitals that treated patients with hip fractures and summarized the hospital volume distribution by the ratio of hip fracture volumes for high-volume hospitals versus low-volume hospitals. We then examined age- and sex-standardized outcomes and treatment for patients treated at high-volume and low-volume hospitals. Data Sources and Analytic Sample: We used nationally representative administrative data on adults aged ≥ 66 years hospitalized with hip fracture from 2011 to 2019. We followed them until death or 365 days after the discharge date. Principal Findings: Across countries, the percentage of all acute-care hospitals that treated hip fractures differed widely (from 37.0% in Canada to 82.8% in Israel), with high-volume hospitals treating 4–14 times as many hip fractures as low-volume hospitals. The absolute risk-adjusted difference in 30-day mortality for high-volume compared to low-volume hospitals ranged between (−1.9% [95% CI, −2.2 to −1.7] in Canada and +1.1% [95% CI, 0.4–1.8] in the Netherlands). The proportion of patients receiving non-operative fracture treatment was lower in high-volume hospitals than low-volume hospitals in all countries (−5.4% [95% CI, −6.5 to −4.3] in Israel to −0.1% [95% CI, −0.5 to 0.3] in the Netherlands). Conclusions: Hip fracture regionalization differed substantially across countries. The direction and the magnitude of association between greater regionalization and improved patient outcomes were inconsistent across countries.