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Comparative Study
. 2025 Aug;40(11):2602-2612.
doi: 10.1007/s11606-024-09274-9. Epub 2024 Dec 20.

Comparison of Management and Outcomes of Hip Fractures Among Low- and High-Income Patients in Six High-Income Countries

Nicole Huang  1 , Laura A Hatfield  2 , Saeed Al-Azazi  3   4 , Pieter Bakx  5 , Amitava Banerjee  6   7 , Nitzan Burrack  8 , Yu-Chin Chen  9 , Christina Fu  2 , Carlos Godoy Junior  5 , Renaud Heine  5 , Dennis T Ko  10   11   12 , Lisa M Lix  3   4 , Victor Novack  8 , Laura Pasea  6 , Feng Qiu  11 , Bheeshma Ravi  13   14 , Therese A Stukel  11   13   15 , Carin Uyl-de Groot  5 , Peter Cram #  12   15   16 , Bruce E Landon #  2   17
Affiliations
Comparative Study

Comparison of Management and Outcomes of Hip Fractures Among Low- and High-Income Patients in Six High-Income Countries

Nicole Huang et al. J Gen Intern Med. 2025 Aug.

Abstract

Background: There is a perception that income-based disparities are present in most countries but may differ in magnitude. However, there are few international comparisons that describe income-based disparities across countries and none that focus on hip fractures.

Objective: To compare treatment patterns and outcomes of high- and low-income older adults hospitalized with hip fracture across six high-income countries.

Design: Retrospective serial cross-sectional cohort study.

Participants: Adults aged ≥ 66 years hospitalized with hip fracture from 2013 to 2019 in Canada, England, Israel, the Netherlands, Taiwan, and the USA using population-representative patient-level administrative data.

Main measures: Older adults in the top and bottom income quintiles within countries were compared on 30-day and 1-year mortality, treatment approaches, hospital length of stay (LOS), 30-day readmission rates, time to surgery, and discharge disposition.

Key results: Annual age- and sex-standardized incidence rates of hip fracture were higher for low- than for high-income populations in all countries except in the USA. In all countries, adjusted 1-year mortality was lower for high-income than low-income patients, with the largest difference in Israel (- 10.0 percentage points [95% confidence interval [CI], - 15.2 to - 4.8 percentage points]). Across countries, utilization of total hip arthroplasty was 0.1 (95% CI, 0.0-0.2 percentage points) to 6.9 percentage points (95% CI, 4.6-9.2 percentage points) higher among high- vs. low-income populations. With few exceptions, LOS, adjusted 30-day readmission rate, and time to surgery were shorter and lower for high-income patients.

Conclusions: Income-based disparities in treatments and outcomes for older adults hospitalized for hip fractures differed in magnitude, but were present in all six high-income countries. Defying our expectations, the USA did not have consistently larger disparities than other countries suggesting that the impacts of poverty exist in vastly different healthcare systems and transcend geopolitical borders.

Keywords: Disparities in healthcare; Hip fracture; International comparisons.

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Conflict of interest statement

Declarations:. Conflict of Interest:: The authors declare that they do not have a conflict of interest.

Figures

Figure 1
Figure 1
a Adjusted 30-day mortality rate*. b Adjusted 1-year mortality rate*. Adjusted for age, sex, and comorbidity.
Figure 2
Figure 2
a Age- and sex-standardized total hip arthroplasty rate. b Age- and sex-standardized hemi-arthroplasty rate. c Age- and sex-standardized internal fixation rate. d Age- and sex-standardized non-operative rate.
Figure 2
Figure 2
a Age- and sex-standardized total hip arthroplasty rate. b Age- and sex-standardized hemi-arthroplasty rate. c Age- and sex-standardized internal fixation rate. d Age- and sex-standardized non-operative rate.
Figure 3
Figure 3
a Age- and sex-standardized length of stay (days). b Adjusted 30-day readmission rate*. Adjusted for age, sex, and comorbidity.
Figure 4
Figure 4
a Age- and sex-standardized days from presentation to operation. b Age- and sex-standardized percentage of patients discharged to home.
See this image and copyright information in PMC

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