Trends in secondary prevention of hip fracture: National Hip Fracture Database (NHFD) data for England, Wales and Northern Ireland
Abstract
Trends in secondary prevention of hip fracture: National Hip Fracture Database (NHFD) data for England, Wales and Northern Ireland
Antony Johansen, Will Eardley and Liz Fagan
Introduction
Patients with a hip fracture are at ‘imminent risk’ of further fragility fractures. In 2021 the NHFD introduced a new ‘key performance indicator’ (KPI7: the proportion of people known to be on bone protection 120-days after hip fracture) specifically to address this. In 2023 the ‘Call to Action’ paper published in Age and Ageing challenged clinicians to respond by giving a first dose of intravenous zoledronate during patients' inpatient stay.
Method
We set out to monitor the impact of these two drivers for improvement, monitoring trends in prescribing across the different hospitals of England, Wales and Northern Ireland, using data made available by the NHFD website www.nhfd.co.uk.
Results
In 2020 just 29.2% of people were identified as meeting KPI7, but by this figure had doubled to 59.0% (for patients admitted in August 2025). The main reason for this was not increasing rates of prescription (the proportion of people so treated on discharge only rose from 50.8% to 62.2%), but increasing awareness that poor persistence with oral bisphosphonates meant that few patients were still taking this at 120-days.
Oral medication had been the commonest approach, being prescribed for 31.5% of patients in 2020, but this fell to just 7.6% in 2025. In contrast, injectable medication rose from 14.3% to 52.2%, primarily because use of intravenous zoledronate quintupled, from 9.2% to 47.2% over the same period.
Conclusion
Most people (59%) are now known to be benefitting from long-term bone protection 120-days after a hip fracture, with another 15% referred for this to be considered.
This picture reflects a dramatic improvement in the use of intravenous zoledronate in place of oral bisphosphonates, particularly following the publication of the ‘Call to Action’. in September 2023. All geriatricians should now consider how they extend such fracture prevention to the other high-risk groups under their care.
Comments
Poster
Really nice poster, I like how you’ve used national NHFD data to show clear prescribing trends over time, and especially how you’ve linked that to real policy drivers like KPI7 and the ‘Call to Action.’
I was wondering to what extent do you think the improvement in KPI7 reflects true improvements in patient outcomes, versus better recognition of poor persistence with oral bisphosphonates?
And building on that, how confident are we that the shift toward intravenous zoledronate is actually improving long-term adherence and fracture prevention, rather than just changing prescribing patterns?
So in that context, do you think KPI7 is the right metric, or should we be focusing more on actual outcomes like re-fracture rates or persistence beyond 120 days?”
KPI7
We know that many units previously used prescription of oral bisphosphonates as a tick-box for secondary prevention, and that in the best of them follow-up only achieved 25% persistence. The vast majority of people were on nothing, and the majority who were 'treated' were also on nothing.
The IV Zol protocol aims to mimic the approach taken in the original Horizon study, and it is reasonable to assume that it will achieve similar fracture prevention. Fracture reduction after a single dose will continue for a number of years, and for most patients some protection will persist for the remainder of their life.
So this is a great population strategy - even if it is not the most potent regime we can offer to every individual.
My view is that no-one should be allowed to go looking for individuals who might benefit from expensive anabolics, until they've made sure that the remainder of their case-load has been considered for and treated appropriately with massively cost-saving IV Zol.
The question of follow-up doses of IV Zol is challenging, but Catherine Grose has another poster at this BGS showing that this only need be considered in a relatively small number of patients.
With my public-health hat on I'd suggest that if you want to provide effective fracture prevention in your area, then the best thing to do with any extra doses of IV Zol you might be in a position to give would be to give them to someone who's not had a first dose. Geriatricians wards are full of people with other fractures, old spinal fractures, steroids, PD, stroke in whom we should all be thinking fracture prevention, and I hope T&O house officers will show everyone how easy it is to give IV Zol to people.