Impact of a national reimbursement policy for secondary fracture prevention on early secondary fractures after hip fracture surgery in Japan: a nationwide interrupted time series analysis.

UNLABELLED: A national reimbursement scheme aimed to enhance secondary fracture prevention after hip fracture. Although prevention processes improved substantially, early secondary fracture incidence did not clearly decline. Differential effects by hospital payment system suggest that financial incentives alone may be insufficient and that organizational readiness and care pathways may influence impact.

PURPOSE: In 2022, Japan introduced a reimbursement scheme to promote secondary fracture prevention (SFP) after hip fracture. We examined whether this implementation was associated with a reduction in secondary major osteoporotic fractures within 6 months after hip fracture surgery at the national level.

METHODS

We conducted a nationwide interrupted time series analysis including adults aged 60 years or older who underwent surgery for hip fracture between April 2017 and February 2023. The primary outcome was the monthly estimated 6-month cumulative incidence of secondary major osteoporotic fractures. Process measures included osteoporosis assessment, initiation of guideline-recommended osteoporosis medication, and receipt of both during the index hospitalization. Effect modification by hospital payment system (Diagnosis Procedure Combination [DPC] versus non-DPC) was examined.

RESULTS

Among 127,676 patients, the introduction of the SFP management fee was associated with substantial immediate and sustained increases in osteoporosis assessment and medication initiation during the index hospitalization. However, no clear immediate change or change in trend in the 6-month cumulative incidence of secondary fractures was observed at the national level. In contrast, a greater post-introduction decline in secondary fracture incidence was observed in DPC hospitals compared with non-DPC hospitals.

CONCLUSION

Although the SFP reimbursement scheme improved in-hospital SFP processes after hip fracture, it was not associated with a clear national-level reduction in secondary fractures within 6 months. Differences by hospital characteristics suggest that organizational capacity and established care pathways may influence how reimbursement incentives translate into clinical benefit.