Lower education tied to higher death risk after hip fracture surgery, study finds

Individual-level socioeconomic status, particularly education, is significantly associated with death rates after hip fracture surgery, according to a nationwide registry study of more than 58,000 patients treated in Sweden, published recently in the British Journal of Anaesthesia.

The study was led by a team of researchers, including corresponding author Rasmus Åhman, a Ph.D. student at Linköping University.

Åhman and his team used Sweden's national Perioperative Registry, cross-linked with data from Statistics Sweden and the Swedish National Board of Health and Welfare, to follow patients who underwent acute hip fracture surgery between January 2015 and December 2020. The final cohort included 58,641 patients with a median age of 83, two-thirds of whom were women. Crude mortality was 7.9% at 30 days and 35.3% at two years after surgery.

Prior research on socioeconomic status and hip fracture outcomes has produced inconsistent results, in part because most earlier studies relied on area-level or aggregated measures, such as postcode-based indices, rather than individual patient data. The authors describe this as the largest hip fracture cohort to examine both short- and long-term mortality using individual-level socioeconomic indicators.

Four socioeconomic indicators were measured: level of education, household disposable income, receipt of social services, and residential area (urban, intermediate or rural). Education showed the clearest gradient.

Education had the strongest link to survival: the less schooling a patient had, the higher their risk of dying within two years. Adjusted odds of two-year mortality were 16% higher for patients with 10 to 12 years of schooling, 20% higher for those with nine years and 25% higher for those with fewer than nine years, each compared with patients who had more than 12 years of education.

Researchers estimate education gaps account for about 14% of two-year deaths in the study, compared with under 2% for income, translating to roughly a 6.3 percentage point higher real-world death rate for the least-educated patients compared with the most-educated. Income followed a similar but weaker stepwise pattern, and receipt of social services was linked to higher long-term mortality, particularly among patients in assisted living facilities, though the researchers cautioned that the measure likely reflects underlying frailty rather than a modifiable socioeconomic exposure. Residential areas showed no meaningful connection either way.

"Educational attainment likely reflects cumulative life-course factors, such as health literacy, social support, and cognitive reserve, and should be interpreted as a risk marker rather than a directly modifiable exposure," Åhman and his colleagues said in the paper. “These factors could influence patients' ability to navigate care pathways, engage in rehabilitation, and manage post-discharge recovery.”

In the United States, between 1999 and 2023, there were 334,905 hip fracture-related deaths among adults ages 65 and older. The age-adjusted mortality rate has been decreasing, though — in this case from 37.07 per 100,000 in 1999 to 23.91 in 2023, according to a 2025 analysis of Centers for Disease Control and Prevention data published in Cureus. This decrease may be attributed to improved surgical techniques and more comprehensive perioperative care, including a focus on early mobilization after surgery.

However, in Sweden, the nationwide projections cited in the present study estimate hip fracture incidence could rise more than 65% by 2050 as life expectancy increases, a trend mirrored in other countries. Current postoperative guidelines do not incorporate socioeconomic considerations, the authors noted, despite growing evidence that individual-level socioeconomic factors, and education in particular, shape outcomes long after the immediate perioperative period ends.

The authors said the findings point toward practical targets for payers and health systems working to close outcome gaps, including enhanced discharge planning, community follow-up, and tailored rehabilitation strategies for patients with lower educational attainment.