When demography challenges policy: the rising burden of proximal femur fractures as a role model and driver for geriatric trauma care in Germany.

PURPOSE: Germany's hospital reforms will substantially reshape service delivery and capacity planning. Proximal femur fractures (PFFs), the most frequent geriatric fractures, are highly sensitive to demographic aging and therefore serve as a model condition to assess future healthcare system requirements. METHODS: Nationwide inpatient data from the German Federal Statistical Office (2000-2023) were analyzed for proximal femur fractures (ICD-10-GM S72.0-S72.2). Demographic projections up to 2050 were combined with Poisson regression, exponential smoothing, and autoregressive integrated moving average models to forecast future incidence and case numbers. Model performance was evaluated in a hold-out period (2016-2023) using mean absolute percentage error and root mean square error. Direct costs were estimated using the official German cost-of-illness framework. Staffing and hospital bed requirements were derived from case-based activity times, profession-specific full-time equivalent coefficients, and observed department-specific occupancy rates. RESULTS: Between 2000 and 2023, annual proximal femur fracture cases in Germany increased from 118,243 to 182,447 (+ 54.3%). Forecasts project a rise to 317,877 cases by 2050 (95% CI 262,436-373,317), corresponding to an increase of approximately 75% compared with 2023. Patients aged ≥ 80 years are projected to account for 74% of all cases. The mean projected incidence will rise to 391 per 100,000 inhabitants (95% CI 322-459), with the strongest relative increases in eastern federal states. The total economic burden is projected to increase from €3.2 billion in 2023 to €6.39 billion in 2050. To meet future demand, the model indicates additional requirements of approximately 700 trauma surgeons, 7,500 geriatricians, and substantial increases in nursing, rehabilitation, and therapy capacity. Trauma bed requirements are projected to increase from 18,762 to 26,960, while geriatric rehabilitation beds are projected to almost double. CONCLUSION: Proximal femur fractures expose critical future gaps in capacity, workforce, and regional access to care. Early and targeted policy action will be required to preserve timely, guideline-conforming geriatric trauma care under demographic aging and structural hospital reform.