Hemiarthroplasty for hip fracture is frequently associated with substantial perioperative blood loss; however, nationwide data on transfusion epidemiology and related risk factors remain limited. This study aimed (1) to assess transfusion rates and temporal trends, (2) to evaluate the use of transfusion-sparing agents, and (3) to identify risk factors of transfusion in a national cohort.

Using the Korean National Health Insurance Service database, we included who underwent primary hemiarthroplasty between 2002 and 2020. The trends in transfusion and the use of transfusion-sparing agents were assessed using each procedure and drug codes. Risk factors were evaluated by multivariable logistic regression analysis.

Among 220,278 hemiarthroplasties, 82.0% received transfusion with annual decrease from 86.3% to 72.2% since 2013, and mean transfusion volume decreased from 1,386 mL to 1,115 mL. The use of anti-fibrinolytic agents and iron supplementation increased gradually, whereas hemostatic agent use decreased. Female, old age, intertrochanteric fracture, preoperative anemia, use of closed suction drainage, hemostatic agents, and hematopoietic agents were associated with an increased transfusion risk, whereas anti-fibrinolytic agents (aOR = 0.53; 95% CI 0.52–0.55; P < 0.001) and iron supplements (aOR = 0.73; 95% CI 0.71–0.76; P < 0.001) were associated with significantly decreased transfusion risk.

In this nationwide cohort, transfusion after hemiarthroplasty remained common, but declined gradually over two decades. The use of anti-fibrinolytic agents and iron supplementation was associated with a decreased risk of transfusion, supporting the implementation of patient blood management (PBM) strategies for hip fracture surgery.