Since 1993 a report card system for fractures of the neck of the femur has been established in the Department of External Quality Assurance of the Chamber of Physicians of Westphalia-Lippe. Several indicators of good quality have changed significantly since then: conservative treatment decreased from 6.8 % in 1993 to 4.2 % in 1997, lethality decreased from 6.9 % to 5.4 %, average length of stay decreased from 30.9 days to 24.9 days, average length of stay before operation decreased from 2.6 to 2.1 days, the frequency of operations on weekends increased, complications in wound healing increased from 4.9 to 6.0 %, and cardiopulmonary complications decreased from 11.2 % to 7.8 %. Between 1993 and 1997, 54.3 % were dismissed to go home; the percentage of patients sent to rehabilitation facilities after acute care rose from 8.3 % in 1993 to 20.1 % in 1997. The most frequent and still increasing procedure was implantation of hemiprosthesis/bipolar prosthesis (from 38.8 % in 1993 to 41.0 % in 1997) followed by total hip replacement (decreasing from 37.4 % in 1993 to 34.2 % in 1997). Operative treatment was performed in more than 90 % of all fractures in all counties of Westphalia-Lippe. However, there was a wide and significant geographical variation in the choice between osteosynthesis and hip replacement: the percentage of hip replacements differed between 57 % and 82 % among different counties. Average length of stay before the operative procedure for patients undergoing reduction and rigid internal fixation of the fracture is still too long (1.6 days in 1997).