Impact of hip fracture on survival, disability, pain, and health-related quality of life in Zimbabwe: a prospective cohort study

Abstract

Background The population in Africa is ageing, and fragility fractures increasing. We assessed 1-year health outcomes following hip fracture in older adults in Zimbabwe. Methods In this prospective cohort study, a cohort of adults aged 40 years or older with hip fracture, presenting to hospitals in Harare (two public and five private hospitals) between Oct 15, 2021, and Oct 14, 2022, were followed up for 12 months. The primary outcome was survival, analysed with Kaplan–Meier curves at different timepoints (30 days, 120 days, 6–8 months, and 12 months after case identification), overall and stratified by age (<70 years vs ≥70 years), delay to presentation (no delay [≤2 weeks] vs delay [>2 weeks]), and facility type and operative management. We also quantified health-related quality of life (HRQoL), measured with 5-level EQ-5D (EQ-5D-5L), hip pain, self-reported from 0 (none) to 5 (all the time) and measured as interference with walking and sleep (1 [no interference] to 10 [complete interference]), as per the Brief Pain Inventory, and disability, measured with the WHO Disability Assessment Schedule version 2.0 (WHODAS). Findings Of 196 patients with hip fracture (96 [49%] female, 100 [51%] male; median age 74 years [IQR 62·5–83]), 162 (83%) had had a fragility fracture (low-energy trauma). In total, 173 (88%) were managed in a public hospital, of whom 96 (55%) received operative hip fixation. In contrast, all of the 23 (12%) managed in private facilities had an operation. After 12 months, 55 (29%) had died (49 [42%] of 117 patients aged ≥70 years, and six [9%] of 70 patients aged <70 years). In public hospitals, 31 (42%) of 73 non-operated patients died, compared with 18 (19%) of 93 patients who were operated on. Overall, survival declined to 88% (95% CI 82–92) by 30 days and to 71% (64–77) by 12 months. The probability of survival was lower in patients aged 70 years or older than in those younger than 70 years (mortality hazard ratio for ≥70 years 6·10, 95% CI 2·61−14·22). The mean HRQoL utility score decreased from 0·81 (95% CI 0·80–0·83) pre-fracture to 0·29 (0·25–0·34) at 30 days post fracture. Minimal recovery was seen after 120 days (0·34, 0·29–0·39). By 12 months, 97 (97%) of 100 patients alive and able to provide data still reported pain from their hip injury. Post-fracture disability was almost universal, with only two (2%) of 100 patients being disability-free (WHODAS=0) by 12 months. Interpretation Following hip fracture, survival and quality of life decreased substantially in the study population. These findings reveal the need for the implementation of guidelines to standardise care and improve operative capacity to manage the predicted rise in fractures in this region.