Challenges of musculoskeletal multimorbidities in sub-Saharan Africa: findings from the Fractures-E3 and MUFASSA studies
Gregson CL, Manyanga T, Bandason T, Chipanga J, Gates L, Burton AJ, Wilson H, Ferrand RA, Ward KA
In sub-Saharan Africa population ageing is leading to a rise in non-communicable diseases, that impact mobility, function and independence. Age-related diseases of bone (osteoporosis) and of muscle (sarcopenia) impact functional ability, through falls and fragility fractures. Currently, there are few data across the region quantifying prevalence of musculoskeletal disorders in ageing populations; such data are necessary to plan future healthcare provision.
The Fractures-E3 (Fractures in sub-Saharan Africa: epidemiology, ethnography and economic impact) multidisciplinary research programme aims to determine the burden of fragility fractures on individuals, communities and health-care systems in Zimbabwe, The Gambia and South Africa. Embedded within Fractures-E3 is a population-based study which will quantify vertebral fracture prevalence, determine clinical risk factors for vertebral fracture and the epidemiology of wider musculoskeletal morbidities, including sarcopenia (MUFASSA study). It also creates a platform for healthy ageing research beyond musculoskeletal health, capturing data on multimorbidity, and generates a sample biobank. This abstract focuses on sarcopenia.
To determine sarcopenia prevalence in women and men aged 40 years and above in Zimbabwe.
By household sampling, a community-based sex- and age-stratified sample of men and women aged 40 years and older was recruited (n=885). Participants had hand grip strength, gait speed, sit-to-stand time and balance measured as part of the Short Physical Performance Battery (SPPB) and self-reported falls in the last year recorded. Sarcopenia was defined as gait speed <1.0metres/second and grip strength <35.5kg in men and <20kg in women1. Differences between groups were tested using T-tests, Mann-Whitney-U and Chi-squared tests.
Sarcopenia was more prevalent in men (92/445[20.7%]) than women (25/440[5.7%], p<0.01). Low gait speed was seen in 76.3% men and 89.9% women, whilst 24.8% men and only 6.4% women had low grip strength (sex-differences p<0.01). Those with sarcopenia were older (median(IQR) 78(70-85) vs. 56(48-67) years, p<0.01) with lower BMI (mean SD, 23.5(4.6) kg/m2 vs. 26.4(6.4) kg/m2; p<0.01). Overall 155/855 (18%) reported at least one fall; falls were associated with sarcopenia, but only 19% of fallers were classified as having sarcopenia.
Sarcopenia prevalence was low in women which contrasts with other populations. In men findings were similar to those reported in The Gambia2, but higher than in US and European populations1. There is a need to validate context-specific sarcopenia definition thresholds.
The Fractures-E3 and MUFASSA studies are generating important evidence needed to inform future health planning for older people, particularly regarding challenges to functional ability, and health ageing.
1 Westbury et al. J Cachex Sarc Musc 2023 https://doi.org/10.1002/jcsm.13160
2 Zengin et al. J Cachex Sarc Musc. 2018 Oct;9(5):920-928. doi: 10.1002/jcsm.12341.
NIHR–Wellcome Partnership for Global Health Research Collaborative Award (217135/Z/19/Z); UK MRC Grant ref MR/W003961/1.
The direct costs of hip fracture care in South Africa: a public healthcare system perspective
Mafirakureva N, Paruk F, Cassim B, Gregson CL, Noble SM
Fragility fractures, sustained from a force that would not ordinarily result in a fracture, pose a major public health problem due to high morbidity, mortality, and costs. Fragility fractures commonly occur in the context of multiple comorbidities and/or frailty. The most common fractures caused by osteoporosis include hip, spinal, and forearm fractures. Hip fractures (HFs) in particular, are associated with high levels of morbidity, prolonged hospital stays, increased healthcare resources utilization, and mortality, with 13% dying within a month of fracture. The worldwide average health and social care cost in the first year post hip fracture was US$43,669 per patient in a 2017 systematic review, with inpatient care costing US$ 13,331. Costs were highly variable, reflecting variation in methodology, elements of care and patient populations included.
Fragility fractures are an emerging healthcare problem in Sub-Saharan Africa (SSA), with significant increases projected over the next few years, largely driven by the growing current and projected number of older adults (age ≥60 years) with prolonged life expectancy and the associated multiple comorbidities. Despite the reported current and projected clinical burden of fragility fractures, including HFs, there have been no studies published to date quantifying fracture-associated costs within SSA. Data on costs associated with HFs are important for quantifying demands on healthcare services, informing accurate cost-effectiveness analyses, and for guiding policy decisions on priority setting, budgeting and planning.
We estimated direct healthcare costs of HF management in the South African (SA) public healthcare system.
We conducted an ingredients-based costing study to estimate costs per patient treated for HF across five regional public sector hospitals in KwaZulu-Natal (KZN), SA. Two hundred consecutive, consenting patients presenting with a fragility HF were prospectively enrolled. Resource use including staff time, consumables, laboratory investigations, radiographs, operating theatre time, surgical implants, medicines, and inpatient days were collected from presentation to discharge. Counts of resources used were multiplied by relevant unit costs, estimated from KZN Department of Health hospital fees manual 2019/20, in local currency (South African Rand, ZAR), and converted to 2020 US$ prices. Generalised linear models were used to estimate total covariate adjusted costs and cost predictors.
The mean unadjusted cost for HF management was US$6,935 (95% CI; US$6,401-7,620) [ZAR114,179 (95% CI; ZAR105,468-125,335)]. The major cost driver was orthopaedics/surgical ward costs US$5,904 (95% CI; 5,408-6,535), contributing to 85% of total cost. The covariate adjusted cost for HF management was US$6,922 (95% CI; US$6,743-7,118) [ZAR114,696 (95% CI; ZAR111,745-117,931)]. After covariate adjustment, total costs were higher in patients operated under general anesthesia [US$7,251 (95% CI; US$6,506-7,901)] compared to surgery under spinal anesthesia US$6,880 (95% CI; US$6,685-7,092) and no surgery US$7,032 (95% CI; US$6,454 -7,651).
Direct healthcare costs following a HF are substantial: 58% of the gross domestic per capita (US$12,096 in 2020), and six-times greater than per capita spending on health (US$1,187 in 2019) in SA. As the population ages, this significant economic burden to the health system will increase. Further research is required to evaluate direct non-medical, and the indirect costs incurred post HF.
Low operative rates associated with higher 30-day mortality following hip fracture; findings from the Fractures-E3 longitudinal study in Zimbabwe
Burton A, Wilson H, Manyanga T, Mushayavanhu P, Masters J, Graham JM, Ndekwere M, Costa M, Ferrand RA, Gregson CL
To characterise the population experiencing hip fractures in Harare, Zimbabwe and assess 30-day outcomes.
All hip fractures in adults aged ≥40 presenting to 1 of 7 hospitals in Harare were identified over 1 year (2021-22). Data were collected for all cases (age, sex, region of residence, presentation date, delayed presentation [i.e. >2weeks from injury], injury mechanism, fracture type). After consent patients were followed-up to 30-days with data collected on anthropometry, surgical management and mortality. Associations were tested using T-tests and chi-squared tests.
Overall, 237 hip fracture cases were identified (123[51.9%] female; mean age 72.4[SD14.2] years), 87.3% followed low impact trauma, e.g. falls, and 81[34.2%] presented >2 weeks after injury. Household income was ≤$100USD/month in 60.6%. By 30-days 24[10.1%] had died. High impact trauma, e.g. traffic accidents, were more common in men than women (26[22.8%] vs. 4[3.3%], p<0.001), whilst presentation delays were similar by sex (45[36.6%] vs. 36[31.6%], respectively, p=0.42).
In the 193 [82.8%] participants consenting to follow-up, 71[43.3%] had a mid-upper arm circumference <25cm (indicating malnutrition), 26[13.5%] reported living with HIV (96% on treatment), 5.3% had known diabetes and 27.8% hypertension. Overall, 113[61.1%] had an operation, with age similar between those operated and non-operated (mean[SD] 70.7[14.6] vs. 73.2[13.4] years, p=0.23). Higher household income was associated with operative management (74.6% operated if income >$100/month, 53.5% if <$100/month, p=0.005). Those attending private vs. public hospitals were more likely to have an operation (17[85.0%] vs. 96[55.5%], p=0.01). Non-operative management was associated with higher 30-day mortality (16[20.0%] vs. 2[1.8%], p<0.001).
In Zimbabwe, where malnutrition and HIV infection are common, most adult hip fractures are fragility fractures (national adult HIV prevalence is 12.9%). Non-operative management was common and associated with higher mortality. Reasons for not operating may include lack of surgical capacity, perceived surgical risk and/or patient inability to pay. Understanding barriers to operative management is important to inform future healthcare delivery.
Low operative rates for hip fracture challenge survival in Zimbabwe; findings from the Fractures-E3 Study
Wilson H, Burton A, Manyanga T, Mushayavanhu P, Masters J, Graham S, Ndekwere M, Costa M, Ferrand RA, Gregson CL
As populations age in sub-Saharan Africa, hip fracture rates are predicted to rise, yet data on hip fracture epidemiology are scarce.
To characterise the population with hip fractures in Harare, Zimbabwe and understand short-term survival.
All hip fracture cases presenting to one of seven hospitals in Harare were recorded for one year (10/2021-10/2022), data collected: age, sex, region of residence, presentation date, presentation delays (>2weeks after injury), injury mechanism, fracture type and 30-day survival. Consenting patients completed a researcher-administered questionnaire and anthropometric measurements. Chi-squared tests for associations were used.
We identified 237 hip fracture cases (n=123[51.9%] female), most followed low-energy trauma, e.g. falls (n=207[87.3%]), 81[34.2%] were delayed in hospital presentation. High-energy trauma, e.g. traffic accidents, were more common in men than women (26[22.8%] vs. 4[3.3%], p<0.001), whilst presentation delays were similar (45[36.6%] vs. 36[31.6%] respectively, p=0.42). Overall, 30-day mortality was 10.3%(n=24).
193(81.4%) participants consented to further data collection; mean(SD) age 71.9(14.3)years, 71(43.3%) had a mid-upper arm circumference <25cm (indicating malnutrition), 26(17.2%) were living with HIV (n=25[96%] on treatment). Presentation delays were common (n=68[35.2%]), with 30-day mortality similar in those presenting within 2 weeks of injury (6[8.8%] vs. 12[9.6%], p=0.86). Overall, 113(58.6%) had an operation; non-operative management was associated with higher 30-day mortality (non-operated 16[20.0%] vs. operated 2[1.8%], p<0.001). Operated and non-operated patients had similar mean[SD] ages (70.7[14.6] vs. 73.2[13.4]years, p=0.23). People attending private vs. public hospitals were more likely to receive an operation (17[85.0%] vs. 96[55.5%], p=0.01).
Hip fractures in Zimbabwe mostly comprise fragility fractures, where malnutrition and HIV infection are common. Non-operative management was common and associated with high mortality, potentially reflecting lack of surgical capacity to offer necessary fixation, avoidance of surgery in multimorbid patients, and/or a patient’s inability to pay. Understanding barriers to operative management is important to inform future healthcare delivery.
Allopathic medical and traditional bone setter fractures service availability and readiness in the Gambia
Burton A/Jarjou L, Marenah K, Wedner S, Graham S, Masters J, Jallow A, Wilson H, Costa M, Ward K, Gregson CL
To identify and quantify hip fracture service availability and readiness in The Gambia (adult population: 1.2million)
All health care facilities to which a person with a hip fracture could present were identified through Gambian Government Ministry of Health, regional directorates and health service-related networks; traditional bonesetters (TBS) were included as medical pluralism is common in The Gambia. From Oct2021-Dec2022 all facilities completed a modified WHO Service Availability & Readiness Assessment, in person with a trained fieldworker (5% completed by phone), with data captured in REDCap. Capacity per 100,000 adults ≥18 years in the population was quantified using global burden of disease population estimates 2010-2019 extrapolated to 2022 assuming linear growth.
Nationally, 152 medical facilities were identified, 3 declined to participate. Of 149 participating facilities, 99 were public (41 community health centres, 19 rural or district hospitals, 6 regional or provincial hospitals, 3 central hospitals), 14 private and 36 either non-governmental organisations, religious, service, or research facilities. These 149 facilities provided a total of 2470 inpatient beds, 198.2 per 100,000 adults, of which 195 beds were trauma & orthopaedic (15.6/100,000). There were 426 doctors (34.2/100,000) of which just 9 were orthopaedic and trauma surgeons (0.8/100,000).
Seven (4.7%) facilities had available and functional radiography facilities, with 28 radiographers reported across all facilities (2.2/100,000). Five (3.4%) facilities could provide diagnostic investigation and surgery for hip fractures (0.4/100,000), only one was a public facility. These 5 facilities reported 155 hip fractures in 2020.
Of the 42 TBS identified, 35 (83.3%) chose to participate. Most (91.4%) had been trained by another TBS family member. The median period worked as a TBS was 20 years (range 2-72). 71.4% reported being able to set a hip fracture, and 25.7% had treated a hip fracture in the previous year.
Health services provision for diagnosis and treatment of hip fractures in The Gambia is low, and likely similar in the wider West Africa region. As lifespans increase so will the number of fragility fractures; fracture services, potentially including TBS, will need to expand to meet demand.
Incidence and number of hip fractures in South Africa: estimated projections from 2020 to 2050, August 2021
Hawley S, Dela S, Burton A, Paruk F, Cassim B, Gregson CL
Hip fracture is an established major public health problem among older adults in high-income settings; however, data from the sub-Saharan African region are scarce. Yet, this century, the number of older adults in sub-Saharan Africa is expected to grow faster than any other region globally. We aimed to use emerging data on hip fracture incidence in South Africa to estimate future burden of hip fracture for the country over the next three decades.
Previously collected data on hip fracture patients from eight districts within the Gauteng, KwaZulu-Natal and Western Cape regions of South Africa were re-analysed. All patients aged ≥40 years with a radiograph-confirmed hip fracture over a 12-month period in one of 94 included hospitals were enrolled. High-velocity trauma, pathological and peri-prosthetic fractures were excluded. Age-, sex- and ethnicity-specific incidence rates were generated and standardised to the 2011 South African census population and to future South African population projections estimated by the United Nations (UN). A correction factor was applied to UN projections for the population size aged ≥80 years, derived from the under-estimated 2011 UN population size compared to the South African 2011 census.
The 2767 included hip fracture patients had mean (SD) age 73.7 (12.7) years; 69% were female. Incidence rates (per 100,000 people), standardised to the estimated South African population in 2020, were 104 for females and 47 for males. Rates for Black Africans (the largest ethnic group in South Africa; 79.2% of total population) were lower at 63 for females and 40 for males. Overall projected incidence rates were discernibly higher by the year 2040 (122 and 53 for females and males, respectively) and increased further by the year 2050 (141 and 60 for females and males, respectively). In terms of the overall annual number of hip fractures for the country, estimates increased from approximately 10,000 in 2020 to approximately 23,000 by 2050 (approximately 16,500 in Black Africans and approximately 6500 in other ethnic groups). The overall and age-stratified number of hip fractures are shown in the figure.
The hip fracture burden for South Africa, whose last census population was 52 million, is estimated to more than double over the next 30 years, to approximately one-third of those currently seen in the UK. Significant investment in fracture prevention services and inpatient fracture care is likely to be needed to meet this demand.
Healthcare costs of acute hip fractures in South Africa, August 2021
Mafirakureva N, Paruk F, Cassim B, Gregson CL, Noble SM
Hip fractures are associated with high costs to healthcare systems in high-income countries. Despite rapidly ageing populations, data on healthcare costs in sub-Saharan Africa are limited. We aimed to estimate the direct healthcare costs associated with the acute management of hip fractures in the public healthcare system in South Africa (SA).
We conducted a micro-costing study to estimate the cost per patient treated for hip fracture in five regional public health hospitals in eThekwini, in KwaZulu-Natal (KZN), SA. Data for 200 consecutive patients presenting with a hip fracture, identified from orthopaedic admission registers, were collected prospectively. Resource data included staff time, consumables, blood tests, X-rays, theatre time, implants, medicines, and length of stay (LOS) from initial presentation up to discharge post-fracture. We valued the resources by multiplying the quantity used by the unit prices/costs, estimated from the KZN Department of Health hospital fees manual for 2019/20. Costs were measured in local currency and reported in 2020 prices.
The mean cost per patient for the acute management following an index hip fracture was R108,525 (SD=R64,076). The major cost driver was the surgical ward cost, R92,520 (SD=R63,058), largely driven by LOS (mean [SD]=21 days), contributing 85.3% of the total cost. The second greatest cost driver was theatre costs, R 11,606 (SD=R1,288), largely driven by implant costs, contributing 10.7%. Figure 1 shows the distribution of mean healthcare costs. Costs were approximately R4,000 higher in patients operated under spinal anaesthesia.
Healthcare costs following a hip fracture are high and may represent a significant economic burden to patients, the health system and society. As the population ages, this economic burden is expected to increase. Efforts to reduce fracture incidence and inpatient lengths of stay are warranted.
NIHR-Wellcome Partnership for Global Health Research (217135/Z/19/Z)
Unrestricted Educational grant from Servier® PTY (LTD)
UKZN competitive grant