Impact of hip fracture on survival, disability, pain, and health-related quality of life in Zimbabwe: a prospective cohort study
Nasser M, Burton A, Wilson H, Manyanga T, Madanhire T, Mushayavanhu P, Ndekwere M, Chipanga J, Hawley S, Graham SM, Masters J, Ward KA, Costa ML, Ferrand RA, Gregson CL
Year of Publication: 2025
Abstract
Background:
The population in Africa is ageing, and fragility fractures increasing. We assessed one-year
health outcomes following hip fracture in older adults in Zimbabwe.
Methods:
A cohort of adults ≥40 years, with hip fracture, presenting to hospitals in Harare (2 public; 5
private) between 2021-22 were followed-up for one-year. Operative management, survival,
health-related quality of life (HRQoL) utilities from EQ-5D-5L, and disability (WHODAS) were
quantified. Associations between patient characteristics and odds of operative management
were assessed.
Findings:
Of the 196 hip fracture patients (49% female and median age 74·0 years [IQR 63·0-83·0]),
86·2% were fragility fractures. In total, 173 (88·3%) were managed in a public hospital, where
just 96 (55·5%) received operative hip fixation; all 23 (11·7%) managed in private facilities
received an operation. After one-year, 55 (29·4%) had died (41·9% of those aged ≥70 years,
and 8·6% of those <70 years). In public hospitals, 42.5% of non-operated patients died, versus
19·4% of those operated.
By 30-days, the mean HRQoL utility score had fallen from 0·81[95%CI 0·79,0·82] pre-fracture
to 0·29[95%CI 0·25,0·33]. Minimal recovery was seen after 120-days. Larger reductions
occurred in those age ≥70 years. Post-fracture disability was almost universal, with only 2%
disability-free by 365-days. Higher household income was associated with higher odds
(OR=3.05[95%CI 1.54,6.05]), and malnutrition with lower odds (OR=0·31[95%CI 0·14,0·65]),
of being operated.
Interpretation:
Following hip fracture, quality-of-life and survival fall substantially, more so than after stroke,
demanding implementation of guidelines to standardise care and improve operative capacity
to manage the predicted rise in fractures
Hip fracture care in Zimbabwe: a cohort-based health economic analysis
Mafirakureva N, Ishumael PC, Manyanga T, Mushayavanhu P, Ndekwere M, Wilson H, Burton A, Graham SM, Masters J, Costa ML, Ferrand RA, Gregson CL, Noble SM
Year of publication: 2025
paper: Hip fracture care in Zimbabwe: a cohort-based health economic analysis
Abstract
Aims
Hip fractures are a leading cause of morbidity and mortality worldwide, particularly among
older people. While early surgical management improves outcomes compared to non-surgical
approaches, high costs of surgery pose significant barriers in low- and middle-income countries.
A cost-utility analysis of hip fracture management was undertaken in Zimbabwe, to guide
resource allocation and policy.
Methods:
Patient-level data were obtained from a prospective cohort of adults aged 40 years and above
with acute hip fractures presenting to hospital in Harare (two public; five private) between
October 2021 and October 2022. Healthcare resource use and costs in 2023 USD$ were
assessed from individual billing data, with imputed values used for missing resources. Health
outcomes were measured in quality-adjusted life-years (QALYs). Incremental cost-effectiveness
ratios (ICERs), defined as the ratio of incremental costs to incremental QALYs, were estimated
using a regression approach. Sensitivity analyses assessed the impact of different assumptions
on cost-effectiveness.
Results:
The cohort had 190 patients with an average age of 72 years (SD 14.3), and 51% (n = 97) were
male; 61% (n = 116) had surgery for their hip fracture. Patients who underwent surgery had 0.17
(95% CI 0.10 to 0.25) additional QALYs and incurred substantially higher healthcare costs: $1,676
(95% CI 730 to 2,621) higher per patient. The ICER for the primary analysis was $9,647/QALY
gained. Restricting the analysis to patients who did not experience extensive surgical delays
resulted in smaller difference in costs and an ICER of $4,126/QALY gained. The results were
sensitive to the exchange rate used to estimate costs.
Conclusion:
Although patients who underwent surgery for hip fractures had higher costs, they had better
health outcomes in terms of QALYs. Targeted improvements in provision of surgical care,
particularly in minimizing surgical delays, could improve both patient outcomes and lower
healthcare costs.
Age and sex specific incidence rates and future projections for hip fractures in the Gambia, West Africa, and comparison across four countries in Africa
Year of publication: 2025
Abstract
Longevity in African populations is increasing, where deprivation and malnutrition are common; hence fragility fracture incidence is expected to increase. Healthcare systems must adapt to provide for this aging population; however, currently fragility fracture incidence has yet to be determined in any West African setting. This study aimed to determine age- and sex-specific hip fracture incidence rates in adults in The Gambia, compare these with rates from other Southern African countries, and estimate future national hip fracture projections. All hip fracture cases in adults aged ≥40 yr, presenting to a hospital or traditional bone setter (TBS) in the study area over 2-yr, were identified. Age- and sex-specific hip fracture incidence per 100 000 person-years were estimated using the 2024 Gambian Population census. Incidence rate estimates were compared between The Gambia, Zimbabwe, South Africa, and Botswana. In The Gambia, future hip fracture numbers were estimated through to 2054 using United Nations population projections. Over 2-yr, 226 hip fracture patients, mean (standard deviation [SD]) age 71.2(12.5) years, 64.6% female, presented to hospital (184[81.4%]) or TBS (42[18.6%]). Most presented with a fragility fracture (205[90.7%]). High-impact trauma (eg, traffic accidents) was more common in younger men. Delays in presentation were common (68[30.1%]). Incidence rates for adults ≥40 yr in The Gambia were 28.1 and 51.7 per 100 000 person years for men and women, respectively, increasing with age. In those age ≥ 80 yr, incidence rates plateaued in men. The number of hip fractures is estimated to increase from 166 in 2024 to 621 by 2054. Age-specific hip fracture incidence rates were broadly comparable between The Gambia, Zimbabwe, Botswana, and Black South Africans. In summary, fragility fractures in Gambian adults were common, indicative of age-associated osteoporosis. Hip fracture cases will almost quadruple over coming decades; therefore, health service capacity must expand to manage this rising demand.
Challenges to fracture service availability and readiness provided by allopathic and traditional health providers: national surveys across The Gambia and Zimbabwe
Burton A, Manyanga T, Wilson H, Jarjou L, Costa ML, Graham SM, Masters J, Jallow MK, Hawley S, Nyassi MT, Mushayavanhu P, Ndekwere M, Ferrand RA, Ward KA, Marenah KS, Gregson CL
Year of publication: 2025
Abstract
Populations in Africa are ageing, hence the number of age-related fragility fractures, including hip fractures, is rising. Hip fractures are an indicator condition for older adult health provision, as they require a multifaceted pathway of care. To enable health service planning, detailed national-level understanding of current fracture service provision is needed.
Age- and sex-specific incidence rates and future projections for hip fractures in Zimbabwe
Wilson H , Manyanga T, Burton A, Mushayavanhu P, Chipanga J, Hawley S, Ward KA, Graham SM, Masters J, Bandason T, Costa ML, Ndekwere M, Ferrand RA, Gregson CL
Year of publication: 2025
Paper: Age- and sex-specific incidence rates and future projections for hip fractures in Zimbabwe
Abstract
Population ageing in Africa is increasing healthcare demands. Hip fractures require multidisciplinary care and are considered an indicator condition for age related health services. We aimed to estimate current hip fracture incidence in Zimbabwe, compare rates against other regional estimates and estimate future fracture numbers.
Weight-bearing and mobilisation timing after hip fracture surgery in older adults: an international survey of clinicians’ perspectives
Turabi RY, O’Connell MDL, Wyatt D, Bretherton C, Cannon S, Gregson CL, Moppett I, McNicoll L, Sheehan KJ
Year of publication: 2025
Abstract
Objectives:
This exploratory study aimed to describe international variations in mobilisation timing and weight-bearing after hip fracture surgery, focusing on differences between high-income countries (HICs) and low- and middle-income countries (LMICs) and identify the possible reasons for these variations.
Methods:
This international cross-sectional study was administered through an online, English-language, self-reported questionnaire. Healthcare professionals from various multidisciplinary teams were invited to participate via professional organisations, including the Fragility Fracture Network, social media, and through snowballing from key individual stakeholders.
Results:
A total of 389 healthcare professionals from 71 countries participated in the survey. Among them, 72.5% prescribed mobilisation the day after surgery, higher in HICs (79.1%) than LMICs (56.3%). Of those who prescribed early mobilisation, 38.3% achieved it 76–100% of the time, more frequently in HICs (42.9%) than LMICs (21.9%). Additionally, 73.5% prescribed unrestricted weight-bearing, also more common in HICs (86.3%) than LMICs (41%). For those who prescribed unrestricted weight-bearing, 50.4% achieved it 76–100% of the time, with HICs at 54.0% and LMICs at 31.9%. Multiple patient-related, process-related, and structure-related barriers were reported, with structure-related barriers more common in LMICs than HICs, underscoring the global complexities in implementing these practices.
Conclusion:
This study offers insights into global variations in the timing of mobilisation and weight-bearing after hip fracture surgery in older adults. It reveals disparities in postoperative services and resources between HICs and LMICs. Additionally, it establishes a foundation for future research and underscores the importance of international collaboration and knowledge sharing in enhancing postoperative care services.
Prevalence, factors and quality of life associated with frailty and pre-frailty in middle-aged and older adults living with HIV in Zimbabwe: A cross-sectional study
Manyara A, Manyanga T, Burton A, Wilson H, Chipanga J, Bandason T, Grundy C, Madela Y, Ward KA, Cassim B, Ferrand RA, Gregson CL
Year of publication: 2024
Abstract
Objectives:
We investigated associations between HIV, frailty and health-related quality of life (HRQoL). Methods: This cross-sectional study recruited men and women aged≥40 years in Zimbabwe. A researcher collected clinical and HRQoL data, and performed physical assessments and HIV testing. Frailty was defined using five criteria: unintentional weight loss, exhaustion, low physical activity, low gait speed, low handgrip strength. The presence of three or more criteria defined frailty, one to two pre-frailty, and zero non-frail. Data analysis used adjusted regression modelling.
Results:
Of 1034 adults (mean ± SD, 62.0 ± 14.0 years), 21.6% (n = 223) were living with HIV: 93.3% knew their status, of whom 96.2% were on antiretroviral therapy (ART) and 89.7% of these had a viral load <50 copies/mL. Mean age at HIV diagnosis was 44.6 ± 10.4 years (only 8.1% were ≥70 years), people had been living with HIV for 9.8 ± 5.0 years and had been on ART for 9.4± 5.2 years. Overall, HIV was not associated with frailty: adjusted odds ratio(aOR) was 0.99 [95% confidence interval (CI): 0.42–2.33] for frailty versus non-frailty. However, each 5 years lived with HIV was associated with twice the odds of frailty/pre-frailty (aOR = 2.03, 95% CI: 1.03–4.13), independent of age and ART duration. Furthermore, each 5 years of ART use was associated with60% lower odds of frailty/pre-frailty (aOR = 0.39, 95% CI: 0.19–0.78), independent of age and years lived with HIV. Older age, minimal education and poverty were associated with frailty. Frailty was associated with lower HRQoL in people both with and without HIV.
Conclusion:
Reduced survival and good viral suppression may explain the lack of association between HIV and frailty. Early ART initiation could reduce future risk of frailty.
Fractures in sub-Saharan Africa: epidemiology, economic impact and ethnography (Fractures-E3): study protocol
Burton A, Drew S, Cassim B, Jarjou LM, Gooberman-Hill R, Noble S, Mafirakureva N, Graham SM, Grundy C, Hawley S, Wilson H, Manyanga T, Marenah K, Trawally B, Masters J, Mushayavanhu P, Ndekwere M, Paruk F, Lukhele M, Costa ML, Ferrand RA, Ward KA, Gregson CL
Year of publication: 2023
Abstract
The population of older adults is growing in sub-Saharan Africa. Ageing exponentially increases fragility fracture risk. Of all global regions, Africa is projected to observe the greatest increase in fragility fractures. Fractures cause pain, disability and sometimes death, and management is expensive, often requiring complex healthcare delivery. For countries to plan future healthcare services, understanding is needed of fracture epidemiology, associated health service costs and the currently available healthcare resources.
The healthcare system costs of hip fracture care in South Africa
Mafirakureva N, Paruk F, Cassim B, Lukhele M, Gregson CL, Noble SM
Year of publication: 2023
Paper: The healthcare system costs of hip fracture care in South Africa
Abstract
Summary: Despite rapidly ageing populations, data on healthcare costs associated with hip fracture in Sub-Saharan Africa are limited. We estimated high direct medical costs for managing hip fracture within the public healthcare system in SA. These findings should support policy decisions on budgeting and planning of hip fracture services.
Incidence and number of fragility fractures of the hip in South Africa: estimated projections from 2020 to 2050
Hawley S, Dela S, Burton A, Paruk F, Cassim B and Gregson CL
Year of publication: 2022
Abstract
Summary:
Sub-Saharan Africa is undergoing rapid population ageing and better understanding of the burden of musculoskeletal conditions is needed. We have estimated a large increase in the burden of hip fractures for South Africa over the coming decades. These findings should support preparation of hip fracture services to meet this demand.
Introduction:
A better understanding of the burden of fragility fractures in sub-Saharan Africa is needed to inform healthcare planning. We aimed to use recent hip fracture incidence data from South Africa (SA) to estimate the future burden of hip fracture for the country over the next three decades. Methods: Hip fracture incidence data within the Gauteng, KwaZulu-Natal and Western Cape provinces of SA were obtained from patients aged ≥ 40 years with a radiograph-confirmed hip fracture in one of 94 included hospitals. Age-, sex- and ethnicity-specific incidence rates were generated using the 2011 SA census population for the study areas. Incidence rates were standardised to United Nations (UN) population projections, for the years 2020, 2030, 2040 and 2050, and absolute numbers of hip fractures derived. Results: The 2767 hip fracture patients studied had mean (SD) age 73.7 (12.7) years; 69% were female. Estimated age- and ethnicity-standardised incidence rates (per 100,000 person-years) for the overall SA population in 2020 were 81.2 for females and 43.1 for males. Overall projected incidence rates were discernibly higher by the year 2040 and increased further by the year 2050 (109.0 and 54.1 for females and males, respectively). Estimates of the overall annual number of hip fractures for SA increased from approximately 11,000 in 2020 to approximately 26,400 by 2050. Conclusion: The hip fracture burden for SA is expected to more than double over the next 30 years. Significant investment in fracture prevention services and inpatient fracture care is likely to be needed to meet this demand.
Fragility fractures in sub-Saharan Africa: time to break the myth, published. 2019
Gregson CL, Cassim B, Micklesfield LK, Lukhele M, Ferrand RA, Ward KA on behalf of the SAMSON Collaborative Working Group Abstract
Year of publication: 2019
Abstract
The number of older adults (aged ≥60 years) in Sub-Saharan Africa is two times higher than in northern Europe; a figure that is expected to increase from 46 million in 2015 to 157 million by 2050. In sub-Saharan Africa, at age 60 years, life expectancy is 16 years for women and 14 years for men, suggesting that for individuals who survive challenges in early life, a long period of old age is now a reality. As sub-Saharan Africa undergoes an epidemiological transition as a result of rapid urbanisation, the burden of non-communicable diseases, including osteoporosis, is rising. Similar to many chronic diseases such as hypertension, osteoporosis often remains undiagnosed until a fracture occurs. Increasing evidence is dispelling the outdated myth that fragility fractures are not a problem in sub-Saharan Africa.