Conference Abstracts

Prevalence of disability and use of assistive devices among older adults from a community-based population survey in peri-urban Harare

Mattick K, Manyanga T, Wilson H, Davey G, Tembo M, Horboin H, Burton A, Chipanga J, Bandason T, Manyara  A, Mushayavanhu P, Ndekwere M, Ferrand RA, Gregson CL

Objectives

The Zimbabwean population is ageing, increasing the prevalence of age-related disability. Assistive devices(AD) can support older adults with activities and independence, yet access is limited. This study aimed to establish disability prevalence and AD use in peri-urban Harare.

Methods

A cross-sectional study using household sampling recruited a population-representative sample of men and women aged ≥40 years from three suburbs in Harare (Mufakose, Highfields and Dzivarasekwa). Data were collected using questionnaires (e.g., self-reported disability and Washington Group(WG) Disability) and objective assessments (e.g., hearWHO, Short-Physical-Performance-Battery(SPPB)). Analyses included descriptive statistics and bivariate associations.  

Results

Overall, 1109 participants, 572(51.6%) female, mean(SD) age 62.5(14.1) years, were recruited. While 19(3.5%) men and 16(2.8%) women identified themselves disabled, 92(17.1%) men and 127(22.2%) women were disabled based on WG questionnaire. Disability increased with age with disability highest for those age ≥70: self-reported 23/385(6.0%) and WG questionnaire 104/385(27.0%).  

Overall, 180(16.2%) self-reported hearing loss whilst 244(22.8%) had a low hearWHO score, yet only 4(1.2%) had a hearing aid. Similarly, 168(15.2%) self-reported visual loss, objectively 403(37.0%) had vision deficits, but only 48(11.6%) had glasses. 

Furthermore,189(17.0%) self-reported mobility difficulty, whilst objectively 740(67.7%) had a mobility limitation (SPPB score ≤9), of whom only 111(14.5%) had a mobility aid. 

Conclusion

There are many more people living with impairments than self-report as disabled. Despite high numbers of functional difficulties, very few people used AD. The substantial unmet AD need, with under-reporting of disability raises concerns for assessment and provision of AD, and public health awareness of disability among older populations. 

 

---

Low operative rates are associated with higher mortality post hip fracture; findings from the Fractures-E3 Longitudinal Study in Zimbabwe 

Gregson CL,  Nasser M,  Manyanga  T, Mushayavanhu P, Wilson H, Chipanga  J, Burton A, Graham S, Masters J, Bandason T,  Costa M, Ndekwere  M,  Ferrand RA 

Objectives

To characterise the adult hip fracture population in Zimbabwe and determine 365-day outcomes. 

Methods

All hip fracture cases presenting to one of 7 hospitals in Harare were recorded for 1-year (10/2021-10/2022) and followed-up to 365-days. Pain, disability, health-related quality of life(HRQoL) trajectories, and survival were studied, as were predictors of receiving operative management. 

Results

We identified 196 hip fracture cases (n=96[49%] female; median age 74.0[IQR:63-83] years), 169(86.2%) followed low-impact trauma, 115(60.5%) had household incomes ≤$100USD/month, 173(88.3%) attended a public hospital. By 30-days 25(12.8%) had died; 54(27.6%) by 365-days; all deaths occurred in public hospitals. HRQoL dropped sharply after hip fracture and barely recovered (58.2% decline by 120-days, p<0.001); HRQoL dropped most in those age ≥70years (71.0% decline by 120-days, p<0.001) and continued to decline over 365-days. Pain commonly persisted to 365-days, reducing mobility and sleep. Disability was rare pre-injury but common 365-days later (WHODAS median 4.1[0.0,20.3]) vs.42.7[29.1,58.3], p<0.001 respectively). 

Overall, 77(39.3%) never received a hip operation. Malnutrition was associated with reduced odds of operation (OR=0.28 [0.14–0.55], p<0.001), as was household income ≤$100USD/month (OR=0.35 [0.17–0.69], p<0.001). All private patients were operated. In public hospitals, non-operative management more-than doubled 365-day mortality (20% vs.41%, p<0.001). 

Conclusion

Hip fractures in Zimbabwe mostly comprise fragility fractures. Non-operative management is common, associated indicators of poverty, and more than doubles mortality; potentially reflecting challenges sourcing high out-of-pocket costs. Pain, disability, and quality of life are severely affected in those surviving hip fracture. Understanding barriers to operative management is important to inform future healthcare delivery. 

 

---

Understanding patient and carer priorities in the treatment of hip fractures in Zimbabwe: an ethnographic study 

Buwu N, Mareke P,  Chingono R, Manyanga T,  Chiweshe T, Ferrand RA, Gregson CL, Gooberman-Hill R, Drew S

Objective

Age-related hip fractures, increasing in numbers across Africa, highlight an urgent need to strengthen healthcare systems. We aimed to identify patient and carer priorities in the treatment of hip fractures to inform healthcare improvement strategies.

Methods

Ethnographic study provide detailed characterisation of fracture treatment. 40 hip fracture patients (aged ≥40years) and carers were recruited from five public hospitals (urban and rural). Data collected included in-depth interviews and observations of living and hospital environments, including audio-recordings, photography and fieldnotes, and were analysed using a framework approach. 

Results

Findings highlighted key priorities: (i) timeliness to treatment, (ii) pain management, (iii) affordability and financial impact, (iv) communication with healthcare professionals, (v) dignity and social connectedness. Patients expressed concerns about treatment delays, prolonged hospital stays without treatment decisions, and difficulties accessing pain medication. Financial challenges, including the high cost of implants and medications, delayed treatment. Several patients complained about minimal communication with doctors, unclear treatment plans and varying attitudes of healthcare professionals in providing practical assistance. Toileting in the wards was a priority; bed pans were only provided at specific times hence most patients reported soiling themselves, something they experienced as dehumanising. Several patients attributed social isolation and low mood to long hospital stays waiting for surgery, and negative effects of deaths of fellow patients.

Conclusion

Hip fracture management is usually severely delayed by the need of patients to find high out-of-pocket costs. Lack of communication by healthcare professionals exacerbates uncertainties. Dignity is not prioritised. Findings demonstrate the urgent need to improve services.

 

---

AGE- AND SEX-SPECIFIC INCIDENCE RATES AND FUTURE PROJECTIONS FOR HIP FRACTURES IN ZIMBABWE

Wilson H, Manyanga T, Burton A, Mafirakureva N, Mushayavanhu P, Ndekwere M, Chipanga J, Graham S, J. Masters J, Costa M,  Ferrand RA, Gregson CL

Objective

In Southern Africa, rapidly ageing populations are increasing demands on healthcare services, hence we estimated current and future hip fracture incidence in Zimbabwe.

Methods

Cumulative hip fracture incidence was determined over 2 years (Oct2021-Oct2023) in all adults aged ≥40 years, resident in Harare, presenting to any of the 7 hospitals in Harare. Sex-specific incidence hip fracture rates per 100,000 were calculated for 5-year age bands using United Nations (UN) population estimates for the city in 2021. National UN estimates were then used to calculate age-standardised hip fracture incidence rates in adults age ≥40 years across Zimbabwe, and predict future hip fracture numbers up to 2051.

Results

In 2021 there were an estimated 212,830 women and 208,607 men aged ≥40 years living in Harare, equating to 16.2% of the city’s population. Over 2 years we identified 243 hip fracture cases (133[54.7%] female), mean(SD) age 71.2(15.9) years, most presented to public
hospitals (202[83.1%]), with a fragility fracture (210[86.8%]). High-impact trauma e.g., traffic accidents, was most common in younger men.
In women, crude incidence per 100,000 person-years rose exponentially with age, reaching a rate of 1261.9 in those aged ≥80 years. By contrast, between 40-49 years, incidence was higher in men than women (11.3 vs. 1.2), the rate in men fell to match women at age 50-59,
and then rose steadily with age to reach 900.6 in those age ≥80 years. From 2021 to 2051, the overall projected sex-specific age-standardised hip fracture incidence rate (per 100,000 adults age ≥40 in Zimbabwe) is estimated to increase for women (from 17.8 to 31.2) and men (from 11.3 to 26.4) (Fig.1). The greatest increase is expected in women and men aged ≥80 years, with rates increasing from 20.8 to 33.9 for women and from 8.1 to 13.7 in men. Across Zimbabwe, the total number of hip fractures in adults aged ≥40 years is projected to increase from 813 in 2021 to 2,172 by 2051.

Conclusion

Hip fracture incidence rates in Zimbabwe are similar to those previously reported in Black South Africans. The majority are fragility fractures, reflecting population ageing. Demands on an already over challenged healthcare system will increase; fracture services will need to
respond.

 

---

The prevalence and clinical risk factors for frailty and associated impact on health-related quality of life in urban community-dwelling adults in KwaZulu Natal, South Africa

Madela E I Y, Gregson CL,  Paruk F, Burton A, Patel R, Wilson H, Habana F, Manyara AM, Mbanjwa B, Gates L, Grundy C, Ward KA, Cassim B

Introduction 

We investigated the prevalence, clinical risk factors associated with frailty and its relationship with health-related quality of life (HRQoL) in an urban South African population.

Methods

A population-based cross-sectional study, using age– and sex–stratified random sampling of adults aged ≥40 years was conducted. A researcher-administered questionnaire collected socio–demographic, lifestyle and medical data. The Shona symptom questionnaire screened for depression and anxiety and the International Physical Activity Questionnaire measured physical activity. Examination included mid-upper arm circumference (MUAC), walking speed, grip strength and short physical performance battery (SPPB). A modified Fried’s Frailty Phenotype defined frailty. EuroQol-5 Dimensions-5 Levels (EQ-5D-5L) measured HRQoL. The odds of being frail, independently associated risk factors, and HRQoL were calculated using multivariable logistic and linear regression. 

Results

Median age of 962 participants was 59.5 years [IQR 50-70], 53% were female. Overall frailty prevalence was 34.3%; increasing from 12.1% in the 40–49-year group to 51.5% in those ≥70 years (OR 7.1 [95%CI 4.9,10.9], p<0.001) and higher in females than males (64.2% vs 35.7%; OR 1.9 [95%CI 1.5,2.5], p<0.001). Being age ≥65 years, female, having diabetes mellitus, depression/anxiety, visual and hearing impairments, MUAC of <23cm, and SPPB score <9, were independently associated with frailty. Frailty was associated with lower HRQoL index than being robust (0.846 vs 0.864; β -0.04 [95%CI -0.05-0.03] p<0.001).

Conclusion

Frailty is common and associated with poor HRQoL. Older females, those with diabetes, depression/anxiety, visual and hearing impairments, low MUAC and impaired SPPB represent higher-risk groups in South Africa and should be targeted for assessment.

 

---

Frailty and multimorbidity in mid-aged and older adults living with HIV: a cross-sectional study in Zimbabwe

Manyara AM, Manyanga T, Burton A, Wilson H, Chipanga J , Bandason T , Ferrand R A , Gregson CL

Background

We aimed to determine the prevalence and factors associated with frailty and multimorbidity in people living with HIV (PLWH).

Methods

This population-based cross-sectional study recruited, by GIS-mapped household sampling, men and women aged ≥40 years in Harare, Zimbabwe. Data were collected using researcher-administered questionnaires, physical assessments (e.g., handgrip strength) and blood tests (including HIV status, if consenting). Frailty was defined using the five Fried criteria: unintentional weight loss, exhaustion, low physical activity, low gait speed, low handgrip strength.
Presence of ≥3 criteria defined frailty, 1-2 pre-frailty, and absence (0) robust. Long-term conditions defining multimorbidity were based on self-reported diagnosis or diagnosis based on measurements (e.g., blood pressure/glucose). Adjusted regression models were used to analyse data.

Results

he 1109 participants had mean(SD) age of 62.5(14.1) years, 51.6% female. Of 1034(93.2%) with HIV status data, 21.6% (n=223) were living with HIV: 6.4% were newly diagnosed; 96.2% of those who knew their status were on antiretroviral treatment (ART), whilst 89.7% of those on ART had a viral load<50 copies/mL. The prevalence of frailty, prefrailty and robust in PLWH was 3.6%, 61.4%, and 35% respectively. In addition to HIV, 32.7% were living with ≥2 conditions, 36.3% with one condition and 30.9% with only HIV. Time since HIV diagnosis and treatment duration were both independently associated with frailty, but not multimorbidity: independent of age and ART duration, living with HIV was associated with pre-frailty or frailty (adjusted odds ratio [aOR]=2.03 (95%CI 1.03-4.13), for each 5-years lived with HIV) while, independent of age and years lived with HIV, ART duration was protective, 0.39 (0.19-0.78) for each 5-years on ART. PLWH had higher odds of prior tuberculosis (7.92 (4.32-15.05)) and comorbid cancer (2.74 (0.77-9.08)), albeit marginally, compared with
people without HIV. . Frailty and multimorbidity were associated with a lower health-related quality of life in PLWH, although the associations were similar in people without HIV.

Conclusion

Sixty-five percent of PLWH aged 40-83 years were frail or pre-frail, while 33% were living with 2 or more long-term conditions necessitating
interventions to prevent or manage frailty and multimorbidity. Early ART initiation and good viral suppression are interventions that could protect against frailty.

 

---

Prevalence and factors associated with frailty and pre-frailty in mid-aged and older women living with HIV in Zimbabwe

Manyara AM, Manyanga T, Burton A, Wilson H, Chipanga J, Bandason T, Ferrand RA, Gregson CL

Background

Survival of people living with HIV (PLWH) has dramatically improved due to widespread roll-out of antiretroviral therapy (ART). An increasing proportion of PLWH are now entering older age and are at higher risk of frailty. This study assessed the prevalence of frailty and associated factors in older women living with HIV. 

Methods

This cross-sectional study recruited, by household sampling, men and women aged ≥40 years in Harare, Zimbabwe. Data were collected using researcher–administered questionnaires, physical assessments (e.g., handgrip strength) and blood tests (including HIV status, if consenting). Frailty was defined using five criteria: unintentional weight loss, exhaustion, low physical activity, low gait speed, low handgrip strength. Presence of ≥3 three criteria was defined as frailty, 1-2 as pre-frailty, and absence (0) non-frail. Ordinal logistic regression models were used to analyse data, adjusted for covariates: the HIV and frailty models was adjusted for age, employment status, marital status, sensory loss, and cancer diagnosis; factors associated with frailty in women living with HIV were adjusted for age.  The association of frailty with years lived with HIV was adjusted for ART, and the association with ART adjusted for years lived with HIV.  

Results

537/572 women (93.8%) had HIV status data. 21.6% of these (116) were living with HIV and had a mean age (± standard deviation) of 54.0(±9.7) years. In total, 91.4% (n=106/116) knew their status and had lived with HIV for 10.2(±5.0) years. 8.6% (n=10) were newly diagnosed by the research team; their age ranged 40-83 years, mean 58.0(±12.8) years. Of those who knew their status, 97.2% (103/106) were on ART, with 96.0% (97/101) having a viral load of <1000 copies/mL and 87.1% (88/101) a viral load <50 copies/mL. 

Overall, living with HIV was not associated with frailty ((adjusted odds ratios (aOR)=1.03 (95% Confidence Intervals [CI] 0.66, 1.62). In women living with HIV, 4.3%, 62.1%, and 33.6% were categorised as frail, pre-frail, and non-frail, respectively. Living with HIV for longer doubled the odds of frailty, although the CI was wide, aOR=2.01 (0.87, 4.99) per 5-years of HIV; whereas ART duration was inversely associated with frailty (aOR=0.43 (0.17, 0.99), per 5-years of ART. Viral load ≥50 copies/mL was associated with higher odds of frailty albeit with wide CI (aOR=3.04 (0.84, 12.88)). Prior tuberculosis was reported in 11.2% of the women living with HIV and was associated with higher odds of frailty (aOR=4.30 (1.18, 18.15)). Health-related quality of life index value was on average 9.4 units lower in women living with HIV who were frail compared to those who were pre-frail or non-frail, mean index values, 77.9(±16.3) versus 86.9(±9.3) and 87.3(±6.2) respectively, p=0.026. 

Conclusion

In women with high viral suppression, living with HIV was not associated with frailty. However, longer ART duration was protective. Prior tuberculosis was associated with frailty. Given the decline seen in health-related quality of life with frailty, there is need to optimise tuberculosis prevention and management, early ART initiation, and good viral suppression to protect against frailty.  

 

---

The Prevalence of Vertebral Fractures and Associated Factors in The Gambia, South Africa and Zimbabwe: The Fractures-E3 study 

Gates LS , Burton A, Manyanga T, Jallow MK, Cassim B, Grundy C, Wilson H, Ferrand RA, Paruk F, Crabtree N, Clark E, Gregson CL, Ward KA

Introduction

Vertebral fractures (VFs) are the most common osteoporotic fracture. Few data describe the prevalence and associated factors for vertebral fractures (VFs) from resource-limited settings, where the populations are rapidly ageing. We aimed to determine the prevalence and associated factors for VF in women and men in the Fractures-E3 study.  

Methods

A population-based, cross-sectional study of community dwelling adults was conducted across three urban sites; Harare, Zimbabwe; Brufut/Sukuta, The Gambia; Kwamashu, South Africa. Recruitment was stratified in sex- and age groups (40-54, 55-69, ≥70 years). Prevalence of vertebral fractures was determined using Genant semi-quantitative assessment on iDXA images in The Gambia and Zimbabwe, and lateral thoracic/lumbar spine radiographs in South Africa. Demographic and clinical factors were compared in those with and without prevalent VFs, by country and sex. Logistic regression determined associations between VFRAC clinical decision tool2 factors : age, weight, wall–to–tragus, back pain, prior fragility fracture (humerus/wrist/hip/leg/ankle/spine/pelvis), and glucocorticoid use.  

Results

Mean BMI (kg/m2) was higher in women for all countries (Gambia: 28.0 [6.1] vs 23.6 [4.1], South Africa (34.9 [9.0] vs 25.4 [5.8] and Zimbabwe (28.9 [6.7] vs 23.0 [4.2]). Prevalence of VF was 10.6% (n=116) in The Gambia, 4.1% (n=39) in South Africa and 7.7% (n=84) Zimbabwe. Those with VF were older; The Gambia (69.6 (10.1) vs 59.3 (12.4) years, p<0.001), South Africa (66.4 (11.4) vs 59.8 (11.9) years, p<0.001) and Zimbabwe (71.6 (13.4) vs 61.6 (13.9) years, p<0.001). Sex was not associated overall, however VF prevalence was higher in younger men (in Gambia and South Africa) and higher in older women (Table 1). The odds of having a prevalent VF  were higher in those who reported a prior adult fracture (Odds ratios [95% confidence intervals] Gambia 2.29 [0.96,5.47]; South Africa 2.28 [1.18,4.41]; Zimbabwe 2.18 [1.15,4.13]). Increasing weight in South Africa (0.98 [0.96,0.99]) and Zimbabwe (0.98 [0.97,1.00]) was associated with lower odds of having a prevalent VF and greater odds of VF with current steroid use in The Gambia (2.95 [1.47,5.95]).  The remaining VFRAC variables were not associated with having a prevalent fracture VFs are common in African populations. Given the rising ageing population in countries with limited and stretched healthcare resources, it is important to understand further context specific factors associated with fragility fractures such as bone trauma in young, alcohol consumption, the role of fat mass, bone mineral density and HIV.  

References

1. Burton et al. Wellcome Open Research, 2023 10.12688/wellcomeopenres.19391.1

2. Khalid TY et al.  Arch Osteoporos. 2024 Feb 7;19(1):12

 

---

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

Introduction

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. 

Objective

To determine sarcopenia prevalence in women and men aged 40 years and above in Zimbabwe. 

Methods

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. 

Results

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. 

Discussion

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. 

Conclusion

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.  

References

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. 

 Funder

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

Background 

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. 

Methods 

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. 

Results 

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).  

Conclusion 

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

Objective 

To characterise the population experiencing hip fractures in Harare, Zimbabwe and assess 30-day outcomes. 

Methods 

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. 

Results 

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). 

Conclusion 

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 

Background 

As populations age in sub-Saharan Africa, hip fracture rates are predicted to rise, yet data on hip fracture epidemiology are scarce.  

Purpose 

To characterise the population with hip fractures in Harare, Zimbabwe and understand short-term survival. 

Methods 

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. 

Results 

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). 

Conclusion 

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

Objective 

To identify and quantify hip fracture service availability and readiness in The Gambia (adult population: 1.2million) 

Methods 

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.   

Results 

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. 

Conclusion 

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

Conference presentation, Bone Research Society annual Meeting 2021 and NOFSA

Background

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.

Methods

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.

Results

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.

Conclusion

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

Conference presentation at NOFSA