Quality of life in postoperative Japanese hip fracture patients: a hospital-based prospective study

This is the first study reporting QOL changes in postoperative hip fracture patients in Japan. Contrary to the results of previous studies from other countries, we found that QOL recovered to pre-facture levels 1 year following hospitalization. This discrepancy might be due in part to ethnic differences; however, differences in study design limit such international comparisons with previous studies. One important difference is the criteria for including or excluding subjects as mentioned below. In general, Asians are known to report higher QOL levels compared to Westerners of the same health condition [35]. Further international studies are required to understand how cultural values and norms might result in QOL differences.

An individual’s concept of QOL may change over time and in response to changing circumstances. The ‘secondary gain’ in QOL occurs when patients with impairments adapt to their new conditions [36]. Patients who experience disability can find enriched meaning in their lives after becoming disabled. Similar interpretations for a small change in QOL following physical decline can be explained by the “disability paradox” [36] and “response shift” [37]. These concepts refer to a change in the meaning of one’s evaluation of QOL, such that patients might provide different answers to QOL questions over time, not only because their health or QOL has changed, but also because their perception of what health or QOL means may have changed.

Another explanation for the high QOL in our cohort is their favorable postoperative functional recovery. Early functional recovery and independence in daily life are very important to a patient’s QOL [10]. Studies examining patients from other countries have reported significant functional decline following hip fracture [8, 9, 21], whereas we detected only a slight decrease. The favorable recovery of patients in this study compared to some previous studies could be explained, in part, to our exclusion of patients with severe cognitive decline [9, 21]. However, our patients exhibited better functional outcomes even when compared with the majority of previous studies that excluded those with cognitive decline [8]. For elderly hip fracture patients, early surgery and promptly initiated post-surgical rehabilitation have been reported to improve functional recovery and prevent postoperative complications [11]. Many of our patients were operated on within 2 days of admission and started rehabilitation the following day. This is earlier than average in Japan and might have contributed to the favorable ADL recovery.

Despite the possible positive shift in one’s internal standard of measurement, changes in EQ-5D and EQ-VAS varied quite dramatically. We thus investigated factors associated with the changes in QOL. Our results revealed that older age, femoral neck fracture, and residence at home all exerted a positive influence on change in EQ-5D, while normal cognitive function, ADL recovery (as measured by Barthel index), and living without household help had positive influences on changes in EQ-VAS. Associated factors differed between the two QOL outcomes, suggesting that they may assess different aspects of QOL. One previous study of Japanese patients noted a significant correlation between EQ-5D and EQ-VAS, but a relatively low correlation coefficient (r = 0.46, p < 0.01) [38]. The two measurements in our study had an even lower correlation coefficient (r = 0.29, p < 0.05).

A positive correlation between age and change in QOL may imply a stronger response shift among older patients. Older individuals have decreased functional capacity and reduced expectations for self-performance, on average, than younger individuals. A previous study examined differences between ‘self-reported’ and ‘observed’ functionality and found that ‘self-reported’ function gradually increased, while ‘observed’ function decreased with age [39]. In other words, younger individuals expect to function at a higher level and thus are more likely than older individuals to report a higher level of disability.

Controlling for age, mental and physical factors were significantly associated with changes in QOL in our study. Hip fracture patients with impaired cognitive function have an increased risk of complications, poor long-term outcomes and an increased mortality rate [40]. When examining QOL, individuals with severe cognitive dysfunction are often excluded, as in our study. As such, only a few studies among this population have been conducted. One prospective clinical study in Sweden found that hip fracture patients with severe cognitive dysfunction showed a continuous deterioration in EQ-5D score compared with patients who did not have severe cognitive dysfunction [40]. These findings probably reflect the natural course of cognitive impairment, the difficulty for these patients to follow rehabilitation regimens and to adjust to physical and functional changes, and inadequate rehabilitation resources for this specific group. Regarding ADL, the same research team from Sweden later reported that patients with a high level of functional independence had significantly higher EQ-5D scores than those who were more dependent at both 4 months and 17 months after hip fracture [41]. The significant association between ADL and QOL in our subjects (who exhibited favorable postoperative functional recovery) suggests that there is a strong influence of ADL on QOL.

With regards to fracture type, a previous study comparing trochanteric and femoral neck fractures reported that patients with the former were characterized by poorer health and consequent delayed recovery [42]. Our findings agree with these in that changes in QOL were greatest in patients with femoral neck fractures. However, the results obtained regarding fracture type and cognitive decline should be interpreted with caution because of the significant differences between patients who were and were not included in the overall analyses. The proportion of patients with trochanteric fracture and moderate cognitive decline was significantly higher in the group of patients who were excluded from overall analyses. As such, even stronger associations may have been masked.

It is noteworthy that living arrangements (including residence type and household help) at the time of follow-up were associated with changes in QOL. We found that patients who lived at home and/or without household help had more positive changes in QOL. It should be noted that the cause–effect relationships are unclear due to the cross-sectional nature of these survey items, and that the results do not necessarily mean, for example, that having household help negatively influences QOL. In other words, it is likely that the recovery of individuals who maintained high QOL was such that daily assistance was not required and living at home was possible. In either case, these results emphasize the importance of assessing and being aware of patients’ living conditions [43].

This study had three methodological limitations. Firstly, the survey took place at a single private hospital and the total number of registered subjects was small (N = 113). Data from only 50 follow-up respondents (62%) were included in our analyses after excluding for severe cognitive decline. Since respondents of epidemiological surveys tend to be healthier, the high attrition rate might have led to an underestimation of decline in QOL and its association with surveyed factors. The 1-year follow-up rate, however, was comparable to previous studies (50–80%) [21, 41]. For future research, a multi-center study with a larger sample size is warranted. Secondly, a large proportion (27%) of patients with severe cognitive decline was excluded from analyses because of difficulties in completing QOL questions and less reliable answers. A previous study that included patients with severe cognitive decline suffered from a low response rate. Only 51% of patients were able to complete the SF-36 questionnaire and respondents were considerably younger, had less cognitive impairment and had better functional status than non-respondents [21]. Similarly, only three of the 31 patients with severe cognitive decline were able to answer the QOL questions in our study. Although our findings can only be generalized to hip fracture patients without severe cognitive dysfunction, this does not alter the internal validity of the results regarding factors associated with changes in QOL. Thirdly, a recall bias of baseline QOL and ADL levels could not be avoided because we used “pre-injury recall” as previously noted. Since patients’ recall may not be accurate, we repeated the same multivariate analyses using QOL and ADL scores at the time of discharge as the baseline data and found that no factor remained significant related to either EQ-5D or EQ-VAS.

In conclusion, we found that there was less of a decline in Euro-QOL after hip fracture in our cohort of Japanese patients. Changes in Euro-QOL, however, varied between patients, and were associated with age, cognitive function, ADL, fracture type, residence type, and household help. These findings suggest that to maintain and improve QOL in Japanese hip fracture patients, closer attention should be paid to patient age, cognitive status, and fracture type. They also highlight the importance of providing social support in addition to medical care to these patients.