Background
With age, the incidence of hip fractures in the elderly increases exponentially due to increased prevalence of osteoporosis and increased risk of falls [
1‐
4]. In the elderly, the majority of hip fractures are a result of a low-energy trauma [
4,
5], defined as falls from standing height or less [
6]. Fracture at the hip may imply pain and reduced physical functioning months and years after the fracture [
7‐
9], and may consequently affect quality of life (QOL).
QOL is considered a subjective phenomenon, which is often assessed through self-report and thereby supplements objective factors associated with disease, in this context hip fracture and bone mineral density (BMD). Traditionally, QOL comprises both health-related quality of life (HRQOL) and global quality of life (GQOL) [
10]. HRQOL may be defined as the individual's experience of their general state of health, such as physical, social, and mental well-being [
11], and GQOL may be defined as a broad range of human experiences related to one's overall well-being and satisfaction, and has a meaning beyond an individual's health [
12‐
14]. A broad QOL perspective includes both the health aspect (HRQOL) and satisfaction with life as a whole (GQOL).
Previous QOL studies in patients with hip fracture have shown that HRQOL decreases
after a hip fracture, and that physical health is influenced more by the fracture than mental health [
8,
9,
15‐
18]. Furthermore, HRQOL seems to decrease more after a hip fracture in patients who had low HRQOL before the fracture than in those with higher scores [
18]. Additionally, studies focusing on
predictors of changes in HRQOL after a hip fracture show that low body mass index (BMI) and low BMD are associated with reduced HRQOL two years after a low-energy hip fracture in postmenopausal women [
7].
To the best of our knowledge, no studies have assessed whether patients with hip fractures regain their pre-fracture GQOL after the fracture, nor have predictors of changes in GQOL in patients with low-energy hip fracture been identified. Furthermore, the complexity of the consequences of hip fractures, including both an objective perspective (e.g., BMD, BMI, demographic, and clinical indicators) and a subjective perspective (e.g., QOL) on changes, needs to be addressed. Knowledge about these issues may provide patients, providers, and decision makers with important information on the impact of disease and treatment on physical, psychological, social functioning, and well-being, and satisfaction with life. Thus, the patient's subjective perspective may be included in decision making and health care plans, such as contact and collaboration of health care between the hospitals and the health care units in the municipalities after the fracture [
19,
20].
Hence, the present study aims to:
a) Explore whether patients with low-energy hip fracture regain their pre-fracture levels in HRQOL and GQOL compared with changes in age- and sex-matched controls over a two year period;
b) Identify predictors of changes in HRQOL and GQOL after two years.
Discussion
Compared with pre-fracture the patients with hip fractures reported modestly or moderately decreased HRQOL and GQOL one year after fracture that remained nearly unchanged at two-year follow-up, whereas the controls reported no significant changes in HRQOL and moderately or modestly decreased GQOL. Changes in HRQOL physical health two years after baseline were predicted by age and being a patient with hip fracture, while co-morbidity predicted changes in HRQOL mental health.
Our findings of lower pre-fracture scores of patients compared with controls within some HRQOL domains and decreased HRQOL one year after a low-energy hip fracture, especially within the physical domains, are in line with earlier studies in the field [
8,
9,
17,
18,
35]. Furthermore, the patients seem to reach a plateau with regard to HRQOL one year after the fracture. Our findings show that the burden of a hip fracture on self-reported physical health is particularly pronounced among the oldest patients. These findings might emphasize that health care providers should have a special focus on the oldest patients with regard to targeted rehabilitation efforts, so that the patients could achieve the highest possible function and independence level in everyday life.
The patients with hip fractures had lower GQOL before the fracture occurred, compared with controls. However, both the patients with a hip fracture and the controls reported moderately decreased GQOL one year after inclusion and modestly decreased GQOL two years after inclusion. We might interpret these changes as being to aging. The findings are in line with changes over a period of one or two years in other patient groups [
36,
37]. In contrast to our results, studies have shown that GQOL does not seem to be influenced by old age [
38,
39]. Furthermore, it is possible that those patients and controls who agreed to participate in our study did so at a point in time when their GQOL was better than their own typical (long-term) level, thus creating a "regression to mean" effect two years later when these same individuals may have returned to their usual level of GQOL [
33]. There seems to be a difference regarding how a low-energy hip fracture influences GQOL and HRQOL over a period of two years, as the patients' experiences of change in overall satisfaction with life (i.e., GQOL) appear to be in line with that of the elderly population in general. In contrast, the patients' experience of their health (i.e., HRQOL) is substantially influenced by the fracture.
To be a patient with a hip fracture was a strong predictor of worsened physical health in an elderly population, even when known correlates of decreased physical health such as co-morbidity, age, and marital status [
40‐
42] were adjusted for. This indicates a strong association between a hip fracture and worsened health. In contrast to previous studies, we did not find BMD as a significant predictor of changes in HRQOL, and there is no clear explanation for this [
8,
16‐
18,
35,
43]. The findings underline the burdens and complexity related to a hip fracture.
The overview of the excluded patients and the patients unwilling to participate in this study shows that those who were included were probably the healthiest and the youngest ones. The majority of the excluded patients were excluded because of dementia or because they were unable to give informed consent. Furthermore, nursing home patients who were sent home within two days after fracture were not included in the study. These patients suffered from mental and physical diseases, and were less able to take care of activities of daily living than the patients included in the study. However, even in the relatively exclusive group of patients included in the study, the baseline HRQOL level was not regained over the two-year period. Furthermore, the relatively high number of excluded patients indicates that many patients with hip fractures are not capable of self-reporting their HRQOL and GQOL. This may be the reason why patient-based outcomes such as HRQOL and GQOL among patients with hip fractures are available only for rather limited samples. Thus, the knowledge derived from this study, as well as others, can probably be generalized primarily to a rather healthy sub-group of the elderly population with hip fractures. We do not know the reason for the 10 deaths among the patients during the two-year follow-up. However, we could assume that the deaths might be related to age, co-morbidity or complications associated with the hip fracture.
The patients' ability to correctly recall their HRQOL and GQOL before the hip fracture may be questioned. One possible way is to apply epidemiological surveys of QOL and from a huge cohort identify people who fracture, and thereafter examine how they manage compared with those not fracturing. To perform such a large study was not possible for us to do. And a cohort study would also have limitations because QOL may change between the time of data capture and fracture, and thus may no longer be valid for the time of fracture. Thus, an alternative method is to use pre-injury recall, like in this trauma study and in other studies [
9,
18,
35]. Changes in health status, such as that resulting from experiencing a fracture, might cause a shift in how the patients judged their HRQOL and GQOL (selective reporting bias and response shift) [
44]. On the other hand, patients who have experienced a recent change in health are more likely to make accurate health-related responses [
32,
45,
46]. To minimize the recall problem it is recommended that QOL assessments should be performed with the shortest possible time lag after the fracture event, which we aimed for in our study. The elapsed time from fracture to assessment was relatively short and most patients completed the baseline QOL questionnaires within five days after fracture. Thus, it seems unlikely that the patients would have forgotten about their QOL before and at the time of the fracture. To minimize further the retrospective design of our baseline data, the questionnaires were administered with an instruction that the patients should think of the period before the fracture. Furthermore, demographic and clinical characteristics before the fracture were also based on recall, and the validity on reports of numbers of e.g. fall may be questioned. Two studies [
47,
48] have shown that the number of falls reported by recall, may be underestimated among elderly. However, as the participants are the only source of information in these matters, we are forced to rely on self-reports.
This study has a case-control, prospective, and longitudinal design, and population based controls were chosen as the control population. We could argue that a hospital based control population would have been better to assess the influence of fracture as well as the outcome. On the other hand, the disease giving rise to the hospitalization and the impact of the disease, would have influenced characteristics and outcomes in ways which would be hard to assess. Furthermore, comparisons with elderly from the general population were a guiding principle in this study. Other studies have recruited controls from general practitioners [
8,
18], both cases and controls were recruited from general practitioners [
17,
43,
49], or population-based HRQOL (SF-36) norms were used in cross-sectional comparisons [
7,
16,
35].
A low-energy hip fracture seems to have substantial clinical implications with respect to HRQOL in most patients. Elderly people who barely manage alone before the fracture might be in need of assistance afterwards. This assistance might include both practical help and community care. An intensive interdisciplinary approach is therefore required to improve functioning in everyday life, which would also include a focus on patient-reported outcomes such as HRQOL and GQOL. Furthermore, the impact of a hip fracture on self-reported outcomes, such as the HRQOL revealed in our study, might give support to the implementation of patient-reported outcomes in daily clinical practice, and thereby reach the patient's perspective and evaluation of the health care both in the hospitals and the rehabilitation units in the municipalities [
19,
20]. With a growing number of elderly and an incidence of hip fractures in Norway that is among the highest in the world [
2‐
4], low-energy fractures seem to be a challenge for both the society and the individuals in the years to come. An increased contact and collaboration between the different levels of care might thereby be required, i.e. between hospitals and community health care [
19,
20].
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
GR initiated this paper as a part of a larger study of fracture patients, collected and analyzed the data and wrote the manuscript. GH was the principal investigator for the study and supervised GR. AM supervised GR during the analyzes and drafting of the paper. TM provided statistical advice. AKW supervised GR during the analyzes and drafting of the paper. All authors critiqued revisions of the paper and approved the final manuscript