Archives of Osteoporosis (2019) 14: 56 https://doi.org/10.1007/s11657-019-0607-0 SHORT COMMUNICATION The impact of hip fracture on health-related quality of life and activities of daily living: the SPARE-HIP prospective cohort study D. Prieto-Alhambra 1,2,3 & D. Moral-Cuesta 4 & A. Palmer 5 & I. Aguado-Maestro 6 & M. F. Bravo Bardaji 7 & F. Brañas 8 & G. Adrados Bueno 9 & J. R. Caeiro-Rey 10 & I. Andrés Cano 11 & M. Barres-Carsi 12 & L. Gracia Delgado 13 & M. Salomó-Domènech 14 & I. Etxebarria-Foronda 15 & B. Llado Ferrer 16 & S. Mills 17 & L. Ezquerra Herrando 18 & D. Mifsut 19 & L. D. R. Evangelista 20 & X. Nogués 21 & I. Perez-Coto 22 & J. Martínez-Iñiguez Blasco 23 & C. Martín-Hernández 24 & H. Kessel 25 & J. Teixidor Serra 26 & J. Rodriguez Solis 27 & O. Torregrosa Suau 28 & E. Vaquero-Cervino 29 & C. Pablos Hernández 30 & L. Rodríguez Mañas 31 & A. Herrera 32 & A. Díez-Perez 33 Received: 18 February 2019 / Accepted: 13 May 2019 / Published online: 29 May 2019 # The Author(s) 2019 Abstract Purpose The medical morbidity and mortality associated with neck of femur fractures is well-documented, whereas there is limited data for patient-reported outcomes. The aim of this study was to characterize the impact of neck of femur fractures on activities of daily living and patient-reported health-related quality of life. Methods Design and participants: Multicentric prospective cohort study. Consecutive sample patients with fragility hip fracture over 50 years old admitted in 48 hospitals in Spain. Outcomes: daily living activity function (Barthel Index) and health-related quality of life (EQ-5D) pre-fracture, admission to hospital and at 1- and 4-month follow-up post-fracture. Statistics: Barthel and EQ-5D over time are described as mean (SD) and median (interquartile range). Results A total of 997 patients were recruited at baseline with 4-month outcomes available for, and 856 patients (89.5%). Barthel Index fell from 78.77 (23.75) at baseline to 43.62 (19.86) on admission to hospital with the fracture. Scores partially recovered to 54.89 (25.40) and 64.09 (21.35) at 1- and 4-month post-fracture, respectively. EQ-5D fell from a median of 0.75 (0.47–0.91) to − 0.01 (− 0.03 to 0.51) on admission. Partial recovery was observed again to (0.51 (− 0.06 to 0.67)) and (0.60 (0.10 to 0.80)) at 1- and 4-month post-fracture, respectively. Conclusions Hip fracture results in a large decline in the ability to perform activities of daily living and patient-reported health- related quality of life with only partial recovery amongst survivors 4-month post-fracture. Keywords Fragility hip fracture . Osteoporosis . Registries . Quality of life Introduction It is estimated that between 2020 and 2050, the number of hip fractures worldwide will increase to more than 2 billion cases [3]. A total of 620,000 hip fractures were sustained in the This will represent a large socioeconomic burden [4, 5]. European Union in 2010.Osteoporotic hip fractures are asso- Despite the increasing socioeconomic burden, there is a ciated with significant morbidity, mortality and societal costs scarcity of data on the impact of hip fracture to patients in [1]. Fragility fractures of any site had an estimated economic terms of patient-reported outcomes and activities of daily liv- burden of € 37 billion and accounted for almost 1.2 million ing. Particularly, there is no previous reports to our knowledge quality-adjusted life years in that same year [2]. of both in a same cohort in Spain. This is important for a comprehensive assessment of the burden of hip fractures in the Spanish population. The aim of this study is to determine the association be- * D. Prieto-Alhambra tween proximal femur fragility fractures and patient-reported Daniel.prietoalhambra@ndorms.ox.ac.uk health-related quality of life and activities of daily living dur- ing the 4-month following fracture. Extended author information available on the last page of the article 56 Page 2 of 5 Arch Osteoporos (2019) 14: 56 Methods Results Study design and setting Baseline outcome data was available for 997 patients, of whom 856 (85.9%) completed 4 months of follow-up. Of Multi-centre prospective observational cohort study in 48 hos- the 141 without follow-up data, 99 (9.9%) have died, and 42 pitals in Spain (4.2%) were lost to follow-up. Detailed patient characteristics have been previously reported [6]. Complete data on baseline and 1- and 4-month Barthel and EQ-5D-3L were collected for Eligibility criteria 824/856 (96.3%) and 746/856 (90.2%) participants respectively. Details on sampling strategies, data collection and follow-up On average, overall health-related quality of life dropped have been reported elsewhere [6]. One thousand consecutive by 57% at the time of fracture, to then recover by 23% in the men or women aged ≥ 50 years old with a diagnosis of a first month and by a total 37% at 4-month post-admission. fragility femur fracture were recruited. Consent was obtained from patient or principal carer and/or legal representative of the patient. Discussion Measurements Our study demonstrates a significant fall in both EQ-5D and the Barthel Index on sustaining a proximal femoral fracture, Data was collected during consultations on admission and at and this falls only partial recovers at 4-week follow-up. 1-month and 4-month follow-up appointments. Phone consul- Barthel Index, assessing the ability to perform activities of tations were conducted for the 1 month and 4 months when daily living fell from 79 to 44% immediately after sustaining face-to-face visits were not possible. Baseline (pre-fracture) the fracture, with a recovery to 64% function 4-month post- measures were collected on admission to hospital-based on fracture. The impact on patient quality of life is even more patient recollection of their previous activity and health status. striking: participants started with 75% of full health which fell Outcome measures were Barthel Index (ability to perform to 0% of full health ‘like dead’ immediately after the fracture. activities of daily living) [7]) and EQ-5D-3L (global health- Partial recovery was again seen in the following 4 months, related quality of life [8]). Barthel scores range from 0 to 100, increasing to a 60% full health. with lower scores indicating more disability. EQ-5D-3L mea- Our results are similar to those found in similar cohort from sures five dimensions (mobility, self-care, usual activities, the UK [10], Norway [11] and Portugal [5]. In those, the pain and anxiety/depression) and a global visual analogue authors reported a gradual recovery up to 1 year in terms of scale (VAS). Utility indices were derived from EQ-5D-3L quality of life. These findings are also comparable to those using Spanish national preference tables [9]. These range from obtained from a smaller Spanish cohort [12]. As in our study, 0 (death) or even negative values (worse than death) to 1 (full improvement in quality of life seemed to be mirrored by func- health). tional recovery in these previous studies. Other studies [13, 14] including the UK (WHiTE) study [15] have also shown similar deterioration in functional status [16]. Statistical analyses Our study has limitations. Our findings are only represen- tative of the subjects who survived, as almost 10% of the study Barthel EQ-5D-3L is expressed as mean (standard deviation) participants died within 4 months, and it is possible that their and as median (interquartile range) (Table 1). Change in utility function and health status were worse at baseline and post- indices over time is plotted as a histogram (Fig. 1). fracture. In addition, recall bias is possible in the Table 1 Change in health-related quality of life at the time of a femur fracture, and in the following 1 and 4 months of follow-up Change in EQ-5D-3L utility at index admission Change in EQ-5D-3L from index Change in EQ-5D-3L from 1 to 4 months admission to 1 month of follow-up Mean (sd) − 0.57 (0.43) 0.23 (0.40) 0.37 (0.43) Median (IQR) − 0.56 (− 0.90 to − 0.28) 0.16 (0.0 to 0.50) 0.34 (0.09 to 0.70) *Positive values are equivalent to improvement/recovery; negative values mean worsening Arch Osteoporos (2019) 14: 56 Page 3 of 5 56 Fig. 1 Histogram of EQ-5D-3L utility indices at baseline (pre-fx), at admission for a femur fracture (fx date), and at 1 and 4 months of follow-up determination of pre-fracture (baseline) health status, as this References was recorded during the index hospital admission. This analysis also has strengths. First, the prospective na- 1. Pedersen AB, Ehrenstein V, Szépligeti SK, Lunde A, Lagerros YT, Westerlund A, Tell GS, Sørensen HT (2017) Thirty-five–year ture of data collection and the fact that the information was trends in first-time hospitalization for hip fracture, 1-year mortality, recorded by trained clinician/s and/or nurses give high validity and the prognostic impact of comorbidity: a Danish nationwide to our findings. Secondly, we have low attrition, with < 5% cohort study, 1980–2014. Epidemiology 28(6):898–905 loss to follow-up at 4-month post-fracture. Finally, our partic- 2. Svedbom A, Hernlund E, Ivergård M, Compston J, Cooper C, ipants were recruited from a representative sample of hospitals Stenmark J et al (2013) Osteoporosis in the European Union: a com- pendium of country-specific reports. Arch Osteoporos 8(1–2):137 around the country. 3. Cooper C, Campion G, Melton LJ 3rd (1992) Hip fractures in the In conclusion, we report a sustained detriment of proximal elderly: a world-wide projection. Osteoporos Int 2(6):285–289 femoral fractures on the ability of a patient to perform activi- 4. Borgström F, Lekander I, Ivergård M, Ström O, Svedbom A, ties of daily living and their health-related quality of life. Alekna V, Bianchi ML, Clark P, Curiel MD, Dimai HP, Jürisson These data should be used to estimate the socioeconomic bur- M, Kallikorm R, Lesnyak O, McCloskey E, Nassonov E, Sanders KM, Silverman S, Tamulaitiene M, Thomas T, Tosteson ANA, den of osteoporosis-related fractures and to inform the plan- Jönsson B, Kanis JA (2013) The international costs and utilities ning of care for these patients. related to osteoporotic fractures study (ICUROS)—quality of life during the first 4 months after fracture. Osteoporos Int 24(3):811– Funding information This work has been sponsored by an unrestricted 823 grant of AMGEN to the Hospital del Mar Institute of Medical 5. Marques A, Lourenço Ó, da Silva J (2015) The burden of osteopo- Investigation (IMIM). rotic hip fractures in Portugal: costs, health related quality of life and mortality. Osteoporos Int 26(11):2623–2630 6. Prieto-Alhambra D, Reyes C, Sainz MS, González-Macías J, Compliance with ethical standards Delgado LG, Bouzón CA, Gañan SM, Miedes DM, Vaquero- Cervino E, Bardaji MFB, Herrando LE, Baztán FB, Ferrer BL, Conflicts of interest ADP is advisor or speaker for Amgen/UCB, Perez-Coto I, Bueno GA, Mora-Fernandez J, Doñate TE, Blasco Roche, Gilead, EchoLight and Lilly. Institutional grant EchoLight and JMI, Aguado-Maestro I, Sáez-López P, Doménech MS, Climent- Kiowa-Kirin and Shareholder Active Life Sci. DPA’s research group Peris V, Rodríguez ÁD, Sardiñas HK, Gómez ÓT, Serra JT, Caeiro- has received unrestricted research grants from Servier, Amgen and Rey JR, Cano IA, Carsi MB, Etxebarria-Foronda I, Hernández UCB; and speaker and consultancy fees from Amgen and UCB. All other JDA, Solis JR, Suau OT, Nogués X, Herrera A, Díez-Perez A authors report no conflict of interests. (2018) In-hospital care, complications, and 4-month mortality fol- lowing a hip or proximal femur fracture: the Spanish registry of Open Access This article is distributed under the terms of the Creative osteoporotic femur fractures prospective cohort study. Arch Commons Attribution 4.0 International License (http:// Osteoporos 13(1):96 creativecommons.org/licenses/by/4.0/), which permits unrestricted use, 7. Collin C, Wade D, Davies S, Horne V (1988) The Barthel ADL Index: distribution, and reproduction in any medium, provided you give appro- a reliability study. Disability and rehabilitation 10(2):61–63 priate credit to the original author(s) and the source, provide a link to the 8. EuroQol G (1990) EuroQol–a new facility for the measurement of Creative Commons license, and indicate if changes were made. health-related quality of life. Health policy 16(3):199 56 Page 4 of 5 Arch Osteoporos (2019) 14: 56 9. Badia X, Roset M, Herdman M, Kind P (2001) A comparison of after accidental hip fractures: a prospective cohort study. BMC United Kingdom and Spanish general population time trade-off Geriatr 14(1):124 values for EQ-5D health states. Med Decis Mak 21(1):7–16 15. Costa ML, Griffin XL, Achten J, Metcalfe D, Judge A, Pinedo- 10. Griffin X, Parsons N, Achten J, Fernandez M, Costa M (2015) Villanueva R, Parsons N (2016) World hip trauma evaluation Recovery of health-related quality of life in a United Kingdom (WHiTE): framework for embedded comprehensive cohort studies. hip fracture population: the Warwick hip trauma evaluation-a pro- BMJ Open 6(10):e011679 spective cohort study. Bone Joint J 97(3):372–382 16. Moerman S, Vochteloo AJ, Tuinebreijer WE, Maier AB, 11. Gjertsen J-E, Baste V, Fevang JM, Furnes O, Engesæter LB (2016) Mathijssen NM, Nelissen RG (2016) Factors associated with the Quality of life following hip fractures: results from the Norwegian course of health-related quality of life after a hip fracture. Arch hip fracture register. BMC Musculoskelet Disord 17(1):265 Orthop Trauma Surg 136(7):935–943 12. Caeiro JR, Bartra A, Mesa-Ramos M, Etxebarría Í, Montejo J, Carpintero P et al (2017) Burden of first osteoporotic hip fracture in Spain: a prospective, 12-month, observational study. Calcif Tissue Int 100(1):29–39 13. Ruths S, Baste V, Bakken MS, Engesæter LB, Lie SA, Haugland S (2017) Municipal resources and patient outcomes through the first Publisher’s note Springer Nature remains neutral with regard to year after a hip fracture. BMC Health Serv Res 17(1):144 jurisdictional claims in published maps and institutional affiliations. 14. Vergara I, Vrotsou K, Orive M, Gonzalez N, Garcia S, Quintana JM (2014) Factors related to functional prognosis in elderly patients Affiliations D. Prieto-Alhambra 1,2,3 & D. Moral-Cuesta 4 & A. Palmer 5 & I. Aguado-Maestro 6 & M. F. Bravo Bardaji 7 & F. Brañas 8 & G. Adrados Bueno 9 & J. R. Caeiro-Rey 10 & I. Andrés Cano 11 & M. Barres-Carsi 12 & L. Gracia Delgado 13 & M. Salomó-Domènech 14 & I. Etxebarria-Foronda 15 & B. Llado Ferrer 16 & S. Mills 17 & L. Ezquerra Herrando 18 & D. Mifsut 19 & L. D. R. Evangelista 20 & X. Nogués 21 & I. Perez-Coto 22 & J. Martínez-Iñiguez Blasco 23 & C. Martín-Hernández 24 & H. Kessel 25 & J. Teixidor Serra 26 & J. Rodriguez Solis 27 & O. Torregrosa Suau 28 & E. Vaquero-Cervino 29 & C. Pablos Hernández 30 & L. Rodríguez Mañas 31 & A. Herrera 32 & A. Díez-Perez 33 1 10 GREMPAL (Grup de Recerca en Epidemiologia de les Malalties Traumatology and Orthopaedics Unit, Complejo Hospitalario Prevalents de l’Aparell Locomotor) Research Group, CIBERFES, Universitario de Santiago de Compostela, Rúa da Choupana, s/n, IDIAP Jordi Gol (Universitat Autònoma de Barcelona) and Instituto 15706 Santiago de Compostela, A Coruña, Spain de Salud Carlos III, Av Gran Via de les Corts Catalanes, 587, Atic, 11 Hospital Puerta del Mar, Av. Ana de Viya, 21, 11009 Cádiz, Spain 08007 Barcelona, Spain 12 2 Hospital Universitari i Politècnic La Fe, Av de Fernando Abril Musculoskeletal Pharmaco and Device Epidemiology - Centre for Martorell, 106, 46026 València, Spain Statistics in Medicine, Nuffield Department of Orthopaedics, 13 Rheumatology, and Musculoskeletal Sciences, University of Oxford, Hospital Universitario Reina Sofía de Cordoba, Av Menendez Botnar Research Centre, Windmill Road, Oxford OX3 7LD, UK Pidal, 14004 Córdoba, Spain 14 3 Musculoskeletal Research Unit, IMIM-Parc Salut Mar, CIBERFES, Corporación sanitaria Universitaria Parc Tauli, Parc Taulí, 1, Universitat Autònoma de Barcelona, Doctor Aiguader 88, 08208 Sabadell, Barcelona, Spain 08003 Barcelona, Spain 15 Department of Orthopaedic, Alto Deba Hospital, Arrasate- 4 Geriatric Unit, Hospital Universitario La Paz, Paseo de la Castellana, Mondragon, Gipuzkoa, Spain 261, 28046 Madrid, Spain 16 Hospital Son Llàtzer, Carretera de Manacor, PQ 4 (Son Ferriol), 5 Traumatology and Orthopaedics Unit, Nuffield Orthopedic Centre, 07198 Palma de Mallorca, Spain Windmill Rd, Headington, Oxford OX3 7HE, UK 17 Traumatology and Orthopaedics Unit, Hospital Universitario La 6 Hospital Universitario Rio Hortega, Calle Dulzaina, 2, Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain 47012 Valladolid, Spain 18 F.E.A of the Traumatology and Orthopaedics Unit, Hospital Clínico 7 Hospital Regional Universitario de Malaga, Av. de Carlos Haya, s/n, Universitario Lozano Blesa, Av. San Juan Bosco, 15, 29010 Málaga, Spain 50009 Zaragoza, Spain 19 8 Geriatric Unit, Hospital Universitario Infanta Leonor, Gran Vía del Hospital Clínico de Valencia, Av de Blasco Ibáñez, 17, Este, 80, 28031 Madrid, Spain 46010 Valencia, Spain 20 9 Internal Medicine Unit, Hospital Infanta Cristina, Av. de Elvas, s/n, Geriatric Unit, Hospital Universitario Severo Ochoa, Av. De 06080 Badajoz, Spain Orellana s/n, 28911 Leganés, Madrid, Spain Arch Osteoporos (2019) 14: 56 Page 5 of 5 56 21 28 Internal Medicine Department IMIM (Hospital del Mar Medical Bone Metabolism Unit, Internal Medicine Unit, Hospital General Research), CIBER FES ISCIII, Universitat Autónoma de Universitari d’Elx, Carrer Almazara, 11, 03203 Elche, Alicante, Barcelona, Barcelona, Spain Spain 22 29 Hospital Universitario San Agustín, Camino de Heros, 6, Complejo Hospitalario de Pontevedra, Av Montecelo, 0, 36164, 33401 Avilés, Asturias, Spain Casas Novas, Pontevedra, Spain 23 30 Hospital San Pedro, Calle Piqueras, 98, 26006 Logroño, La Rioja, Geriatric Unit, Hospital de Salamanca, Paseo de San Vicente, 139, Spain 37007 Salamanca, Spain 24 31 IIS Aragón (Instituto de Investigación Sanitaria de Aragón), Geriatric Unit, Hospital Universitario de Getafe, Carr. De Madrid - Hospital Universitario Miguel Servet, Paseo Isabel la Católica 1-3, Toledo, Km 12,500, 28905 Getafe, Madrid, Spain 50009 Zaragoza, Spain 32 Department of Surgery, Aragón Health Research Institute, 25 Geriatric Care Unit, Complejo Hospitalario Torrecárdenas, Calle University of Zaragoza, Zaragoza, Spain Hermandad de Donantes de Sangre, 04009 Almería, Spain 33 Musculoskeletal Research Unit, IMIM-Parc Salut Mar, CIBERFES, 26 Hospital Universitari Vall de Hebron, Passeig de la Vall d’Hebron, Universitat Autònoma de Barcelona, Doctor Aiguader 88, 119-129, 08035 Barcelona, Spain 08003 Barcelona, Spain 27 Geriatric Unit, Hospital Universitario de Guadalajara, Calle Donante de Sangre, s/n, 19002 Guadalajara, Spain