The healthcare system costs of hip fracture care in South Africa

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. Purpose We estimated direct healthcare costs of hip fracture (HF) management in the South African (SA) public healthcare system. Methods We conducted a micro-costing study to estimate costs per patient treated for HF in five regional public sector hospitals in KwaZulu-Natal (KZN), SA. Two hundred consecutive, consenting patients presenting with a fragility HF were prospectively enrolled. Resources used 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 unit costs, estimated from the KZN Department of Health hospital fees manual 2019/2020, in local currency (South African Rand, ZAR), and converted to 2020 US$prices. Generalized linear models estimated total covariate-adjusted costs and cost predictors. Results The mean unadjusted cost for HF management was US$6935 (95% CI; US$6401–7620) [ZAR114,179 (95$5904 (95% CI; 5408–6535), contributing to 85% of total cost. The covariate-adjusted cost for HF management was US$6922 (95$6743–7118) [ZAR113,976 (95% CI; ZAR111,031–117,197)]. After covariate adjustment, total costs were higher in patients operated under general anaesthesia [US$7251 (95$6506–7901)] compared to surgery under spinal anaesthesia US$6880 (95$6685–7092) and no surgery US$7032 (95$6454–7651). Conclusion Healthcare costs following a HF are high relative to the gross domestic product per capita and per capita spending on health in SA. As the population ages, this significant economic burden to the health system will increase

Fractures in sub-Saharan Africa: epidemiology, economic impact and ethnography (Fractures-E3): study protocol

Background: 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. Methods: The Fractures-E3 5-year mixed-methods research programme will investigate the epidemiology, economic impact, and treatment provision for fracture and wider musculoskeletal health in The Gambia, South Africa and Zimbabwe. These three countries are diverse in their geography, degree of urbanisation, maturity of health service infrastructure, and health profiles. The programme comprises five study types: (i) population-based cross-sectional studies to determine vertebral fracture prevalence. Secondary outcomes will include osteoarthritis and sarcopenia. Age- and sex-stratified household sampling will recruit 5030 adults aged 40 years and older; (ii) prospective cohort studies in adults aged 40 years and older will determine hip fracture incidence, associated risk factors, and outcomes over one year (e.g. mortality, disability, health-related quality of life); (iii) economic studies of direct health costs of hip fracture with projection modelling of future national health costs and cost-effectiveness analyses of different hip fracture care pathways; (iv) national surveys of hip fracture services (including traditional bonesetters in The Gambia); and (v) ethnographic studies of hip fracture care provision and experiences will understand fracture service pathways. Conclusions: Greater understanding of current and expected fracture burdens, fracture risk factors, and existing fracture care provision, is intended to inform national clinical guidelines, health service policy and planning and future health service development in sub-Saharan Africa.</ns4:p

Development of a Lower Limb Arthroplasty Service in a Developing Country: Lessons learned after the first 100 cases (joints)

There is emerging evidence that total hip arthroplasty (THR) can be safely practiced in developing countries but scant evidence of safety of total knee replacement (TKR). The purpose of this study is to evaluate the outcomes of these procedures focusing on procedure related complications. This is a retrospective study of the first 100 arthroplasties (92 patients) consisting of 58 TKR and 42 THR with a minimum follow-up of 26 months (range of 26 to 47 months). Major complications included deep infection in one TKR and dislocation of one THR and one TKR.  Two patients died in the second post-operative week from cardiac events following TKR. Blood transfusion rate for hips and knees was 13.7% and 5.6% respectively.  THR can be safely performed in less than ideal circumstances in developing countries in carefully selected patients. More importantly this study demonstrates that TKR can be safely practiced under the same circumstances