Introduction

The prevalence of hip fracture is increasing exponentially in the Asia Pacific region with an estimated increase of 1.12 million in 2018 to 2.56 million by 2050 [1]. Malaysia is projected to have the highest rate of increase in hip fracture injuries by 2050. Although international guidelines proposed a seamless approach to the management of hip fracture among older adults, replicating the same standards in Malaysia is highly challenging due to discrepancies in cultural beliefs, lower health literacy, and healthcare funding provision for older adults [2].

In Malaysia, a majority of older hip fracture patients are managed by the orthopedic team with limited orthogeriatric input due to the scarcity of geriatricians in the country [3, 4]. The length of time to surgical intervention varies, depending on whether the public or private system is used. In public hospitals, the average waiting time is around 5 days to 2 weeks while the private sector provides much faster access to surgery within a few days. The hip implants for hemiarthroplasty have to be paid for before surgery in both sectors. Private healthcare for older adults is therefore entirely out-of-pocket as most older adults do not have private health insurance coverage. Care at public hospitals is funded fully by taxation, where patients only need to pay nominal fees in this heavily subsidized public sector. As a result, in the case of hip surgery, the operation cost is fully borne by the tax payer but the patient is required to pay for the implant. The full cost of private healthcare and supplemental cost for public healthcare for our older population is usually borne by adult children, as few older adults have any income or savings. While implants are eventually paid for by a welfare fund for patients who could not afford the cost, the protracted application process inevitably leads to long delays.

Despite the projected increase in number of older persons with hip fractures, studies on the long-term outcomes for hip fracture in Malaysia remain limited. Our study is aimed at identifying the characteristics and long-term outcomes of older patients admitted with acute hip fracture in a teaching hospital in Malaysia. A better understanding of the clinical burden, management, and outcomes of older adults with hip fracture is needed in order to improve the care of this vulnerable group of individuals.

Methods

Study design and setting

This was a prospective observational study performed in University Malaya Medical Centre (UMMC), a 1000-bedded teaching hospital in Kuala Lumpur, Malaysia. UMMC is a government-funded public medical institution offering subsidized care. A proportion of the patients are government pensioners for whom all charges, including hospitalization and procedural fees as well as hip implants, are borne by their pension fund.

Consecutive patients aged 65 years and above who sustained an acute hip fracture between 22 March 2016 and 31 August 2018 were recruited into the study. Informed consent was obtained from patients or their next-of-kin for the conduct of this study. Patients with hip fracture were admitted to the orthopedic trauma ward with routine geriatric consultation on weekdays, from 8am to 5 pm. Geriatricians provide preoperative assessment, optimization of medical conditions, postoperative prevention of complications, and initiation of antiosteoporosis medication. Hip fractures were defined as all fractures from the femoral neck to subtrochanteric regions. Patients with pathological hip fracture, periprosthetic fracture, fractures associated with high-energy injury, and polytrauma were excluded. This study was approved by the University Malaya Medical Centre Ethics Committee Board (20,163–2260).

Data collected included patient baseline socio-demographics, pre-fracture residence, pre-fracture mobility status, and performance of activities of daily living (ADL) such as bathing, feeding, grooming, and toileting. Pre-fracture mobility status was recorded as independent walking without aid, walking with one aid, use of walking frame, or chairbound/bedbound. Ability to perform ADL was further dichotomized to independent or dependent on others (requiring assistance in one or more ADL) for the purpose of analysis. The comorbidities recorded in this study were self-reported, physician-diagnosed conditions of hypertension, diabetes mellitus, chronic kidney disease, stroke, osteoporosis, and dementia. The diagnosis of ischemic heart disease included patients with previous history of angina and coronary artery disease. The presence of lung disease included the presence of the diagnosis of asthma, obstructive airway disease, lung fibrosis, and bronchiectasis. Details of fracture type and reason for non-operative decision in patients who were managed conservatively were documented. For patients who underwent surgical intervention for hip fracture, waiting time to surgery (defined as time of admission to time of surgery), type of surgical and anesthesia procedure were recorded. Patients who were transferred out of bed within 24 h postoperatively were classified as having early mobilization. Length of hospitalization and inpatient mortality were also determined.

Outcome measures

Patients or their next of kin were contacted via telephone consultation at 6 months to determine their post-fracture mobility and residence status. For patients who underwent hip surgery, differences between their pre-fracture and post-fracture mobility measured at six months were recorded. A decline in mobility from their pre-fracture ability was categorized as poor mobility recovery from fracture incident. Vital status at one year post discharge was obtained from the national death registry department. Mortality data was collected up to 15 October 2019.

Statistical analysis

Descriptive statistics were presented as mean with standard deviation (SD) for parametric data or median with interquartile ranges (IQR) for non-parametric continuous data. Categorical data was presented as frequencies with percentages in parenthesis and compared with the chi-squared test. The Mann–Whitney \(U\) test was employed to determine differences in rating scores, which were considered continuous data. A probability value of less than 0.05 was considered statistically significance. A survival curve was first obtained to estimate mortality risk for individuals who underwent hip fracture surgery via the Kaplan–Meier method. Additional adjusted curves were plotted for risk factors that were associated with death following surgery. Cox proportional hazards analyses adjusted for all confounding factors was utilized to determine the hazard ratio for mortality. All predictor variables with a p value of < 0.10 were entered into the proportional hazard model to identify independent factors associated with mortality in our patient group. All statistical analysis was performed using SPSS Version 21.0 (IBM Corp., Armonk, NY, USA).

Results

A total of 326 patients met the inclusion criteria during the study period. Of those, 310 patients with completed hospital admission data were included in the analysis of the study (Fig. 1). The characteristics of the patients are shown in Table 1. The median time from fall incident to hospital admission was 1 (IQR = 0–2) day, whereas 4 patients reported no falls leading to the fracture episode.

Fig. 1
figure 1

Study flowchart

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Table 1 Characteristics of patients with hip fracture
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Two hundred and eighty-four (91.6%) patients underwent surgical intervention for hip fracture, and 26 (8.4%) patients did not undergo hip surgery. Reasons for not operating included refusal by families and/or patients (n = 19), severe acute medical illness (n = 3), and death (n = 4). The median time from hospital admission to surgery was 5 (IQR 3–8) days, with 18% of patients operated within 48 h of admission to hospital. Twenty-seven patients (9.5%) who had financial difficulties paying for their hip implants which required assistance from either the social welfare department or donations from non-government organizations were operated within 7 (IQR 4–10) days from hospital admission. Details of type of surgery and anesthesia are reported in Table 2. Of the patients who underwent hip surgery, 114 (40.1%) patients received early mobilization within 24 h, postoperatively. The median length of hospitalization was 9 (IQR 7–15) days with discharges occurring within a median of 4 (IQR 3–6) days, postoperatively. The reported inpatient mortality following hip fracture surgery was 10/284 (3.5%). Of patients who survived hip fracture surgery, 224/274 (81.8%) of patients were discharged to their own homes, 35/274 (12.8%) to institutionalized care, and 6/274 (2.2%) to a rehabilitation center. 14 (5.4%) patients who were community dwellers were discharged to a care institution after their hip surgery.

Table 2 Predictors of mortality post hip fracture surgery in older patients
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All survivors to discharge were contacted via telephone at 6 months. 38 patients had died, and 19 (6.9%) were lost to follow-up. Of the 217 (93.1%) patients with successful follow up telephone call, 131 (60.4%) patients did not recover to their pre-fracture mobility status. The largest decline were from patients who were independently mobile without aid prior to hip fracture (Fig. 2). 77 (35.5%) of patients required the use of walking frames at 6 months following hip fracture surgery. Among patients who were managed conservatively for hip fracture, 6/11 (54.5%) remained chairbound/bedbound at six months post discharge. Overall, 91.2% were living in their own homes, and 8.8% were in institutional care.

Fig. 2
figure 2

Mobility status at 6 months after hip fracture surgery

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The 1 year mortality rates for patients post hip fracture surgery was 20.1% with median follow-up period of 27.5 (IQR 12–35) months for all patients. From the unadjusted Cox proportional hazard analysis for patients who underwent hip surgery, age, men, ADL dependency, diabetes mellitus, ischemic heart disease, chronic kidney disease, total number of comorbidities, intertrochanteric fracture, regional anesthesia, and length of hospitalization were significantly associated with mortality (Table 2). Ten factors with p value ≤ 0.10 were entered into the final model to determine the best predictor model for mortality. From this, age, ADL dependence, and length of hospitalization appeared as independent predictors of mortality following hip fracture surgery in older adults (Fig. 3). For patients with hip fracture who were managed conservatively, the 1 year mortality rate was 73.1%.

Fig. 3
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Differences in survival by treatment group, age, dependency, and hospitalization

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Discussion

One in five individuals who underwent surgery for hip fracture at a teaching hospital in Kuala Lumpur was no longer alive at 1 year follow-up. Furthermore, a reduction in mobility was observed in three out of five individuals. Overall, the outcome characteristics of patients presenting with hip fractures in our study were comparable with other countries [5]. Those who sustained a hip fracture were primarily community-dwelling and functionally independent. Only a small percentage had a previous diagnosis of osteoporosis [6, 7].

Non-surgical management of hip fracture is still prevalent in Asian countries, mostly due to perceived high risk of surgical death within the perioperative period and the reluctance of patients themselves or their family members for patients to undergo surgery [8,9,10,11]. A systematic review by Loggers et al. reported that one-third of non-operative management of hip fractures were due to non-medical reasons such as declination of surgery, economic reasons, and proxy preferences [12]. Our study, however, found that non-operative management were mainly due to family or patient refusal. While this discrepancy may have emanated from the low expectation of functional recovery and quality of life from the sequelae of severe illness by the Asian older adult and their family members which may have led to the acceptance of the morbidity associated with non-operated hip fractures. Such decisions were possibly made without the adequate knowledge of the potential consequences of not having an operation. Even in frail older patients with functional disabilities, severe cognitive impairment, and multimorbidities, which were associated with poor prognosis following hip fracture injuries, considerations for non-surgical treatment had to be balanced with the risk of pain, complications, and mortality [13, 14].

Our study revealed that most patients with hip fracture waited for more than 48 h for their hip surgery. Delay in time to surgery was also found in single-center studies from other lower and middle income countries in the Asia Pacific region, including Thailand, Myanmar, and India, which did not achieve international hip fracture clinical practice standards of having surgery by 48 h of admission to hospital [15,16,17,18,19]. The use of hip fracture clinical care pathways has been shown to address concerns regarding clinical management and optimization of patients prior to surgery, thus reducing delay to surgery. However, challenges specific to lower and middle income countries in the Asia Pacific region which involve delays in informed consent from family members and/or patients, burden of out-of-pocket expenditure for hip implants and surgical cost, lack of prioritization of older adults with hip fracture, and poor coordination of care are among patient and system factors were associated with delays to surgery [20]. Hence, country-specific adjustment is necessary to address the different health care systems and policies across countries and regions in order to improve hip fracture care.

For patients who underwent hip fracture surgery in our study, higher 1-year mortality rates were consistent with the widely recognized observations seen in patients who were older, higher level of dependency, and longer length of hospitalization. As there were limited step-down care facilities, rehabilitation centers, and shortage of public hospital beds in Malaysia, patients were promptly discharged on average at day 4 post-surgery with limited access to continued rehabilitation. Patients were either discharged home, with any care needs met by informal family caregivers or formal salaried caregivers, or directly to residential long term care. Hence, the longer duration of hospitalization in our study may represent patients who had increased comorbidity burden and complications that occurred during hospitalization which subsequently increases mortality risk. Indeed, the length of stay was primarily dictated by time to surgery with the median length of stay postoperatively being only four days compared to a median time to surgery of five days.

Hip fracture in older adults leads to pronounced functional decline and loss of mobility, particularly in individuals with cognitive impairment and poor pre-fracture ambulatory ability [21]. Recovery after hip fracture surgery has been associated with multiple factors starting from the time of injury through to post-discharge care. Studies have shown that early hip fracture surgery by 48 h, early mobilization within 36 h postoperatively, and multidisciplinary rehabilitation helped to improve mobility status and reduce institutionalization rates [22,23,24]. Despite surgical intervention, more than 50% of patients in our study did not regain their pre-fracture level of mobility at 6 months, with a majority of patients declining to requiring the use of a walking frame. Follow-up attendance of outpatient rehabilitation services needed to be initiated on discharge. Many of those who may benefit did not receive it due to lack of referral to community-based rehabilitation services. The delivery of seamless, integrated care beyond acute hip fracture care in hospital remains an aspiration as it is not supported by the current system.

While this was a single-center study and hence may not reflect hip fracture care throughout Malaysia, this study provides a glimpse on the potential differences and deficits in hip fracture care within an upper-middle income nation in South-east Asia. Furthermore, reasons for delay in time to surgery and cause of death in patients after discharge from hospital were not identified in the study. Hence, it is not possible to elucidate if patients with delayed surgery were requiring more time for medical optimization which subsequently led to higher risk of mortality, and this should be considered in a future study which should be extended to multiple centers within Malaysia. Interventions which could reduce time to surgery, improve discharge outcomes, and reduce declination rates for surgery should now be developed as a matter of priority to reduce the burden of hip fracture-related disability in a region with a rapidly aging population.

Conclusion

One in 5 individuals who underwent hip fracture surgery at a teaching hospital in Kuala Lumpur was no longer alive at 1 year. Factors associated with higher mortality following hip fracture surgery include advanced age, functional dependency, and longer length of hospitalization. For patients who survived hip fracture surgery, 60.1% experienced a decline in mobility status. The higher rates of refusal of surgical treatment and longer time-to-surgery observed in this study should be addressed with culturally appropriate intervention strategies as a matter of urgency to reduce the burden of hip fracture related disability in a rapidly aging population.