Health economic evaluation of hip fracture care pathways in The Gambia

Hip fractures cause substantial morbidity, mortality and healthcare costs among older adults. While advances in surgical and postoperative care have improved outcomes in high-income countries, these interventions are often inaccessible in low-income and middle-income countries due to cost constraints. This study assessed the costs and outcomes of surgical versus non-surgical management of hip fractures to inform resource allocation in a resource-limited setting. Data from a prospective cohort study of patients with acute hip fractures over a 12-month postfracture follow-up period were used. Outcomes included quality-adjusted life years (QALYs), healthcare resource use and costs in 2024 US$. Differences in costs and QALYs were estimated using multivariable regression analysis, while a range of sensitivity analyses assessed the impact of different assumptions. The analysis included 137 patients with a mean age of 70 years (SD: 13.4); 60% (n=82) were female and 81.8% (n=112) had fragility fractures. Fewer than half (47%, n=64) had surgery. Surgical management incurred US$988 higher costs (95% CI US$843 to US$1132) and generated 0.122 additional QALYs (95% CI −0.034 to 0.277) compared with non-surgical care, yielding an incremental cost-effectiveness ratio (ICER) of US$8117 per QALY gained. The probability of surgery being cost-effective exceeded 50% at willingness-to-pay thresholds of US$8200 per QALY gained or higher. The results were sensitive to surgical timing: operating within 3 days of admission more than doubled health gains to 0.247 QALYs (95% CI 0.056 to 0.439) and reduced the ICER to $4974 per QALY gained compared with no surgery. In this resource-limited setting, surgical management of hip fractures is more expensive but delivers clinically meaningful benefit for patients; a gain of 0.12 QALYs per patient translating to an extra 44 days in good health. Health systems in resource-limited settings should prioritise expanding surgical access while optimising early intervention and postoperative care to maximise benefits.