Health-Related Quality of Life in Osteoporosis Patients with and without Fractures in Tehran, Iran

Article information

J Bone Metab. 2023;30(1):37-46
Publication date (electronic) : 2023 February 28
doi : https://doi.org/10.11005/jbm.2023.30.1.37
1Vice-Chancellor for Public Health, Bushehr University of Medical Sciences, Bushehr, Iran
2Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
3Department of Health Management, Policy and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
4Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
Corresponding authors: Rajabali Daroudi, Department of Health Management, Policy and Economics, School of Public Health, Tehran University of Medical Sciences, Poursina Ave., Tehran 1417613191, Iran, Tel: +98-21-8898-9120, Fax: +98-21-8898-9129, E-mail: rdaroudi@sina.tums.ac.ir; rdaroudi@yahoo.com. Noushin Fahimfar, Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Poursina Ave., Tehran 1417613191, Iran, Tel: +98-21-8822-0072, Fax: +98-21-8822-0052, E-mail: nfahimfar@sina.tums.ac.ir; nfahimfar@gmail.com
*Noushin Fahimfar and Rajabali Daroudi contributed equally to this work and should be considered co-corresponding authors.
Received 2022 September 6; Revised 2022 December 16; Accepted 2022 December 20.

Abstract

Background

This study aimed to measure the health-related quality of life (HRQOL) of patients with osteoporosis with and without fractures in Tehran, the capital city of Iran.

Methods

We surveyed a sample of 478 patients with osteoporosis aged over 50 years. Participants with fractures included patients referred to hospitals due to osteoporotic fractures which were alive 6 months after the fracture. Participants without fractures were randomly selected from patients with a definite diagnosis of osteoporosis admitted to 3 outpatient clinics in Tehran. Data were collected using the EuroQol 5-dimensional 5-level questionnaire. Statistical differences between patients with and without fracture were tested with Pearson’s χ2 test, Student’s t-test, and the Mann–Whitney U-test. The association between HRQOL and other variables was evaluated using a multiple linear regression model.

Results

The patients’ mean age±standard deviation was 67.3±11.9 years, and 74.1% were women. One hundred and seventeen (23%) patients had hip fractures, 56 (11%) had vertebral fractures, 127 (25%) had forearm fractures, and 178 (40%) had no fractures. The median (interquartile range) values of HRQOL scores of those with hip, vertebral, and forearm fractures and those with no history of fracture were 0.53 (0.22), 0.60 (0.28), 0.64 (0.26), and 0.64 (0.27), respectively. The multiple regression model revealed a significant relationship between the HRQOL scores and sex, marital status, employment status, presence of any chronic illness in addition to osteoporosis, and type of fracture.

Conclusions

Osteoporosis and its related fractures can reduce the HRQOL.

GRAPHICAL ABSTRACT

INTRODUCTION

Osteoporosis is a common disease among elders, associated with decreased bone density and increased risk of fractures.[1] More than 200 million people with osteoporosis live all around the world, and more than 9 million osteoporotic fractures occur annually.[2] It was estimated that the prevalence of osteoporosis was nearly 17% (95% confidence interval [CI], 13%–22%) in 2012 in Iran, and its prevalence is on the rise. The higher the age, the higher would be osteoporosis prevalence.[3]

Based on the results of a systematic review and meta-analysis the age-standardized prevalence of osteoporosis among the Iranian elderly population (aged≥60 years) was 62.7% (95% CI, 60.0–65.4) in women, and 24.6% (95% CI, 21.9–27.3) in men.[4]

Osteoporosis makes the patients prone to fragility fractures, so even partial traumas may result in fracture.[5] Most osteoporotic fractures occur in hip, spine, and forearm.[6] A meta-analysis study showed that the annual cumulative incidence of hip fractures in Iran was 138.26 (95% CI, 98.71–193.65) and 157.52 (95% CI, 124.29–199.64) per 100,000 population in men and women, respectively.[7]

The health-related quality of life (HRQOL) is a multidimensional concept that measures the impacts of disease on various aspects of health, such as physical, mental, and social,[8] which has become a common concept to assess the effectiveness of therapeutic interventions diseases, including for osteoporosis. There are 2 types of HRQOL instruments: generic and specific.[9] The EuroQol 5-dimensional (EQ-5D) is one of the most widely used generic preference-based instruments to measure the HRQOL that contains 5D: Mobility; Self-care; Usual activities; Pain/discomfort, and Anxiety/depression. Five levels were identified in each dimension: No problems; Slight problems; Moderate problems; Severe problems; and Incapacity.[10]

Osteoporotic Fractures cause acute pain, impaired daily activity, and reduced HRQOL.[1114] According to the literature, even those patients with osteoporosis who don’t experience a bone fracture have lower HRQOL compared to healthy people.[1517]

The prevalence of osteoporosis is increasing in many countries, including Iran. However, few studies have been conducted to assess the HRQOL of osteoporosis patients in Iran. Therefore, the current study aimed to measure the HRQOL of patients with osteoporosis, both with a history of fracture and no fracture in Iran.

METHODS

This is a cross-sectional descriptive study to measure the HRQOL in osteoporosis patients with and without a history of fracture.

1. Study participants

The sample consisted of 2 groups of osteoporosis patients: (1) with a history of common osteoporotic fractures, including hip, clinical vertebral, and forearm (distal forearm, distal radius, wrist) fractures, during the previous year before the study; and (2) osteoporosis patients without a history of fracture who were receiving services from outpatient clinics.

Subjects of the first group were patients who were referred to the educational hospitals affiliated with the Tehran University of Medical Sciences (including Shariati, Sina, Baharlo, and Ziaeian Hospitals) in 2017 due to common fractures caused by osteoporosis, including hip, clinical vertebral, and forearm fractures and were alive 6 months after the fracture. Inclusion criteria were: (1) Fragility fracture of hip (International Classification of Diseases, Tenth Revision [ICD-10] code S72), clinical vertebral (ICD-10 code S32), or forearm (ICD-10 code S52); (2) Age over 50; (3) a T-score ≤-2.5 standard deviation (SD) in hip or spine.

Subjects of the second group were randomly selected using simple randomization among patients with a definite diagnosis of osteoporosis admitted to 3 outpatient clinics in Tehran during the year 2017. The inclusion criterion for this group having a T-Score ≤-2.5 SD in hip or spine and age over 50.

Bone mineral density of all patients was measured using dual energy X-ray absorptiometry (DXA) scan.

2. Data collection tools and methods

Data were collected using a questionnaire with 2 main parts. The first section included demographic questions (about age, gender, marital status, education level, and employment status) and questions about having health insurance and the presence of any chronic illness in addition to osteoporosis. The second part was consisted of the official Iranian version of EQ-5D-5 level (EQ-5D-5L) questionnaire. The EQ-5D-5L questionnaire contains 5D, including mobility, personal care, usual activity, physical pain/discomfort, and anxiety/depression, each encompasses 5 levels: No problems; Slight problems; Moderate problems; Severe problems; and Incapacity. Subjects of the first group, i.e., patients with a history of fracture, were interviewed by telephone 6 months after the fracture. For subjects of the second group, i.e., those with no history of fracture, in-person interviews were conducted at the time of patients’ referral to the clinics.

3. Data analysis

We made a descriptive analysis of our data by calculating frequencies, mean, median, and SD. To calculate the respondents’ HRQOL scores according to the EQ-5D-5L questionnaire we used the 5L crosswalk-based value set derived from the EQ-5D-3L value set in Iran.[18] In order to obtain the Iranian crosswalk-based EQ-5D-5L value set and use a face-to-face time trade-off method, the crosswalk methodology developed by van Hout et al.[19] was applied to the Iranian EQ-5D-3L value set.[18]

Statistical differences between patients with and without a history of fracture were established with Pearson’s χ2 test, Student’s t-test and Mann–Whitney U-test. The association between HRQOL and other variables was evaluated using a multiple linear regression model that included the EQ-5D-5L scores as the dependent variable and the age, sex, marital status, employment status, having health insurance, presence of any chronic illness in addition to osteoporosis and type of fractures as the explanatory variables. Statistical significance level was set at P value of less than 0.05. Data were analyzed with the STATA 14.0 software (Stata Corp., College Station, TX, USA).

RESULTS

The demographic characteristics of the participants by the type of fracture are described in Table 1. In total, 478 patients were sampled, among which 178 had no history of any osteoporotic fracture. Among participants, 117, 56, and 127 patients had hip, clinical vertebral, and forearms fracture, respectively, and 65%, 60.7%, and 74% were women, respectively. The mean and SD of participants’ age was 68.5 (10.7). Nearly 41.8% of participants were unmarried and their marital status was single, divorced, and widow. About 95.8% of participants had basic health insurance. Around 61.5% of participants had at least one chronic illness in addition to osteoporosis. The mean (SD) of years of education was 6.9 (5.7). There were statistical differences between patients with and without a history of fracture in terms of sex, age, employment status, having complementary health insurance, presence of any other chronic illness in addition to osteoporosis, and years of education (P<0.05).

Sociodemographic characteristics of the sample by type of fracture

Distribution of participants based on their answers to the EQ-5D-5L questionnaire, separated by the type of fracture, is provided in Table 2. For those with hip, clinical vertebral, and forearm fractures, the percentage of those with “no problems” in the mobility dimension was 4.3%, 10.7%, and 30.7%, respectively. This figure for a patient with no fracture was 25.3%. About 9.4% of patients with hip fractures were unable to walk. While 1.8% and 2.4% of patients with clinical vertebral and forearm fractures, respectively, and 0% of patients with no fracture were not able to walk. In the self-care dimension, 27.4%, 35.7%, and 48% of patients with hip, clinical vertebral, and forearm fractures reported, “no problem”, respectively. This is while 60.1% of patients with no fracture reported “no problem”. Besides, 6%, 1.8%, 1.6%, and 0% were not able to wash or wear clothes, respectively. Regarding the usual activities dimension, 35.9%, 39.3%, 52.8%, and 60.7% of those with the hip, clinical vertebral, forearms fractures and those without a history of fracture had “no problem” in doing their usual activities, respectively. Besides, 6.0%, 3.6%, 0.8%, and 0.6% were unable to perform usual activities. In the pain/discomfort dimension, 5.1%, 5.4%, 7.1%, and 12.9% of those with a history of hip, clinical vertebral, and forearm fracture, and those without a history of fracture reported "no pain and physical discomfort", respectively. Besides, 8.6%, 14.3%, 9.4%, and 9% of participants, respectively, noted that they had infinite pain or physical discomfort. In terms of anxiety/depression, the percentages of those with a history of hip, clinical vertebral, and forearm fracture and those with no history of fracture who reported "no anxiety or depression" were 35%, 26.8%, 30.7%, and 37.1%, respectively. Furthermore, 6.8%, 5.4%, 5.5%, and 6.2% of participants reported extreme anxiety or depression, respectively. There were statistical differences between patients with a history of fracture and those without a history of fracture in terms of distribution of their answers to the EQ-5D-5L questions in the mobility, self-care and usual activities dimensions (P<0.05).

Frequency of item responses in each the EuroQol 5-dimensional 5-level 5-level dimension by type of fracture

The median, interquartile range (IQR), and distribution of HRQOL, measured using the EQ-5D-5L and separated by the type of fracture and sex, are provided in Table 3 and Figure 1, respectively. The median (IQR) values of HRQOL scores of those with a history of hip, clinical vertebral, and forearm fracture and no history of fracture were 0.53 (0.22), 0.60 (0.28), 0.64 (0.26), and 0.64 (0.27), respectively. The HRQOL scores in women were significantly lower than in men (P=0.003).

Median (interquartile range) of the EuroQol 5-dimensional 5-level scores by type of fracture

Fig. 1

Distribution of the EuroQol 5-dimensional 5-level (EQ-5D-5L) scores by type of fracture.

The mean of responses in each EQ-5D-5L dimension based on fracture types and sex are presented in Figure 2. Almost in all dimensions, the patients with a history of hip fracture had the highest and those without a history of fracture had the lowest mean. Furthermore, in all dimension the mean of responses was higher in women than in men.

Fig. 2

The mean of responses in each the EuroQol 5-dimensional 5-level (EQ-5D-5L) dimension based on fracture types and sex. Fx, fracture.

Table 4 shows the associates of the quality of life (QOL) in multiple linear regression analyses. The results showed that compared to the osteoporotic patients without a history of fractures, QOL was significantly lower in patients with hip fracture (β=−0.077, P<0.001) and clinical vertebral fracture (β=−0.075, P=0.005), but not in patients with forearm fracture (β=−0.010, P=0.611). Being married at the time of the study had a significant positive association with the QOL (β=0.054, P=0.002), while a negative association was detected between the presence of chronic disease and QOL in patients under study (β=−0.033, P=0.039). Women with complementary health insurance also tended to have a higher QOL, though not statistically significant (β=0.032, P=0.071).

The associates of quality of life in the linear regression model

DISCUSSION

In the current study, the HRQOL of those with osteoporotic fractures of the hip, clinical vertebral, and forearms as well as patients suffering osteoporosis with no history of fractures was measured using the EQ-5D questionnaire. The median (IQR) values of HRQOL scores of those with hip, clinical vertebral, and forearm fractures and those with no history of fracture were 0.53 (0.22), 0.60 (0.28), 0.64 (0.26), and 0.64 (0.27), respectively. According to the result of multiple regression model, there was a significant association between the HRQOL scores and gender, marital status, employment status, presence of any chronic illness, and type of fracture.

Almost 95.7% of patients with hip fracture had mobility problems, 72.6% had self-care problems, 64.1% had problems with usual activities, 94.9% had pain/discomfort, and 65% had anxiety/depression.

Worse mobility was reported by hip fracture survivors in comparison with other fractures. After a hip fracture, nearly 10% to 20% of people who have a hip fracture die within the next year and about half of them lose their ability to perform usual activities.[20] Almost 40% to 60% of patients with a history of hip fracture regain their full mobility within 1 year.[21]

Based on a study conducted in Russia, the HRQOL of people with a history of hip fractures 2 weeks, 4 months, and 12 months after the fracture was −0.22, 0.39, and 0.46, and this value increased to 0.64 eighteen months after the fracture.[22] Another study that measured the HRQOL of people with a history of hip fracture in Sweden reported that the HRQOL after fracture was 0.18, and this number increased to 0.62 4 months later and reached 0.67, 12 months later.[23] Besides, the results of a new study in Spain reported that HRQOL of people over the age of 65, a month after the fracture was 0.16.[24] Another study reported that the HRQOL of postmenopausal women with hip fractures was 0.64.[25]

In the present study almost 95.7% of patients with hip fracture had mobility problems, 72.6% had self-care problems, 64.1% had problems with usual activities, 94.9% had pain/discomfort, and 65% had anxiety/depression. The results of one study in Spain on elderly patients with a history of hip fracture showed that one month after fracture 99.5% of patients had problems in mobility, 98.2% in self-care, 99.1% in doing usual activities, 85.4% in pain/discomfort, and 53% in anxiety/depression.[24] Besides, a study conducted in Russia revealed that 83% of patients with hip fracture had problems with mobility, 71% in self-care, 73% in doing usual activities, 28% in pain/discomfort, and 15% in anxiety/depression.[22]

Vertebral fracture is also common among patients with osteoporosis.[6] Various studies found that vertebral fracture decreases HRQOL.[26] Hagino et al.[27] conducted a study to estimate the HRQOL changes in patients with vertebral fractures and reported that 2 weeks after the fracture the HRQOL was 0.53, 3 months later it increased to 0.75, 6 months later it was 0.74, and one year after the fracture this number reached to 0.83. Another study that estimated HRQOL of patients with a history of vertebral fracture in Sweden reported that after the fracture, the HRQOL was 0.18, 4 months later it increased to 0.47, and 12 months later it was 0.49.[23] In the current study, the HRQOL of patients with vertebral fracture was 0.55. A systematic review and meta-analysis conducted by Al-Sari et al.[9] revealed that the physical dimension of HRQOL of osteoporosis patients with vertebral fracture was significantly lower than HRQOL of osteoporosis patients without a history of vertebral fracture. However, in terms of the mental dimension of HRQOL, no significant difference was overserved between 2 groups.[9] In the current study also the HRQOL of patients with a history of vertebral fracture was significantly lower than patients with no history of fracture. For example, 89.4% of patients with vertebral fracture had problems in mobility, while 72% of patients with no history of fracture had such a problem. Moreover, 64.3 and 37.5% of patients with vertebral fracture and without a history of fracture had problems in self-care, respectively. According to the result of the multiple regression model in our study, the HRQOL scores in patients with clinical vertebral fractures were 0.075 less than in patients without a history of fracture.

Among the most common osteoporotic fractures, patients with a forearm fracture have the highest HRQOL. In a Swedish study, the HRQOL of people with a forearm fracture was 0.56 after the fracture, 4 months later it was 0.82, and 12 months after the fracture it was 0.86.[23] Another study conducted in Korean reported that the HRQOL of those with a forearm fracture was 0.83.[28] In the current study, the median score of HRQOL of patients with forearm fracture was 0.64.

Emrani et al.[29] measured the HRQOL of the general population aged 60 to 69 years using the EQ-5D-5L questionnaire in Iran and reported that the mean score of HRQOL was 0.74. In the current study, the mean age of patients with no history of fracture was nearly 66.3 years, and the median value of HRQOL score was 0.64, which can indicate that the HRQOL of osteoporosis patients with no history of fracture is lower than healthy individuals. Wilson et al. [17] also reported that osteoporosis alone has negative effects on the HRQOL.

In the current study, the EQ-5D-5L questionnaire, the most widely used general preference-based instrument to measure the HRQOL,[30] was used to measure the HRQOL of patients with osteoporosis and common fractures in Iran. Other researchers and/or policymakers can use the results of this study to conduct economic evaluation studies and to provide information for decision-making regarding resource allocations. However, this study also had some limitations. In the current study, the HRQOL of patients with osteoporotic fractures was measured 6 months after the fracture. Given that the HRQOL of these patients usually changes during the first year after the fracture, the results cannot be generalized to the first 6 months after the fracture. Besides, patients with osteoporotic fractures were sampled from hospitals and therefore the results cannot be generalized to outpatients. Although this limitation was more for vertebral and forearm fractures, as almost all patients with hip fractures are hospitalized.

CONCLUSION

Osteoporosis and its related fractures can reduce the HRQOL. Since Iran’s population is aging, age-related health conditions such as osteoporosis are increasing. Due to the significant negative impacts of osteoporotic fractures on HRQOL and healthcare expenditures, it is necessary to design interventions to prevent and improve the HRQOL of patients with osteoporosis.

Notes

Funding

This study was funded by Tehran University of Medical Sciences (grant no. 9611119004).

Authors’ contributions

Conceptualization: MR, NF, and RD; Data curation: RD, MR, AO, AS, SMS-J, AM, BL, and NF; Formal analysis: RD, MR, AO, AS, SMS-J, AM, BL, and NF; Methodology: RD, MR, AO, AS, SMS-J, AM, BL, and NF; Writing - original draft: MR, NF, and RD; Writing - review & editing: RD, MR, AO, AS, SMS-J, AM, BL, and NF; All authors read and approved the final manuscript.

Ethics approval and consent to participate

This study was approved by the ethics committee of the Deputy of Research and Technology of the Tehran University of Medical Sciences (IR.TUMS.EMRI.REC.1396.0016). The participants were assured that their information would remain confidential. Informed consent was obtained from all individual participants included in the study.

Conflict of interest

No potential conflict of interest relevant to this article was reported.

References

1. Lee YK, Kim HJ, Park JW, et al. Transcultural adaptation and psychometric properties of the Korean version of the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO-41). Arch Osteoporos 2019;14:96. https://doi.org/10.1007/s11657-019-0647-5.
2. Pisani P, Renna MD, Conversano F, et al. Major osteoporotic fragility fractures: Risk factor updates and societal impact. World J Orthop 2016;7:171–81. https://doi.org/10.5312/wjo.v7.i3.171.
3. Irani AD, Poorolajal J, Khalilian A, et al. Prevalence of osteoporosis in Iran: A meta-analysis. J Res Med Sci 2013;18:759–66.
4. Fahimfar N, Noorali S, Yousefi S, et al. Prevalence of osteoporosis among the elderly population of Iran. Arch Osteoporos 2021;16:16. https://doi.org/10.1007/s11657-020-00872-8.
5. Porter JL, Varacallo M. Osteoporosis. In : Aboubakr S, Abu-Ghosh A, Acharya AB, et al, eds. StatPearls Treasure Island, FL: StatPearls Publishing; 2022. p. NBK441901.
6. Cooper C, Dennison EM, Leufkens HG, et al. Epidemiology of childhood fractures in Britain: a study using the general practice research database. J Bone Miner Res 2004;19:1976–81. https://doi.org/10.1359/jbmr.040902.
7. Tanha K, Fahimfar N, Nematollahi S, et al. Annual incidence of osteoporotic hip fractures in Iran: a systematic review and meta-analysis. BMC Geriatr 2021;21:668. https://doi.org/10.1186/s12877-021-02603-1.
8. Varni JW, Burwinkle TM, Seid M, et al. The PedsQL 4.0 as a pediatric population health measure: feasibility, reliability, and validity. Ambul Pediatr 2003;3:329–41. https://doi.org/10.1367/1539-4409(2003)003<0329:tpaapp>2.0.co;2.
9. Al-Sari UA, Tobias J, Clark E. Health-related quality of life in older people with osteoporotic vertebral fractures: a systematic review and meta-analysis. Osteoporos Int 2016;27:2891–900. https://doi.org/10.1007/s00198-016-3648-x.
10. EuroQol Research Foundation. EQ-5D-5L 2017. [cited by 2022 Aug 1]. Available from: https://euroqol.org/eq-5d-instruments/eq-5d-5l-about/.
11. Borgström F, Lekander I, Ivergård M, et al. The International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS)-quality of life during the first 4 months after fracture. Osteoporos Int 2013;24:811–23. https://doi.org/10.1007/s00198-012-2240-2.
12. Cook DJ, Guyatt GH, Adachi JD, et al. Quality of life issues in women with vertebral fractures due to osteoporosis. Arthritis Rheum 1993;36:750–6. https://doi.org/10.1002/art.1780360603.
13. Lips P, van Schoor NM. Quality of life in patients with osteoporosis. Osteoporos Int 2005;16:447–55. https://doi.org/10.1007/s00198-004-1762-7.
14. Martin AR, Sornay-Rendu E, Chandler JM, et al. The impact of osteoporosis on quality-of-life: the OFELY cohort. Bone 2002;31:32–6. https://doi.org/10.1016/s8756-3282(02)00787-1.
15. Ciubean AD, Ungur RA, Irsay L, et al. Health-related quality of life in Romanian postmenopausal women with osteoporosis and fragility fractures. Clin Interv Aging 2018;13:2465–72. https://doi.org/10.2147/cia.S190440.
16. Bianchi ML, Orsini MR, Saraifoger S, et al. Quality of life in post-menopausal osteoporosis. Health Qual Life Outcomes 2005;3:78. https://doi.org/10.1186/1477-7525-3-78.
17. Wilson S, Sharp CA, Davie MW. Health-related quality of life in patients with osteoporosis in the absence of vertebral fracture: a systematic review. Osteoporos Int 2012;23:2749–68. https://doi.org/10.1007/s00198-012-2050-6.
18. Goudarzi R, Sari AA, Zeraati H, et al. Valuation of quality weights for EuroQol 5-dimensional health states with the time trade-off method in the capital of Iran. Value Health Reg Issues 2019;18:170–5. https://doi.org/10.1016/j.vhri.2019.01.007.
19. van Hout B, Janssen MF, Feng YS, et al. Interim scoring for the EQ-5D-5L: mapping the EQ-5D-5L to EQ-5D-3L value sets. Value Health 2012;15:708–15. https://doi.org/10.1016/j.jval.2012.02.008.
20. Lewiecki EM, Chastek B, Sundquist K, et al. Osteoporotic fracture trends in a population of US managed care enrollees from 2007 to 2017. Osteoporos Int 2020;31:1299–304. https://doi.org/10.1007/s00198-020-05334-y.
21. Dyer SM, Crotty M, Fairhall N, et al. A critical review of the long-term disability outcomes following hip fracture. BMC Geriatr 2016;16:158. https://doi.org/10.1186/s12877-016-0332-0.
22. Lesnyak O, Svedbom A, Belova K, et al. Quality of life after fragility fracture in the Russian Federation: results from the Russian arm of the International Cost and Utility Related to Osteoporotic Fractures Study (ICUROS). Arch Osteoporos 2020;15:37. https://doi.org/10.1007/s11657-020-0699-6.
23. Borgström F, Zethraeus N, Johnell O, et al. Costs and quality of life associated with osteoporosis-related fractures in Sweden. Osteoporos Int 2006;17:637–50. https://doi.org/10.1007/s00198-005-0015-8.
24. Amarilla-Donoso FJ, López-Espuela F, Roncero-Martín R, et al. Quality of life in elderly people after a hip fracture: a prospective study. Health Qual Life Outcomes 2020;18:71. https://doi.org/10.1186/s12955-020-01314-2.
25. Adachi JD, Adami S, Gehlbach S, et al. Impact of prevalent fractures on quality of life: baseline results from the global longitudinal study of osteoporosis in women. Mayo Clin Proc 2010;85:806–13. https://doi.org/10.4065/mcp.2010.0082.
26. Hall SE, Criddle RA, Comito TL, et al. A case-control study of quality of life and functional impairment in women with long-standing vertebral osteoporotic fracture. Osteoporos Int 1999;9:508–15. https://doi.org/10.1007/s001980050178.
27. Hagino H, Nakamura T, Fujiwara S, et al. Sequential change in quality of life for patients with incident clinical fractures: a prospective study. Osteoporos Int 2009;20:695–702. https://doi.org/10.1007/s00198-008-0761-5.
28. Kwon HY, Ha YC, Yoo JI. Health-related quality of life in accordance with fracture history and comorbidities in Korean patients with osteoporosis. J Bone Metab 2016;23:199–206. https://doi.org/10.11005/jbm.2016.23.4.199.
29. Emrani Z, Akbari Sari A, Zeraati H, et al. Health-related quality of life measured using the EQ-5D-5 L: population norms for the capital of Iran. Health Qual Life Outcomes 2020;18:108. https://doi.org/10.1186/s12955-020-01365-5.
30. Brazier J, Ara R, Rowen D, et al. A review of generic preference-based measures for use in cost-effectiveness models. Pharmacoeconomics 2017;35:21–31. https://doi.org/10.1007/s40273-017-0545-x.

Article information Continued

Funded by : Tehran University of Medical Sciences
Award ID : 9611119004
Funding : This study was funded by Tehran University of Medical Sciences (grant no. 9611119004).

Fig. 1

Distribution of the EuroQol 5-dimensional 5-level (EQ-5D-5L) scores by type of fracture.

Fig. 2

The mean of responses in each the EuroQol 5-dimensional 5-level (EQ-5D-5L) dimension based on fracture types and sex. Fx, fracture.

Table 1

Sociodemographic characteristics of the sample by type of fracture

Categorical variables Total participants (N=478) Type of Fx All Fx (N=300) No Fx (N=178) P-valuea)

Hip Fx (N=117) Clinical vertebral Fx (N=56) Forearm Fx (N=127)
Sex <0.001
 Men 124 (25.9) 41 (35.0) 22 (39.3) 33 (26.0) 96 (32.0) 28 (15.7)
 Women 354 (74.1) 76 (65.0) 34 (60.7) 94 (74.0) 204 (68.0) 150 (84.3)

Marital status 0.10
 Married 278 (58.2) 53 (45.3) 34 (60.7) 79 (62.2) 166 (55.3) 112 (62.9)
 Unmarried 200 (41.8) 64 (54.7) 22 (39.3) 48 (37.8) 134 (44.7) 66 (37.1)

Employment status 0.001
 Employment 27 (5.6) 6 (5.1) 2 (3.6) 9 (7.1) 17 (5.7) 10 (5.6)
 Householder 281 (58.8) 57 (48.7) 26 (46.4) 82 (64.6) 165 (55.0) 116 (65.2)
 No employment 39 (8.2) 15 (12.8) 8 (14.3) 13 (10.2) 36 (12.0) 3 (1.7)
 Retired 131 (27.4) 39 (33.3) 20 (35.7) 23 (18.1) 82 (27.3) 49 (27.5)

Having basic health insurance 0.247
 Yes 458 (95.8) 116 (99.1) 50 (89.3) 119 (93.7) 285 (95.0) 173 (97.2)
 No 20 (4.2) 1 (0.9) 6 (10.7) 8 (6.3) 15 (5.0) 5 (2.8)

Having complementary health insurance <0.001
 Yes 210 (44.0) 35 (29.9) 16 (28.6) 36 (28.3) 87 (29.0) 123 (69.1)
 No 267 (56.0) 82 (70.1) 40 (71.4) 91 (71.7) 213 (71.0) 54 (30.3)

Presence of any other chronic illness in addition to osteoporosis 0.009
 Yes 294 (61.5) 68 (58.1) 38 (67.9) 65 (51.2) 171 (57.0) 123 (69.1)
 No 184 (38.5) 49 (41.9) 18 (32.1) 62 (48.8) 129 (43.0) 55 (30.9)

Continuous variables
 Age (yr) 68.5±10.7 73.6±11.3 69.7±10.4 66.4±10.5 69.8±11.2 66.3±9.3 <0.001
 Years of education 6 [12] 6 [12] 6 [12] 6 [9] 6 [12] 9 [9] <0.001

The data is presented as N (%), mean±standard deviation, or median [interquartile range].

a)

Between all fractures and no fractures. Student’s t-test and Mann–Whitney U test were used for normal and non-normal distributions, respectively.

Fx, fracture.

Table 2

Frequency of item responses in each the EuroQol 5-dimensional 5-level 5-level dimension by type of fracture

Dimension Type of Fx All Fx (N=300) No Fx (N=178) P-valuea)

Hip Fx (N=117) Clinical vertebral Fx (N=56) Forearm Fx (N=127)
Mobility 0.001
 No problems 5 (4.3) 6 (10.7) 39 (30.7) 50 (16.7) 45 (25.3)
 Slight problems 44 (37.6) 23 (41.1) 49 (38.6) 116 (38.7) 76 (42.7)
 Moderate problems 40 (34.2) 16 (28.6) 27 (21.3) 83 (27.7) 31 (17.4)
 Severe problems 17 (14.5) 10 (17.9) 9 (7.1) 36 (12.0) 26 (14.6)
 Incapacity 11 (9.4) 1 (1.8) 3 (2.4) 15 (5.0) 0 (0.0)

Self-care <0.001
 No problems 32 (27.4) 20 (35.7) 61 (48.0) 113 (37.7) 107 (60.1)
 Slight problems 46 (39.3) 21 (37.5) 42 (33.1) 109 (36.3) 48 (27.0)
 Moderate problems 21 (17.9) 10 (17.9) 19 (15.0) 50 (16.7) 19 (10.7)
 Severe problems 11 (9.4) 4 (7.1) 3 (2.4) 18 (6.0) 4 (2.2)
 Incapacity 7 (6.0) 1 (1.8) 2 (1.6) 10 (3.3) 0 (0.0)

Usual activities <0.001
 No problems 42 (35.9) 22 (39.3) 67 (52.8) 131 (43.7) 108 (60.7)
 Slight problems 32 (27.4) 19 (33.9) 33 (26.0) 84 (28.0) 43 (24.2)
 Moderate problems 24 (20.5) 7 (12.5) 18 (14.2) 49 (16.3) 23 (12.9)
 Severe problems 12 (10.3) 6 (10.7) 8 (6.3) 26 (8.7) 3 (1.7)
 Incapacity 7 (6.0) 2 (3.6) 1 (0.8) 10 (3.3) 1 (0.6)

Pain/discomfort 0.056
 No 6 (5.1) 3 (5.4) 9 (7.1) 18 (6.0) 23 (12.9)
 Slight 41 (35.0) 16 (28.6) 37 (29.1) 94 (31.3) 43 (24.2)
 Moderate 40 (34.2) 18 (32.1) 40 (31.5) 98 (32.7) 54 (30.3)
 Severe 20 (17.1) 11 (19.6) 29 (22.8) 60 (20.0) 42 (23.6)
 Extreme 10 (8.6) 8 (14.3) 12 (9.4) 30 (10.0) 16 (9.0)

Anxiety/depression 0.408
 No 41 (35.0) 15 (26.8) 39 (30.7) 95 (31.7) 66 (37.1)
 Slight 35 (29.9) 13 (23.2) 42 (33.1) 90 (30.0) 44 (24.7)
 Moderate 22 (18.8) 12 (21.4) 28 (22.0) 62 (20.7) 30 (16.9)
 Severe 11 (9.4) 13 (23.2) 11 (8.7) 35 (11.7) 27 (15.2)
 Extreme 8 (6.8) 3 (5.4) 7 (5.5) 18 (6.0) 11 (6.2)

The data is presented as N (%).

a)

Between all fractures and no fractures.

Fx, fracture.

Table 3

Median (interquartile range) of the EuroQol 5-dimensional 5-level scores by type of fracture

Type of fracture All participants Men Women P-value
Hip 0.53 [0.22] 0.60 [0.28] 0.52 [0.21] 0.034
Clinical vertebral 0.60 [0.28] 0.62 [0.12] 0.50 [0.30] 0.064
Forearm 0.64 [0.26] 0.67 [0.25] 0.62 [0.24] 0.448
No fracture 0.64 [0.27] 0.74 [0.16] 0.62 [0.27] 0.002
Total 0.61 [0.24] 0.68 [0.25] 0.59 [0.24] 0.003

The data is presented as median [interquartile range].

Table 4

The associates of quality of life in the linear regression model

Independent variables Dependent variable (utility scores) P-value

Coefficient Standard error
Age −0.001 0.001 0.098

Gender
 Male Ref
 Female −0.059 0.026 0.023

Marital status
 Never married, divorced, or widowed Ref
 Married 0.054 0.018 0.002

Employment status
 Unemployed Ref
 Employed 0.088 0.043 0.042
 Home maker 0.098 0.036 0.007
 Retired 0.137 0.033 <0.001
 Having basic health insurance −0.010 0.040 0.801
 Having complementary health insurance 0.032 0.017 0.071
 Presence of any other chronic illness −0.033 0.016 0.039

Type of fracture
 No fracture Ref
 Hip −0.077 0.022 <0.001
 Clinical vertebral −0.075 0.027 0.005
 Forearm −0.010 0.020 0.611