Exploring barriers to, and enablers of, evidence-informed hip fracture care in five low- middle-income countries: China, India, Thailand, the Philippines and Vietnam

Globally, populations are ageing and the estimated number of hip fractures will increase from 1.7 million in 1990 to more than 6 million in 2050. The greatest increase in hip fractures is predicted in Low- and Middle-Income Countries (LMICs), largely in the Asia-Pacific region where direct costs are expected to exceed $US15 billion by 2050. The aims of this qualitative study are to identify barriers to, and enablers of, evidence-informed hip fracture care in LMICs, and to determine if the Blue Book standards, developed by the British Orthopaedic Association and British Geriatrics Society to facilitate evidence-informed care of patients with fragility fractures, are applicable to these settings. This study utilized semi-structured interviews with clinical and administrative hospital staff to explore current hip fracture care in LMICs. Transcribed interviews were imported into NVivo 12 and analysed thematically. Interviews were conducted with 35 participants from 11 hospitals in 5 countries. We identified five themes-costs of care and the capacity of patients to pay, timely hospital presentation, competing demands on limited resources, delegation and defined responsibility and utilization of available data-and within each theme, barriers and enablers were distinguished. We found a mismatch between patient needs and provision of recommended hip fracture care, which in LMICs must commence at the time of injury. This study describes clinician and administrator perspectives of the barriers to, and enablers of, high-quality hip fracture care in LMICs; results indicate that initiatives to overcome barriers (in particular, delays to definitive treatment) are required. While the Blue Book offers a starting point for clinicians and administrators looking to provide high-quality hip fracture care to older people in LMICs, locally developed interventions are likely to provide the most successful solutions to improving hip fracture care.