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1. Time from injury to hip-fracture surgery in low-income and middle-income regions: a secondary analysis of data from the International Orthopaedic Multicentre Study in Fracture Care (INORMUS)

Author

Elizabeth Armstrong, MPH, Kris Rogers, PhD, Chuan Silvia Li, MSc, Jagnoor Jagnoor, PhD, Paul Moroz, MD, Gerald Chukwuemeka Oguzie, MD, Samuel Hailu, MD, ProfMD Theodore Miclau, III, MD, Fernando de la Huerta, MD, Jose de Jesus Martinez-Ruiz, MD, Fernando Bidolegui, MD, ProfMD Junlin Zhou, MD, ProfMD Xinlong Ma, MD, ProfMD Bo Wu, MD, Parag Sancheti, PhD, La Ngoc Quang, MD, Vali Baigi, PhD, Mashyaneh Haddadi, MD, Maoyi Tian, PhD, Sheila Sprague, PhD, ProfMD P J Devereaux, PhD, ProfMD Mohit Bhandari, PhD, ProfPhD Rebecca Ivers, PhD, Gordon Guyatt, Brad Petrisor, Lehana Thabane, Respicious Boniface, Bruce Browner, Andrew Pollak, Gerard Slobogean, Emil Schemitsch, Paula McKay, Kerry Tai, Diane Heels-Ansdell, Lisa Buckingham, Robyn Norton, Jing Zhang, Samina Parveen, Soumyadeep Bhaumik, Saam Morshed, Madeline C. Mackechnie, Zhentao Zhang, Yinghua Ma, Yanguo Qin, Sanbao Hu, Baochang Qi, Wenjie Dai, Xinyu Cai, Gang Rui, Hua Chen, Vijay Shetty, Sampat Dumbre Patil, Sanjay Patil, Sandeep Shrivastava, Ravi Mittal, Thilak Samuel Jepegnanam, Anupam Mahajan, Harvinder Singh Chhabra, Rajagopalan N, Rajkumar S. Amaravathi, Mandeep S. Dhillon, Asolie Chase, Neel M. Bhavsar, Soheil Saadat, Subin Byanjankar, Raja Irfan Qadir, Irewin Alagar Tabu, Wanjak Ponggsamakthai, Paphon Sa-ngasoongsong, Panchu Subramanian, Benjamin Muluku Ndeleva, Mark Lutomia, Fred Mathew Toboso Otseyeno, Geoffrey Chege Mwangi, Henry Tanyi Ndasi, Dominic Konadu-Yeboah, Gregory Firth, Paul Marealle, Rogers Temu, Tony Mutanda, Marcelo Rio, Jose Eduardo Quintero, Mauricio Zuluaga, Tomás Minueza, Ricardo Madrigal, Manuel Ylizaliturri, Mario Garuz, Julio Segovia Altieri, and Igor A. Escalante Elguezabal

Subjects
Geriatrics, RC952-954.6, Medicine
Abstract

Summary: Background: Globally, fall-related injuries are a substantial problem, and 80% of fatal falls occur in low-income and middle-income countries. We aimed to measure time from injury to hip-fracture surgery in people aged 50 years or older living in low-income and middle-income regions, as well as to measure the proportion of patients with surgical stabilisation of their hip fracture within 72 h of admission to hospital and to identify risk factors associated with surgical delay. Methods: For this secondary analysis, we analysed data collected from Africa, Latin America, China, India, and Asia (excluding China and India) for the International Orthopaedic Multicentre Study in Fracture Care (INORMUS) between March 29, 2014, and June 15, 2022. Patients from INORMUS were included in this analysis if they were aged 50 years or older and had an isolated, primary hip fracture sustained from a ground-level fall. Staff at participating hospitals identified patients with musculoskeletal injury and referred them for assessment of eligibility. We report time from injury to surgery as three distinct time periods: time from injury to hospital admission, time from admission to surgery, and a total time from injury to surgery. Date and time of injury were self-reported by patients at the time of study recruitment. If time to hospital admission after injury exceeded 24 h, patients reported the primary reason for delayed admission. Reasons for surgery, no surgery, and surgical delay were reported by the treating team. For patients undergoing surgery, multivariable regression analyses were used to identify risk factors for surgical delay. Findings: 4486 adults aged 50 years or older with an isolated, primary hip fracture were enrolled in INORMUS from 55 hospitals in 24 countries. Countries were grouped into five regions: Africa (418 [9·3%] of 4486), Latin America (558 [12·4%]), China (1680 [37·4%]), India (1059 [23·6%]) and Asia (excluding China and India; 771 [17·2%]). Of 4486 patients, 3805 (84·8%) received surgery. The rate of surgery was similar in all regions except in Africa, where only 193 (46·3%) of 418 patients had surgery. Overall, 2791 (62·2%) of 4486 patients were admitted to hospital within 24 h of injury. However, 1019 (22·7%) of 4486 patients had delayed hospital admission of 72 h or more from injury. The two most common reasons for delayed admission of more than 24 h were transfer from another hospital (522 [36·2%] of 1441) and delayed care-seeking because patients thought the injury would heal on its own (480 [33·3%]). Once admitted to hospital, 1451 (38·1%) of 3805 patients who received surgery did so within 72 h (median 4·0 days [IQR 1·7–6·0]). Regional variation was seen in the proportion of patients receiving surgery within 72 h of hospital admission (92 [17·9%] of 514 in Latin America, 53 [27·5%] of 193 in Africa, 454 [30·9%] of 1471 in China, 318 [44·4%] of 716 in Asia [excluding China and India], and 534 [58·6%] of 911 in India). Of all 3805 patients who received operative treatment, 2353 (61·8%) waited 72 h or more from hospital admission. From time of injury, the proportion of patients who were surgically stabilised within 72 h was 889 (23·4%) of 3805 (50 [9·7%] of 517 in Latin America, 31 [16·1%] of 193 in Africa, 277 [18·8%] of 1471 in China, 189 [26·4%] of 716 in Asia [excluding China and India], and 342 [37·5%] of 911 in India). Interpretation: Access to surgery within 72 h of hospital admission was poor, with factors that affected time to surgery varying by region. Data are necessary to understand existing pathways of hip-fracture care to inform the local development of quality-improvement initiatives. Funding: The National Health and Medical Research Council of Australia, the Canadian Institutes of Health Research, McMaster Surgical Associates, Hamilton Health Sciences, and the US National Institutes of Health.

Published
2024
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2. Delays in hospital admissions in patients with fractures across 18 low-income and middle-income countries (INORMUS): a prospective observational study

Author

Panthea Pouramin, MSc, Chuan Silvia Li, MSc, Jason W Busse, PhD, Sheila Sprague, PhD, P J Devereaux, MD, Jagnoor Jagnoor, PhD, Rebecca Ivers, PhD, Mohit Bhandari, MD, Mohit Bhandari, PJ Devereaux, Gordon Guyatt, Brad Petrisor, Lehana Thabane, Respicious L. Boniface, Bruce Browner, Fernando de la Huerta, Rebecca Q Ivers, Theodore Miclau, III, Paul Moroz, Andrew Pollak, Gerard Slobogean, Parag Sancheti, Emil Schemitsch, Junlin Zhou, Sheila Sprague, Paula McKay, Chuan Silvia Li, Raman Mundi, Nathan O'Hara, Diane Heels-Ansdell, Lisa Buckingham, Nicole Simunovic, Jagnoor Jagnoor, Robyn Norton, Jing Zhang, Maoyi Tian, Soumyadeep Bhaumik, Samina Parveen, Saam Morshed, Madeline C. MacKechnie, Yang Liu, Yanrui Zhao, Junfei Li, Haoran Zhang, Zhentao Zhang, Wei Zhang, Tao Guo, Guang Chen, Zichao Jia, Jianzhong Yang, Lixing Kang, Peng Zhang, Haoqing Ma, Donghai Liu, Yinghua Ma, Yanguo Qin, Jincheng Wang, He Liu, Xinlong Ma, Jianxiong Ma, Haobo Jia, Shuangshuang Cui, Zhihu Zhao, Lin Fu, Hongqiang Jiang, Jianwei Lv, Sanbao Hu, Yongwei Wang, Mingyao Sun, Shuqing Tao, Baochang Qi, Ming Gao, Bo Wu, Chunsheng Zhi, Ben Xing, Jun Yang, Wenjie Dai, Duo Lu, Shisheng He, Xinyu Cai, Gejun Liu, Gang Rui, Baoshan Hu, Pingfang Shi, Hua Chen, Te Wang, Qingqing Wang, Linzhen Xie, Huanguang Xie, Tony Mutanda, Juliet Ntuulo, Flavia Lubega, Gayita Teddy Tracy, Kayondo Zaitun, Sylvester Ndayisaba, Titus Amone, Samuel Remmy Odong, Mark Lutomia, Caesar Okatch, Thomas Bitok, Alexander Kiambuthi, Fred Mathew Toboso Otsyeno, Pankaj G Jani, Vincent Muoki Mutiso, John EO Ating'a, Peter Kavoo Kilonzo, James Muoki, Makena Mbogori, Joan Wambui Wambugu, Dorothy Torutt, Christopher Odok, Elisha Ngetich, Dean Otsyeno, Juma Wakhayanga, Desmond Nzioka, Deogracia Owende, Ruth Lucinde, Brian Ngure Kariuki, Dennis Kinyua, Maureen Kamau, Maureen Mwancha, Mellany Murgor, Marilyn Nyabuti, Rita Njoki, Patricia Wanza, Abraham Odongo, Paul Marealle, Athman Wanini, Marwa Elisha, Damas Zumbulu, Pariyo Bonane Godfrey, Benjamin Mukulu Ndeleva, Murila Johnson, Moses Kimani, Kinuthia Gichui, Rogers Joachin Temu, Angela Neofitus Mselle, Ancelimu Rafael Kimario, Mmampapatla Thomas Ramokgopa, Gregory Firth, Anna Grisillo Biscardi, Machuene Ananias Poopedi, Johan Moolman, Brenda Milner, Matimba Maluleke, Maxwell Jingo, Susan van Deventer, Timothy Pikor, Ravi Bhaga, Michael Mara, Geoffrey Chege Mwangi, Anthony Muchiri Maina, David Wamae Gicheru, Carol Mwangi, Isaac Kingori Wangai, Peter Watson Maina, Ezra Mitei Kiptoo, Olufemi Olukemi Temiloluwa, Adeyeye Adeolu Ikechukwu, Ige Oluwole Olugbenga, Ojodu Ishaq Bamidele, Oladimeji Oladipupo Akanbi, Panchu Subramanian, Olivia L Mosweu, Samuel Hailu, Geletaw Tessema, Bahiru Bezabih, Birhanu Ayana, Hiwot Hailu, Betelhem Zewdneh, Hana Tesfaye, Sosena Tadesse, Dominic Konadu-Yeboah, Vincent Ativor, Peter Konadu, Dominic Awariyah, Raphael Quartey, Raphael Kumah-Ametepey, Osman Saani, Robert Ekow Quansah, Paa Kwesi Baidoo, Peter Trafton, David Anyitey-Korkor, Michael Leat, Johnny Sobotie, Godwin Opuni, Kwasi Kusi, Twimasi Baah, Paul Okyere, Bernice Mensah, Doris Akuoko Sarpong, Felicia Agbenorwu, Phyllis Osei-Donkor, Priscilla Opoku, Michael Segbefia, Gerald Chukwuemeka Oguzie, Emmanuel Chino Iyidobi, Cajetan Uwatoronye Nwadinigwe, Sharon Amarachi Uloma Oguzie, Emina Bami Kesiena, Henry Tanyi Ndasi, Nietiayurk Aminake Ghislain, Mala Irine Shey, Ikose John Nanje, Ashok Shyam, Madhav Borate, Sampat Dumbre Patil, Sachin Karkamakar, Shailesh Patil, Abhijeet Ranaware, Shadab Tamboli, Manish Gandhalikar, Rohini Tupe, Vishal Chaudhari, Avanti Joshi, Sanjay Patil, Mohit Madhukar Dalwekar, Tejas Gandhi, Chintamani Latkar, Gopal Pundkare, Sandeep Shrivastava, Pradeep K Singh, Sanjay Deshpande, Sumit Baheti, Ravi Mittal, Vijay Sharma, Vinoo Mathew Cherian, Thilak Samuel Jepegnanam, Vijay T K Titus, Manasseh Nithyananth, Palapattu R J V C Boopalan, Viju Daniel Varghese, Justin Arockiaraj, Anupam Mahajan, Bobby John, Ritesh Pandey, Jeewan S Prakash, Valsamma Abraham, Arti Rajkumar, Harvinder Singh Chhabra, Rajesh Sharawat, Ritabh Kumar, Pushkar Chawla, Rashmi Yadav, Rajagopalan N Iyer, Naveen Nair, Rajkumar S Amaravathi, Srinivasalu Santhanagopa, Anoop Pilar, Keith Behram Tamboowala, Mandeep S Dhillon, Sarvdeep S Dhatt, Asolie Chase, Neel M Bhavsar, Rameez Musa, Darshan Shah, Sunil Chodavadiyah, Pankaj G Patel, Raja Irfan Qadir, Syed Imran Bukhari, Khushnood Ali Baz, Subin Byanjankar, Ruban Raj Joshi, Rajeev Dwivedi, Jay Raj Sharma, La Ngoc Quang, Nguyen Duc Chinh, Vu Bao Hong, Paphon Sa-ngasoongsong, Noratep Kulachote, Norachart Sirisreetreerux, Wanjak Pongsamakthai, Irewin Alagar Tabu, Paula Veronica Reyes, Iardinne Caiquep, Joni Mitchell Robles Bituin, Jenna González, Mohammadreza Golbakhsh, Mashyaneh Haddadi, Soheil Saadat, Mohammadreza Zafarghandi, Clotilde Fuentes Orozco, José de Jesús Martínez Ruíz, Gustavo Armando Tafoya Arreguin, César Eduardo Pinedo Flores, Irydia Guadalupe Pellegrini Verduzco, Miguel Oscar Hernandez Camacho, Diego Abraham Estrada Téllez, Rodrigo Salcedo López, Ileana Guadalupe Canales Navarro, Mizael Dennis Pérez, Daniel de Jesús Enciso Carrillo, Paola Alejandra Álvarez López, Adán Cervantes Gómez, Fátima Nohemí Franco Bravo, Eugenia de los Ángeles Reyes Arias, Igor A. Escalante Elguezabal, Ennio Antonio Rizzo, Jean Michel Hovsepian, Victor Rodriguez, Manuel Malaret Baldo, Andres Serrano, Carlos G. Sanchez Valenciano, Edgar Efren Mercado Salcedo, Fryda Medina, Fernando Bidolegui, Sebastian Pereira, Gerardo Aguilar, Jorge Rubio-Avila, William Dias Belangero, José Ricardo Lenzi Mariolani, Bruno Livani, André Lugnani, Felipe Rossi, Angela Katayama, Fernando Baldy, Vinícius Ynoe de Moraes, Fabricio Fogagnolo, Kodi Edson Kojima, Jorge dos Santos Silva, Marco Kawamura Demange, Fernando Brandão de Andrade-Silva, Adriana Carvalho Gomes da Silva, Nelson Elias, Dino Aguilar Martinez, Fernando Contreras, Mario Garuz, Jose Eduardo Quintero, Gavino Merchan, Christian M. Lozano Lurita, Aturo D. Torres Manrique, Jorge Hurtado Fernandez, Sergio Iriarte Vincenti, Alfredo Pozzo Bobarin, Dalton Salinas Sanchez, Julio Segovia Altieri, Diego Almada, Derlis Bogado, Carlos Coronel, Cristian Boveda, Victor del Valle, Carlos Montiel, Nelson Marin, Antonio Barquet, Daniel Rienzi, Carlos Amanquez, Georges Beauvoir, Iván J Salce Cutipa, José Eduardo Grandi Ribeiro, José María Jiménez Avila, Luis Padilla, Hernando Cuevas Ochoa, Hernando Cuevas Cano, Adriana Vaca González, Nubia Itzel Gonzalez Gutierrez, and Victor Espinola

Subjects
Public aspects of medicine, RA1-1270
Abstract

Summary: Background: The Lancet Commission on Global Surgery established the Three Delays framework, categorising delays in accessing timely surgical care into delays in seeking care (First Delay), reaching care (Second Delay), and receiving care (Third Delay). Globally, knowledge gaps regarding delays for fracture care, and the lack of large prospective studies informed the rationale for our international observational study. We investigated delays in hospital admission as a surrogate for accessing timely fracture care and explored factors associated with delayed hospital admission. Methods: In this prospective observational substudy of the ongoing International Orthopaedic Multicenter Study in Fracture Care (INORMUS), we enrolled patients with fracture across 49 hospitals in 18 low-income and middle-income countries, categorised into the regions of China, Africa, India, south and east Asia, and Latin America. Eligible patients were aged 18 years or older and had been admitted to a hospital within 3 months of sustaining an orthopaedic trauma. We collected demographic injury data and time to hospital admission. Our primary outcome was the number of patients with open and closed fractures who were delayed in their admission to a treating hospital. Delays for patients with open fractures were defined as being more than 2 h from the time of injury (in accordance with the Lancet Commission on Global Surgery) and for those with closed fractures as being a delay of more than 24 h. Secondary outcomes were reasons for delay for all patients with either open or closed fractures who were delayed for more than 24 h. We did logistic regression analyses to identify risk factors of delays of more than 2 h in patients with open fractures and delays of more than 24 h in patients with closed fractures. Logistic regressions were adjusted for region, age, employment, urban living, health insurance, interfacility referral, method of transportation, number of fractures, mechanism of injury, and fracture location. We further calculated adjusted relative risk (RR) from adjusted odds ratios, adjusted for the same variables. This study was registered with ClinicalTrials.gov, NCT02150980, and is ongoing. Findings: Between April 3, 2014, and May 10, 2019, we enrolled 31 255 patients with fractures, with a median age of 45 years (IQR 31–62), of whom 19 937 (63·8%) were men, and 14 524 (46·5%) had lower limb fractures, making them the most common fractures. Of 5256 patients with open fractures, 3778 (71·9%) were not admitted to hospital within 2 h. Of 25 999 patients with closed fractures, 7141 (27·5%) were delayed by more than 24 h. Of all regions, Latin America had the greatest proportions of patients with delays (173 [88·7%] of 195 patients with open fractures; 426 [44·7%] of 952 with closed fractures). Among patients delayed by more than 24 h, the most common reason for delays were interfacility referrals (3755 [47·7%] of 7875) and Third Delays (cumulatively interfacility referral and delay in emergency department: 3974 [50·5%]), while Second Delays (delays in reaching care) were the least common (423 [5·4%]). Compared with other methods of transportation (eg, walking, rickshaw), ambulances led to delay in transporting patients with open fractures to a treating hospital (adjusted RR 0·66, 99% CI 0·46–0·93). Compared with patients with closed lower limb fractures, patients with closed spine (adjusted RR 2·47, 99% CI 2·17–2·81) and pelvic (1·35, 1·10–1·66) fractures were most likely to have delays of more than 24 h before admission to hospital. Interpretation: In low-income and middle-income countries, timely hospital admission remains largely inaccessible, especially among patients with open fractures. Reducing hospital-based delays in receiving care, and, in particular, improving interfacility referral systems are the most substantial tools for reducing delays in admissions to hospital. Funding: National Health and Medical Research Council of Australia, Canadian Institutes of Health Research, McMaster Surgical Associates, and Hamilton Health Sciences.

Published
2020
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3. Delays in hospital admissions in patients with fractures across 18 low-income and middle-income countries (INORMUS): a prospective observational study

Author

Panthea Pouramin, Chuan Silvia Li, Jason W Busse, Sheila Sprague, P J Devereaux, Jagnoor Jagnoor, Rebecca Ivers, Mohit Bhandari, PJ Devereaux, Gordon Guyatt, Brad Petrisor, Lehana Thabane, Respicious L. Boniface, Bruce Browner, Fernando de la Huerta, Rebecca Q Ivers, Theodore Miclau, Paul Moroz, Andrew Pollak, Gerard Slobogean, Parag Sancheti, Emil Schemitsch, Junlin Zhou, Paula McKay, Raman Mundi, Nathan O'Hara, Diane Heels-Ansdell, Lisa Buckingham, Nicole Simunovic, Robyn Norton, Jing Zhang, Maoyi Tian, Soumyadeep Bhaumik, Samina Parveen, Saam Morshed, Madeline C. MacKechnie, Yang Liu, Yanrui Zhao, Junfei Li, Haoran Zhang, Zhentao Zhang, Wei Zhang, Tao Guo, Guang Chen, Zichao Jia, Jianzhong Yang, Lixing Kang, Peng Zhang, Haoqing Ma, Donghai Liu, Yinghua Ma, Yanguo Qin, Jincheng Wang, He Liu, Xinlong Ma, Jianxiong Ma, Haobo Jia, Shuangshuang Cui, Zhihu Zhao, Lin Fu, Hongqiang Jiang, Jianwei Lv, Sanbao Hu, Yongwei Wang, Mingyao Sun, Shuqing Tao, Baochang Qi, Ming Gao, Bo Wu, Chunsheng Zhi, Ben Xing, Jun Yang, Wenjie Dai, Duo Lu, Shisheng He, Xinyu Cai, Gejun Liu, Gang Rui, Baoshan Hu, Pingfang Shi, Hua Chen, Te Wang, Qingqing Wang, Linzhen Xie, Huanguang Xie, Tony Mutanda, Juliet Ntuulo, Flavia Lubega, Gayita Teddy Tracy, Kayondo Zaitun, Sylvester Ndayisaba, Titus Amone, Samuel Remmy Odong, Mark Lutomia, Caesar Okatch, Thomas Bitok, Alexander Kiambuthi, Fred Mathew Toboso Otsyeno, Pankaj G Jani, Vincent Muoki Mutiso, John EO Ating'a, Peter Kavoo Kilonzo, James Muoki, Makena Mbogori, Joan Wambui Wambugu, Dorothy Torutt, Christopher Odok, Elisha Ngetich, Dean Otsyeno, Juma Wakhayanga, Desmond Nzioka, Deogracia Owende, Ruth Lucinde, Brian Ngure Kariuki, Dennis Kinyua, Maureen Kamau, Maureen Mwancha, Mellany Murgor, Marilyn Nyabuti, Rita Njoki, Patricia Wanza, Abraham Odongo, Paul Marealle, Athman Wanini, Marwa Elisha, Damas Zumbulu, Pariyo Bonane Godfrey, Benjamin Mukulu Ndeleva, Murila Johnson, Moses Kimani, Kinuthia Gichui, Rogers Joachin Temu, Angela Neofitus Mselle, Ancelimu Rafael Kimario, Mmampapatla Thomas Ramokgopa, Gregory Firth, Anna Grisillo Biscardi, Machuene Ananias Poopedi, Johan Moolman, Brenda Milner, Matimba Maluleke, Maxwell Jingo, Susan van Deventer, Timothy Pikor, Ravi Bhaga, Michael Mara, Geoffrey Chege Mwangi, Anthony Muchiri Maina, David Wamae Gicheru, Carol Mwangi, Isaac Kingori Wangai, Peter Watson Maina, Ezra Mitei Kiptoo, Olufemi Olukemi Temiloluwa, Adeyeye Adeolu Ikechukwu, Ige Oluwole Olugbenga, Ojodu Ishaq Bamidele, Oladimeji Oladipupo Akanbi, Panchu Subramanian, Olivia L Mosweu, Samuel Hailu, Geletaw Tessema, Bahiru Bezabih, Birhanu Ayana, Hiwot Hailu, Betelhem Zewdneh, Hana Tesfaye, Sosena Tadesse, Dominic Konadu-Yeboah, Vincent Ativor, Peter Konadu, Dominic Awariyah, Raphael Quartey, Raphael Kumah-Ametepey, Osman Saani, Robert Ekow Quansah, Paa Kwesi Baidoo, Peter Trafton, David Anyitey-Korkor, Michael Leat, Johnny Sobotie, Godwin Opuni, Kwasi Kusi, Twimasi Baah, Paul Okyere, Bernice Mensah, Doris Akuoko Sarpong, Felicia Agbenorwu, Phyllis Osei-Donkor, Priscilla Opoku, Michael Segbefia, Gerald Chukwuemeka Oguzie, Emmanuel Chino Iyidobi, Cajetan Uwatoronye Nwadinigwe, Sharon Amarachi Uloma Oguzie, Emina Bami Kesiena, Henry Tanyi Ndasi, Nietiayurk Aminake Ghislain, Mala Irine Shey, Ikose John Nanje, Ashok Shyam, Madhav Borate, Sampat Dumbre Patil, Sachin Karkamakar, Shailesh Patil, Abhijeet Ranaware, Shadab Tamboli, Manish Gandhalikar, Rohini Tupe, Vishal Chaudhari, Avanti Joshi, Sanjay Patil, Mohit Madhukar Dalwekar, Tejas Gandhi, Chintamani Latkar, Gopal Pundkare, Sandeep Shrivastava, Pradeep K Singh, Sanjay Deshpande, Sumit Baheti, Ravi Mittal, Vijay Sharma, Vinoo Mathew Cherian, Thilak Samuel Jepegnanam, Vijay T K Titus, Manasseh Nithyananth, Palapattu R J V C Boopalan, Viju Daniel Varghese, Justin Arockiaraj, Anupam Mahajan, Bobby John, Ritesh Pandey, Jeewan S Prakash, Valsamma Abraham, Arti Rajkumar, Harvinder Singh Chhabra, Rajesh Sharawat, Ritabh Kumar, Pushkar Chawla, Rashmi Yadav, Rajagopalan N Iyer, Naveen Nair, Rajkumar S Amaravathi, Srinivasalu Santhanagopa, Anoop Pilar, Keith Behram Tamboowala, Mandeep S Dhillon, Sarvdeep S Dhatt, Asolie Chase, Neel M Bhavsar, Rameez Musa, Darshan Shah, Sunil Chodavadiyah, Pankaj G Patel, Raja Irfan Qadir, Syed Imran Bukhari, Khushnood Ali Baz, Subin Byanjankar, Ruban Raj Joshi, Rajeev Dwivedi, Jay Raj Sharma, La Ngoc Quang, Nguyen Duc Chinh, Vu Bao Hong, Paphon Sa-ngasoongsong, Noratep Kulachote, Norachart Sirisreetreerux, Wanjak Pongsamakthai, Irewin Alagar Tabu, Paula Veronica Reyes, Iardinne Caiquep, Joni Mitchell Robles Bituin, Jenna González, Mohammadreza Golbakhsh, Mashyaneh Haddadi, Soheil Saadat, Mohammadreza Zafarghandi, Clotilde Fuentes Orozco, José de Jesús Martínez Ruíz, Gustavo Armando Tafoya Arreguin, César Eduardo Pinedo Flores, Irydia Guadalupe Pellegrini Verduzco, Miguel Oscar Hernandez Camacho, Diego Abraham Estrada Téllez, Rodrigo Salcedo López, Ileana Guadalupe Canales Navarro, Mizael Dennis Pérez, Daniel de Jesús Enciso Carrillo, Paola Alejandra Álvarez López, Adán Cervantes Gómez, Fátima Nohemí Franco Bravo, Eugenia de los Ángeles Reyes Arias, Igor A. Escalante Elguezabal, Ennio Antonio Rizzo, Jean Michel Hovsepian, Victor Rodriguez, Manuel Malaret Baldo, Andres Serrano, Carlos G. Sanchez Valenciano, Edgar Efren Mercado Salcedo, Fryda Medina, Fernando Bidolegui, Sebastian Pereira, Gerardo Aguilar, Jorge Rubio-Avila, William Dias Belangero, José Ricardo Lenzi Mariolani, Bruno Livani, André Lugnani, Felipe Rossi, Angela Katayama, Fernando Baldy, Vinícius Ynoe de Moraes, Fabricio Fogagnolo, Kodi Edson Kojima, Jorge dos Santos Silva, Marco Kawamura Demange, Fernando Brandão de Andrade-Silva, Adriana Carvalho Gomes da Silva, Nelson Elias, Dino Aguilar Martinez, Fernando Contreras, Mario Garuz, Jose Eduardo Quintero, Gavino Merchan, Christian M. Lozano Lurita, Aturo D. Torres Manrique, Jorge Hurtado Fernandez, Sergio Iriarte Vincenti, Alfredo Pozzo Bobarin, Dalton Salinas Sanchez, Julio Segovia Altieri, Diego Almada, Derlis Bogado, Carlos Coronel, Cristian Boveda, Victor del Valle, Carlos Montiel, Nelson Marin, Antonio Barquet, Daniel Rienzi, Carlos Amanquez, Georges Beauvoir, Iván J Salce Cutipa, José Eduardo Grandi Ribeiro, José María Jiménez Avila, Luis Padilla, Hernando Cuevas Ochoa, Hernando Cuevas Cano, Adriana Vaca González, Nubia Itzel Gonzalez Gutierrez, and Victor Espinola

Subjects
Adult, Male, medicine.medical_specialty, Referral, INORMUS investigators, 030231 tropical medicine, MEDLINE, Logistic regression, Time-to-Treatment, 1117 Public Health and Health Services, 03 medical and health sciences, Fractures, Bone, 0302 clinical medicine, Patient Admission, Medicine and Health Sciences, medicine, Humans, 030212 general & internal medicine, Prospective Studies, Prospective cohort study, Developing Countries, business.industry, lcsh:Public aspects of medicine, lcsh:RA1-1270, General Medicine, Emergency department, Odds ratio, Middle Aged, 3. Good health, Socioeconomic Factors, Relative risk, Emergency medicine, Observational study, Female, business, 0605 Microbiology
Abstract

© 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Background: The Lancet Commission on Global Surgery established the Three Delays framework, categorising delays in accessing timely surgical care into delays in seeking care (First Delay), reaching care (Second Delay), and receiving care (Third Delay). Globally, knowledge gaps regarding delays for fracture care, and the lack of large prospective studies informed the rationale for our international observational study. We investigated delays in hospital admission as a surrogate for accessing timely fracture care and explored factors associated with delayed hospital admission. Methods: In this prospective observational substudy of the ongoing International Orthopaedic Multicenter Study in Fracture Care (INORMUS), we enrolled patients with fracture across 49 hospitals in 18 low-income and middle-income countries, categorised into the regions of China, Africa, India, south and east Asia, and Latin America. Eligible patients were aged 18 years or older and had been admitted to a hospital within 3 months of sustaining an orthopaedic trauma. We collected demographic injury data and time to hospital admission. Our primary outcome was the number of patients with open and closed fractures who were delayed in their admission to a treating hospital. Delays for patients with open fractures were defined as being more than 2 h from the time of injury (in accordance with the Lancet Commission on Global Surgery) and for those with closed fractures as being a delay of more than 24 h. Secondary outcomes were reasons for delay for all patients with either open or closed fractures who were delayed for more than 24 h. We did logistic regression analyses to identify risk factors of delays of more than 2 h in patients with open fractures and delays of more than 24 h in patients with closed fractures. Logistic regressions were adjusted for region, age, employment, urban living, health insurance, interfacility referral, method of transportation, number of fractures, mechanism of injury, and fracture location. We further calculated adjusted relative risk (RR) from adjusted odds ratios, adjusted for the same variables. This study was registered with ClinicalTrials.gov, NCT02150980, and is ongoing. Findings: Between April 3, 2014, and May 10, 2019, we enrolled 31 255 patients with fractures, with a median age of 45 years (IQR 31–62), of whom 19 937 (63·8%) were men, and 14 524 (46·5%) had lower limb fractures, making them the most common fractures. Of 5256 patients with open fractures, 3778 (71·9%) were not admitted to hospital within 2 h. Of 25 999 patients with closed fractures, 7141 (27·5%) were delayed by more than 24 h. Of all regions, Latin America had the greatest proportions of patients with delays (173 [88·7%] of 195 patients with open fractures; 426 [44·7%] of 952 with closed fractures). Among patients delayed by more than 24 h, the most common reason for delays were interfacility referrals (3755 [47·7%] of 7875) and Third Delays (cumulatively interfacility referral and delay in emergency department: 3974 [50·5%]), while Second Delays (delays in reaching care) were the least common (423 [5·4%]). Compared with other methods of transportation (eg, walking, rickshaw), ambulances led to delay in transporting patients with open fractures to a treating hospital (adjusted RR 0·66, 99% CI 0·46–0·93). Compared with patients with closed lower limb fractures, patients with closed spine (adjusted RR 2·47, 99% CI 2·17–2·81) and pelvic (1·35, 1·10–1·66) fractures were most likely to have delays of more than 24 h before admission to hospital. Interpretation: In low-income and middle-income countries, timely hospital admission remains largely inaccessible, especially among patients with open fractures. Reducing hospital-based delays in receiving care, and, in particular, improving interfacility referral systems are the most substantial tools for reducing delays in admissions to hospital. Funding: National Health and Medical Research Council of Australia, Canadian Institutes of Health Research, McMaster Surgical Associates, and Hamilton Health Sciences.

Published
2020

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