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. MethodsIn 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 ...

BackgroundAccess to surgical care in Low- and Middle-Income Countries (LMICs) such as Tanzania is extremely limited. Northern Tanzania is served by a single tertiary referral hospital, Kilimanjaro Christian Medical Centre (KCMC). The surgical volumes, workflow, and payment mechanisms in this region have not been characterized. Understanding these factors is critical in expanding access to healthcare. The authors sought to evaluate the operations and financing of the main operating theaters at KCMC in Sub-Saharan Africa.MethodsThe 2018 case volume and specialty distribution (general, orthopaedic, and gynecology) in the main operating theaters at KCMC was retrieved through retrospective review of operating report books. Detailed workflow (i.e. planned and cancelled cases, lengths of procedures, lengths of operating days) and financing data (patient payment methods) from the five KCMC operating theater logs were retrospectively reviewed for the available five-month period of March 2018 to July 2018. Descriptive statistics and statistical analysis were performed.ResultsIn 2018, the main operating theaters at KCMC performed 3817 total procedures, with elective procedures (2385) outnumbering emergency procedures (1432). General surgery (1927) was the most operated specialty, followed by orthopaedics (1371) and gynecology (519). In the five-month subset analysis period, just 54.6% of planned operating days were fully completed. There were 238 cancellations (20.8% of planned operations). Time constraints (31.1%, 74 cases) was the largest reason; lack of patient payment accounted for as many cancellations as unavailable equipment (6.3%, 15 cases each). Financing for elective theater cases included insurance 45.5% (418 patients), and cash 48.4% (445 patients).ConclusionWhile surgical volume is high, there are non-physical inefficiencies in the system that can be addressed to reduce cancellations and improve capacity. Improving physical resources is not enough to improve access to care in this region, and likely in many LMIC settings. Patient financing and workflow will be critical considerations to truly improve access to surgical care.

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There is a near absence of access to orthopaedic surgical care in Northern Tanzania. These findings utilize more precise country and region-specific data and are consistent with prior published global trends regarding surgical access in Sub-Saharan Africa. As the global health community must develop innovative solutions to address the rising burden of musculoskeletal disease and support the advancement of universal health coverage, increasing access to orthopaedic surgical services will play a central role in improving health care in the world's developing regions.