Risk Factors for Delayed Hospital Admission and Surgical Treatment of Open Tibial Fractures in Tanzania

Abstract

Background: Open fractures, especially of the tibia, require prompt intervention to achieve optimal patient outcomes.While open tibial shaft fractures are common injuries in low-and middle-income countries (LMICs), there is a dearth of literature examining delays to surgery for these injuries in low-resource settings. This study investigated risk factors for delayed management of open tibial fractures in Tanzania. Methods:We conducted an ad hoc analysis of adult patients enrolled in a prospective observational study at a tertiary referral center in Tanzania from 2015 to 2017. Multivariable models were utilized to analyze risk factors for delayed hospital presentation of ‡2 hours, median time from injury to the treatment hospital, and delayed surgical treatment of ‡12 hours after admission among patients with diaphyseal open tibial fractures.Results: Two hundred and forty-nine patients met the inclusion criteria. Only 12% of patients used an ambulance, 41% were delayed ‡2 hours in presentation to the first hospital, 75% received an interfacility referral, and 10% experienced a delay to surgery of ‡12 hours after admission. After adjusting for injury severity, having insurance (adjusted odds ratio [aOR] = 0.48; 95% confidence interval [CI] = 0.24 to 0.96) and wounds with approximated skin edges (aOR = 0.37; 95% CI = 0.20 to 0.66) were associated with a decreased risk of delayed hospital presentation. Interfacility referrals (2.3 hours greater than no referral; p = 0.015) and rural injury location (10.9 hours greater than urban location; p < 0.001) were associated with greater median times to treatment hospital admission. Older age (aOR = 0.54 per 10 years; 95% CI = 0.31 to 0.95), single-person households (aOR = 0.12 compared with ‡8 people; 95% CI = 0.02 to 0.96), and an education level greater than pre-primary (aOR = 0.16; 95% CI = 0.04 to 0.62) were associated with fewer delays to surgery of ‡12 hours after admission.Conclusions: Prehospital network and socioeconomic characteristics are associated with delays to open tibial fracture care in Tanzania. Reducing interfacility referrals and implementing surgical cost-reduction strategies may help to reduce delays to open fracture care in LMICs.Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. Musculoskeletal injuries are a leading cause of disability across the world and disproportionally affect people in low-and middle-income countries (LMICs) 1-5 . Among these injuries, tibial shaft fractures are the most common longbone and open fractures 6 . Despite surgical advances, open tibial fractures are associated with high complications rates and poor long-term quality of life for people in LMICs 7,8 . Globally, the surgical treatment of open fractures is used as a benchmark bellwether procedure for what first-level hospitals should be able to perform on a 24/7 basis to ensure appropriate delivery of care to their population 9,10 . However, patients in LMICs continue to face issues with delays to access...

Experiences of injured patients referred to higher levels of care after initial assessment and management at non-tertiary hospitals in Ghana

“…Similarly, prior studies of trauma care delays in Rwanda and Tanzania have found that men are over-represented in comparison to women when examining delayed fracture care and delayed initial presentation after injury. 17 , 18 As such, men may be a population to focus on when implementing interventions to help patients receive definitive trauma care.…”

Special Report: The Moore Pediatric Surgery Center: An Evolving Model for Pediatric Orthopaedic Surgical Care in a Limited Resource Environment

“…Another major risk is that the operation of the center will foster long-term dependence upon the center for provision of select pediatric surgical procedures and thereby negatively impact efforts to develop these resources in country. The preceding paragraphs illustrate our efforts to ameliorate this outcome, but realistically access to such care is fundamentally an economic problem, not likely to be solved in the short term 14…”