Delays in hospital admissions for patients with fractures
Authors: Jayadevan Sreedharan, Aji Gopakumar, Jayakumary Muttappallymyalil, Satish Chandrasekhar Nair
Journal: The Lancet Global Health (2020)

We read with interest the Article by Panthea Pouramin and colleagues in The Lancet Global Health.1Pouramin P Li CS Busse JW et al.Delays in hospital admissions in patients with fractures across 18 low-income and middle-income countries (INORMUS): a prospective observational study.Lancet Glob Health. 2020; 8: e711-e720Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar The study prospectively observes the percentage of delays in hospital admission 18 low-income and middle-income countries as a surrogate for accessing timely fracture care among the patient group with open fractures and closed fractures, based on a delay of more than 2 h for open fractures and more than 24 h for closed fractures. Additionally, exploring the factors associated with delayed admission to hospital, the authors concluded that timely hospital admission for these patients is largely inaccessible in low-income and middle-income countries. Despite the strengths of the study, the methods and statistical analysis raise several concerns. The switch from prospective consecutive sampling to a systematic sampling method, due to a lack of hospital resources as stated by the authors, does not fit logically because the study included all patients with fracture, requiring no need for sampling. The authors report that increasing age increased the risk of delay for both patients with open fractures and closed fractures. For open fractures, the odds ratio [OR] is 1·01 and the risk ratio [RR] is 1·00. However, the 99% CI for the OR is 1·00–1·02, and for the RR is 1·00–1·01. In either case, the 99% CI (value 1), which represents age, does not have any role in the delay of admission. The associated p value (0·001) also indicates a significant association between age and admission delay, leading to contradictions in the reported results. For patients with closed fractures, large sample fallacy is evident in the RR, OR, and their associated 99% CIs: with an OR of 1·01 (99% CI 1·01–1·01), an RR of 1·01 (1·01–1·01), and a p value of less than 0·0001. A much narrowed 99% CI indicates higher precision in the estimates, which might be the result of a large sample.2Chandrasekharan S Sreedharan J Gopakumar A Statistical issues in small and large sample: need of optimum upper bound for the sample size.Int J Compu Theor Stat. 2019; 6: 107-118Crossref Google Scholar With a larger sample, estimates will be highly precise and statistical significance is obvious with lower p values. The authors report statistically significant associations between the delay in admission and various factors with p values of less than 0·01 in many comparisons, which might be a result of the large sample size. Ironically, the authors present an interesting public health issue, although the statistical strategies do not support their observations. We declare no competing interests. Delays in hospital admissions in patients with fractures across 18 low-income and middle-income countries (INORMUS): a prospective observational studyIn 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. Full-Text PDF Open AccessDelays in hospital admissions for patients with fractures – Authors' replyWe thank Jayadevan Sreedharan and colleagues for their valuable perspective on our Article.1 INORMUS is a multicountry study that aims to assess fracture care in low-income and middle-income countries. Given constraints in low-resource settings, eight participating hospitals did not have the capacity to enrol patients every day. Thus, to ensure the fidelity of the data collection process, a schedule was implemented to enrol all eligible patients on consistent days in the week (≥3 days per week). Full-Text PDF Open Access