Global barriers to hip-fracture care
Authors: Naoko Onizuka, Carmen Quatman
Journal: The Lancet Healthy Longevity (2024)

Hip-fracture surgery within 24 h to 48 h of admission to hospital is associated with improved outcomes, including reduced mortality.1Oakley B Nightingale J Moran CG Moppett IK Does achieving the best practice tariff improve outcomes in hip fracture patients? An observational cohort study.BMJ Open. 2017; 7e014190Crossref Scopus (52) Google Scholar, 2British Geriatrics SocietyThe care of patients with fragility fracture (Blue Book).https://www.bgs.org.uk/resources/care-of-patients-with-fragility-fracture-blue-bookDate: 2007Date accessed: May 13, 2024Google Scholar, 3American Academy of Orthopaedic SurgeonsManagement of hip fractures in older adults.https://www.aaos.org/globalassets/quality-and-practice-resources/hip-fractures-in-the-elderly/hipfxcpg.pdfDate: 2021Date accessed: May 13, 2024Google Scholar The effectiveness of the processes and strategies that are designed to expedite surgery times for patients with hip fractures is well documented in high-acuity, well-resourced hospital systems.1Oakley B Nightingale J Moran CG Moppett IK Does achieving the best practice tariff improve outcomes in hip fracture patients? An observational cohort study.BMJ Open. 2017; 7e014190Crossref Scopus (52) Google Scholar, 2British Geriatrics SocietyThe care of patients with fragility fracture (Blue Book).https://www.bgs.org.uk/resources/care-of-patients-with-fragility-fracture-blue-bookDate: 2007Date accessed: May 13, 2024Google Scholar, 3American Academy of Orthopaedic SurgeonsManagement of hip fractures in older adults.https://www.aaos.org/globalassets/quality-and-practice-resources/hip-fractures-in-the-elderly/hipfxcpg.pdfDate: 2021Date accessed: May 13, 2024Google Scholar However, the applicability and success of these processes in resource-limited, rural hospital systems remain unclear. The analysis of data from the International Orthopaedic Multicentre Study in Fracture Care (INORMUS) by Armstrong and colleagues,4Armstrong E Rogers K Li CS et al.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).Lancet Healthy Longev. 2024; (published online July 15.)https://doi.org/10.1016/S2666-7568(24)00062-XSummary Full Text Full Text PDF PubMed Scopus (1) Google Scholar published in The Lancet Healthy Longevity, substantially contributes to the literature on hip-fracture care in low-income and middle-income countries (LMICs) by assessing barriers to and delays in hospital admission and surgery in these hospital systems. Understanding the applicability of these strategies in low-resource, rural hospital systems is crucial for ensuring equitable health-care outcomes and for optimising treatment for people with hip fractures across diverse environments. Patient phases of care (ie, from injury to hospital admission, from hospital admission to treatment or surgery, and from surgery to outcome) are opportunities to implement process-improvement strategies for quality of care and patient safety. In Armstrong and colleagues' analysis, transfer from another hospital was one of the largest drivers of admission delay. Furthermore, 522 (36·2%) of 1441 patients had delays in hospital admission because they did not seek care promptly for various reasons. A qualitative study published in 2022 showed how structural and social barriers, as well as little awareness about the consequences of hip fracture, affect timely patient presentation for hip-fracture care in LMICS.5Armstrong E Yin X Razee H et al.Exploring barriers to, and enablers of, evidence-informed hip fracture care in five low- middle-income countries: China, India, Thailand, the Philippines and Vietnam.Health Policy Plan. 2022; 37: 1000-1011Crossref PubMed Scopus (3) Google Scholar Moreover, cultural beliefs, attitudes about health care, perceptions of illness, and traditional healing practices all influence an individual's decision to seek medical attention.4Armstrong E Rogers K Li CS et al.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).Lancet Healthy Longev. 2024; (published online July 15.)https://doi.org/10.1016/S2666-7568(24)00062-XSummary Full Text Full Text PDF PubMed Scopus (1) Google Scholar The analysis of data from the INORMUS study shows how these barriers are not specific to isolated locations and occur worldwide, with Africa specifically showing the highest proportion of patients with delayed hospital admission due to initial treatment by a traditional healer.4Armstrong E Rogers K Li CS et al.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).Lancet Healthy Longev. 2024; (published online July 15.)https://doi.org/10.1016/S2666-7568(24)00062-XSummary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Once patients are admitted to hospital for hip fracture, other barriers to surgical care can inhibit timely care. In the USA, geriatric consultation and co-management are common practice to promptly optimise patient care.3American Academy of Orthopaedic SurgeonsManagement of hip fractures in older adults.https://www.aaos.org/globalassets/quality-and-practice-resources/hip-fractures-in-the-elderly/hipfxcpg.pdfDate: 2021Date accessed: May 13, 2024Google Scholar By contrast, LMICs might not have the infrastructure or resources to provide these services to optimise patients for safe surgery. Therefore, orthopaedic surgeons could be the primary physicians managing patient medical comorbidities, especially in settings without doctors who work exclusively in hospitals (also known as hospitalists), which could potentially impede timely pre-operative optimisation.6Naito T Will the introduction of the hospitalist system save Japan?.Intern Med. 2023; 62: 1105-1106Crossref PubMed Scopus (2) Google Scholar Various insurance systems substantially affect health-care delivery worldwide, and the INORMUS analysis highlights how insurance systems affect time-to-surgery metrics. For example, previous findings have shown that Japan's national universal health-insurance system, which ensures coverage for everyone, facilitates timely access to treatments.7Sasai Y Suzuki Y Takeuchi Y An analysis of the current condition of the medical insurance system in Japan.J Oral Sci. 2019; 61: 481-482Crossref PubMed Scopus (6) Google Scholar Conversely, government-sponsored insurance systems in some Asian and Latin American countries, such as China and Peru, are associated with obstacles such as bureaucratic barriers and few health-care resources, resulting in delays in care.8Ying M Wang S Bai C Li Y Rural–urban differences in health outcomes, healthcare use, and expenditures among older adults under universal health insurance in China.PLoS One. 2020; 15e0240194Crossref Scopus (27) Google Scholar, 9US Organization for Economic Cooperation and DevelopmentThe World BankHealth at a Glance: Latin America and the Caribbean 2020.https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-latin-america-and-the-caribbean-2020_6089164f-enDate: 2020Date accessed: May 15, 2024Google Scholar According to Armstrong and colleagues,4Armstrong E Rogers K Li CS et al.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).Lancet Healthy Longev. 2024; (published online July 15.)https://doi.org/10.1016/S2666-7568(24)00062-XSummary Full Text Full Text PDF PubMed Scopus (1) Google Scholar government insurance was a cause of delays in surgery in Asia (excluding China and India; relative risk 3·34, 95% CI 2·60–4·29) and Latin America (2·02, 1·52–2·68), whereas private insurance was a cause of delays in Africa (1·29, 1·08–1·53). However, the definitions and implications of private insurance and government insurance might vary across countries, thus influencing time to surgery differently. Therefore, a more detailed assessment of the effects of insurance on time-to-surgery processes would provide valuable insights. Although not assessed in this analysis of data from the INORMUS study, time of day or day of the week of hospital admission for hip fracture are often crucial factors in surgical delays.10Tian C Zhu H Shi L Chen X Xie T Rui Y Is there a "Black Friday" for geriatric hip fracture surgery?.Orthop Surg. 2023; 15: 1304-1311Crossref PubMed Scopus (2) Google Scholar Patients admitted to hospitals during weekends or holidays could experience delays to surgery, depending on the availability of resources. Future work that explores workforce and resource availability in specific regions would provide important information on process optimisation for hip-fracture care in LMICs. Overall, Armstrong and colleagues should be commended. Capturing this large dataset to obtain a robust analysis of the implications of barriers to optimal hip-fracture care across 24 countries was a large undertaking that revealed disparities in health-care access for a common injury. Their research provides valuable insights into timely hip-fracture management and identifies several factors that contribute to delays in care globally. Future research and quality-improvement initiatives should focus on barriers that LMICs have in addressing hip-fracture care. NO is a research fellow for the International Geriatric Fracture Society. CQ receives funding from the US National Institutes of Health and is a research fellow for, board member of, and current vice president of the International Geriatric Fracture Society. 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)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. Full-Text PDF Open Access