The Economic Burden of Non-fatal Musculoskeletal Injuries in Northeastern Tanzania

Metamizole in the Management of Musculoskeletal Disorders: Current Concept Review

Metamizole, or dipyrone, has been used for decades as a non-narcotic analgesic, providing pain relief from musculoskeletal disorders and antipyretic and antispasmolytic properties. Despite being in use since the 1920s, its mechanism of action still needs to be discovered. Despite causing fewer adverse effects when compared to other analgesics, its harmful effects on the blood and lack of evidence regarding its teratogenicity make the usage of the drug questionable, which has led to it being removed from the drug market of various countries. This narrative review aims to provide a detailed insight into the mechanism of action and efficacy, comparing its effectiveness and safety with other classes of drugs and the safety profile of metamizole.

Orthopaedic and trauma research in Tanzania: A scoping review

Tanzania is disproportionately burdened by musculoskeletal injuries as it faces unique challenges when dealing with trauma care. This scoping review aims to summarize and assess the current state of orthopaedic and trauma research in Tanzania. By identifying key themes, trends, and gaps in the literature, this review seeks to guide future research initiatives catered specifically to the needs of Tanzania's healthcare system. Utilizing the PRISMA-ScR protocol, OVID Medline, PubMed, and CINAHL databases were searched from inception to June 17, 2023, using keywords such as "Orthopaedics" "Trauma" and "Tanzania". One hundred and ninety-two eligible studies were included and the Arksey and O'Malley framework for scoping studies was followed. There was a notable growth of relevant publications from 2015 onward, with peaks in growth in the years 2019, 2021, and 2020. The studies employed diverse research methodologies, with cross-sectional (n = 41, 21%) and prospective studies (n = 39, 20%) being the most prevalent, and randomized-controlled trials being the least prevalent methodology, making up eight studies (4.2%). The most common study themes were trauma (n = 101, 52.6%), lower extremity (n = 31, 16%), and spine-related issues (n = 27, 14%). Only three studies looked at work-related injuries (1.6%). Road traffic injuries (RTIs) were the most common mechanism of trauma in 77.0% of the trauma focused studies. Fifty-three percent of the studies were conducted by a majority of Tanzanian authors. This scoping review highlights various trends in orthopaedic and trauma research in Tanzania, with a particular emphasis on road traffic-related injuries. Various gaps are explored, including a lack of research on work-related injuries and a paucity of experimental research. Our findings underline areas where future research is warranted. The future of orthopaedic and trauma care in Tanzania depends on the efforts and collaboration of both local and international stakeholders.

Prevalence and levels of disability post road traffic orthopaedic injuries in Rwanda

Background

Prolonged disability resulting from road traffic injuries (RTIs) contributes significantly to morbidity and disease burden. A good understanding of the prevalence and the level of disability of orthopaedic injuries in developing countries is crucial for improvement; however, such data are currently lacking in Rwanda.

Objectives

To determine the prevalence and levels of disability of 2 years post-road traffic orthopaedic injuries in Rwanda.

Method

A multicentre, cross-sectional study from five Rwandan referral hospitals of 368 adult RTI victims' sustained from accidents in 2019. Between 02 June 2022, and 31 August 2022, two years after the injury, participants completed the World Health Organization Disability Assessment Schedule (WHODAS 2.0) Questionnaire for the degree of impairment and the Upper Extremity Functional Scale and Lower-Extremity Functional Scale forms for limb functional evaluation. Descriptive, inferential statistics Chi-square and multinomial regression models were analysed using R Studio.

Results

The study's mean age of the RTOI victims was 37.5 (±11.26) years, with a sex ratio M: F:3: 1. The prevalence of disability following road traffic orthopedic injury (RTOI) after 2 years was 36.14%, with victims having WHODAS score > 25.0% and 36.31% were still unable to return to their usual activities. Age group, Severe Kampala Trauma Score and lack of rehabilitation contributed to disability. The most affected WHODAS domains were participation in society (33%) and life activities (28%).

Conclusion

The prevalence and levels of disability because of RTOI in Rwanda are high, with mobility and participation in life being more affected than other WHODAS domains. Middle-aged and socio-economically underprivileged persons are the most affected.

Contribution

This study showed that a good rehabilitation approach and economic support for the RTI victims would decrease their disabilities in Rwanda.

Evaluating the Social Impact of a Proposed Orthopedic Center of Excellence in Northern Tanzania: A Novel Use of the Impact Multiple of Money Methodology

BACKGROUND

Musculoskeletal injuries-often a result of Road Traffic Accidents (RTAs)-represent a significant burden in sub-Saharan Africa. RTA victims are faced with lifelong disability and diminished employment. Northern Tanzania in particular lacks the orthopedic surgical capacity needed to provide patients with definitive surgical fixation. While there is great potential in establishing an Orthopedic Center of Excellence (OCE), the precise social impact of such an initiative is currently unknown.

METHODS

To demonstrate the social value of an orthopedic OCE in Northern Tanzania, this paper proposes a methodology for calculating social impact. This methodology draws upon RTA-related Disability Adjusted Life Years (DALYs), current and projected surgical complication rates, anticipated changes in surgical volume, and average per capita income to quantify how much social value can be gained by mitigating the impact of RTAs. These parameters can be utilized to calculate an impact multiplier of money (IMM), stating the social returns on each dollar invested.

RESULTS

Modeling exercises demonstrate that improvements in the complication rate and surgical volume over the current baseline results in significant social impact. In the best-case scenario, the COE is expected to yield over $131 million over 10 years, with an IMM of 13.19.

CONCLUSIONS

Investments in orthopedic care will yield significant dividends, as demonstrated by our novel methodology. The cost-effectiveness of the OCE is comparable to, if not greater, than many other global health initiatives. More broadly, the IMM methodology can be used to quantify the impact of other projects aimed at reducing long-term injury.

Out-of-pocket cost for medical care of injured patients presenting to emergency department of national hospital in Tanzania: a prospective cohort study

OBJECTIVE

We aimed to determine the out-of-pocket (OOP) costs for medical care of injured patients and the proportion of patients encountering catastrophic costs.

DESIGN

Prospective cohort study SETTING: Emergency department (ED) of a tertiary-level hospital in Dar es Salaam, Tanzania.

PARTICIPANTS

Injured adult patients seen at the ED of Muhimbili National Hospital from August 2019 to March 2020.

METHODS

During alternating 12-hour shifts, consecutive trauma patients were approached in the ED after stabilisation. A case report form was used to collect social-demographics and patient clinical profile. Total charges billed for ED and in-hospital care and OOP payments were obtained from the hospital billing system. Patients were interviewed by phone to determine the measures they took to pay their bills.

PRIMARY OUTCOME MEASURE

The primary outcome was the proportion of patients with catastrophic health expenditure (CHE), using the WHO definition of OOP expenditures ≥40% of monthly income.

RESULTS

We enrolled 355 trauma patients of whom 51 (14.4%) were insured. The median age was 32 years (IQR 25-40), 238 (83.2%) were male, 162 (56.6%) were married and 87.8% had ≥2 household dependents. The majority 224 (78.3%) had informal employment with a median monthly income of US$86. Overall, 286 (80.6%) had OOP expenses for their care. 95.1% of all patients had an Injury Severity Score <16 among whom OOP payments were US$176.98 (IQR 62.33-311.97). Chest injury and spinal injury incurred the highest OOP payments of US$282.63 (84.71-369.33) and 277.71 (191.02-874.47), respectively. Overall, 85.3% had a CHE. 203 patients (70.9%) were interviewed after discharge. In this group, 13.8% borrowed money from family, and 12.3% sold personal items of value to pay for their hospital bills.

CONCLUSION

OOP costs place a significant economic burden on individuals and families. Measures to reduce injury and financial risk are needed in Tanzania.

Hospitalized for poverty: orthopaedic discharge delays due to financial hardship in a tertiary hospital in Northern Tanzania

Background

Musculoskeletal injury contributes significantly to the burden of disease in Tanzania and other LMICs. For hospitals to cope financially with this burden, they often mandate that patients pay their entire hospital bill before leaving the hospital. This creates a phenomenon of patients who remain hospitalized solely due to financial hardship. This study aims to characterize the impact of this policy on patients and hospital systems in resource-limited settings.

Methods

A mixed-methods study using retrospective medical record review and semi-structured interviews was conducted at a tertiary hospital in Moshi, Tanzania. Information regarding patient demographics, injury type, days spent in the ward after medical clearance for discharge, and hospital invoices were collected and analyzed for orthopaedic patients treated from November 2016 to June 2017.

Results

346 of the 867 orthopaedic patients (39.9%) treated during this time period were found to have spent additional days in the hospital due to their inability to pay their hospital bill. Of these patients, 72 patient charts were analyzed. These 72 patients spent an average of 9 additional days in the hospital due to financial hardship (range: 1–64 days; interquartile range: 2–10.5 days). They spent an average of 112,958 Tanzanian Shillings (TSH) to pay for services received following medical clearance for discharge, representing 12.3% of the average total bill (916,840 TSH). 646 hospital bed-days were spent on these 72 patients when they no longer clinically required hospitalization. 7 (9.7%) patients eloped from the hospital without paying and 24 (33.3%) received financial assistance from the hospital’s social welfare office.

Conclusions

Many patients do not have the financial capacity to pay hospital fees prior to discharge. This reality has added significantly to these patients’ overall financial hardship and has taken hundreds of bed-days from other critically ill patients. This single-institution, cross-sectional study provides a deeper understanding of this phenomenon and highlights the need for changes in the healthcare payment structure in Tanzania and other comparable settings.

"I Don't Do Anything; I'm Just Being Taken Care Of": Experiences of Patients and Their Caregivers Transitioning Back into the Community Following Traumatic Injury in Northern Tanzania

After discharge from the hospital for traumatic injury, patients and their caregivers face a period of increased vulnerability. This adjustment phase is poorly characterized, especially in low- and middle-income countries. We explored the experiences of patients and their caregivers in Northern Tanzania after hospitalization for a traumatic injury. Patients who received care for traumatic injury at the Kilimanjaro Christian Medical Center and their caregivers were selected as part of a convenience sample from January 2019 to December 2019. Analysts developed a codebook; content and analytic memos were subsequently created. We then applied the biopsychosocial model to further characterize our findings. Participants included 26 patients and 11 caregivers. Patients were mostly middle-aged (mean age 37.7) males (80.8%), residing in urban settings (57.7%), injured in road traffic accidents (65.4%), and who required surgery (69.2%). Most caregivers were female. Seven major themes arose: pain, decreased physical functioning, poor emotional health, lack of support, challenges with daily activities, financial strain, and obstacles to accessing healthcare. This study describes some of the difficulties transitioning back into the community after hospitalization for traumatic injury. Our work demonstrates the importance of mixed methods approaches in characterizing and addressing transitions of care challenges.

Definitive surgical femur fracture fixation in Northern Tanzania: implications of cost, payment method and payment status

Introduction

Kilimanjaro Christian Medical Centre (KCMC) covers major orthopaedic trauma for a catchment population of 12.5 million people in northern Tanzania. Femur fractures, the most common traumatic orthopaedic injury at KCMC (39%), require open reduction and internal fixation (ORIF) for definitive treatment. It is unclear whether payment affects care. This study sought to explore associations of payment method with episodes of care for femur fracture ORIFs at KCMC.

Methods

we performed a retrospective review of orthopaedic records between February 2018 and July 2018. Patients with femur fracture ORIF were eligible; patients without charts were excluded. Ethical clearance was obtained from the KCMC ethics committee. Statistical analysis utilized descriptive statistics, Chi-squared and Fisher’s exact Tests, and Student´s t-tests where appropriate.

Results

of 76 included patients, 17% (n=13) were insured, 83% (n=63) paid out-of-pocket, 11% (n=8) had unpaid balance, and 89% (n=68) fully paid. Average patient charge ($417) was 42% of per capita GDP ($998). Uninsured patients had higher bills ($429 vs $356; p=0.27) and were significantly more likely to pay an advance payment (95.2% vs 7.7%; p<0.001). Inpatient care was equivalent regardless of payment. Unpaid patients were less likely to receive follow-up (76.5% vs. 25%; p=0.006) and waited longer from injury to admission (31.5 vs 13.3 days; p<0.001), from admission to surgery (30.1 vs 11.1 days; p<0.001), and from surgery to discharge (18.4 vs 7.1 days; p<0.001).

Conclusion

equal standard of care is provided to all patients. However, future efforts may decrease disparities in advance payment, timeliness, and follow-up.

Patient patronage and perspectives of traditional bone setting at an outpatient orthopaedic clinic in Northern Tanzania

Background

Much of Sub-Saharan Africa meets the rising rates of musculoskeletal injury with traditional bone setting, especially given limitations in access to allopathic orthopaedic care. Concern for the safety of bone setter practices as well as recognition of their advantages have spurred research to understand the impact of these healers on public health.

Objectives

Our study investigates the role of bone setting in Tanzania through patient utilization and perspectives.

Methods

We surveyed 212 patients at the outpatient orthopaedic clinic at Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania. Surveys were either self-administered or physician-administered. Summary statistics were calculated using XLSTAT. Open responses were analyzed using a deductive framework method.

Results

Of all surveys, 6.3% (n=13) reported utilizing traditional bone setting for their injury prior to presenting to KCMC. Of the self-administered surveys, 13.6% (n=6) reported utilizing bone setting compared to 4.3% (n=7) of the physician-administered surveys (p=0.050). Negative perceptions of bone setting were more common than positive perceptions and the main reason patients did not utilize bone setting was concern for competency (35.8%, n=67).

Conclusion

Our study found lower bone setting utilization than expected considering the reliance of Tanzanians on traditional care reported in the literature. This suggests patients utilizing traditional care for musculoskeletal injury are not seeking allopathic care; therefore, collaboration with bone setters could expand allopathic access to these patients. Patients were less likely to report bone setter utilization to a physician revealing the stigma of seeking traditional care, which may present an obstacle for collaboration.

Psychosocial health of patients receiving orthopaedic treatment in northern Tanzania: A cross-sectional study

Background

Patients with musculoskeletal injuries in Sub-Saharan Africa often receive prolonged inpatient treatment due to limited access to surgical care. Little is known regarding the psychosocial impact of prolonged conservative treatment for orthopaedic injuries, which may add to disability and preclude rehabilitation.

Methods

A cross-sectional, questionnaire study was conducted to characterize the psychosocial health of orthopaedic inpatients at a tertiary hospital in Moshi, Tanzania. Three validated surveys assessing coping strategies, functional social support, and symptoms of depression were orally administered to all orthopaedic patients with a length of stay (LOS) ≥ 6 days by a Tanzanian orthopaedic specialist.

Results

Fifty-nine patient surveys were completed, and revealed 92% (54) of patients were more likely to utilize more adaptive than maladaptive coping strategies. Patients with chest or spinal column injuries were more likely to use maladaptive coping strategies (p = 0·027). Patients with head injuries had more social support compared to others (p = 0·009). Lack of insurance, limited education, and rural origins were associated with less functional social support, although this finding did not reach statistical significance. 23·7% (14) of patients had symptoms consistent with mild depression, 33·9% (20) with moderate depression, and 3·4% (2) with moderately-severe depression. LOS was the only significant predictor for depression severity.

Conclusions

61% (36) of orthopaedic inpatients exhibited depressive symptoms, indicating that the psychosocial health in this population is sub-optimal. Mental health is a crucial element of successful orthopaedic care. Access to timely surgical care would greatly decrease LOS, the most prominent predictor of depressive symptom severity.

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The majority of orthopaedic patients were found to have symptoms of depression.

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Length of stay was the only significant predictor of depression symptom severity.

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Patients with torso injuries tended to use more maladaptive coping strategies.