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.