Lost to follow-up: Challenges to conducting orthopaedic research in South Africa

Abstract

Kimberley Provincial Hospital provides the sole public sector orthopaedic surgical service to the entire Northern Cape Province of South Africa (SA). Ankle fractures form part of the trauma burden and pose a challenge owing to high numbers and limited resources. The incidence of ankle fracture is reported to be 169.7/100 000/year. [1] Currently there are no statistics on the incidence in the Northern Cape. An alternative surgical method of treatment was explored in the form of a prospective cohort series, to increase turnaround time of patients needing surgery and thus improve service delivery. Data collection while conducting this prospective trial highlighted loss to follow-up in ankle fracture patients, which prompted this report. Numerous studies have highlighted the challenges in terms of loss to follow-up when conducting trials in musculoskeletal injuries. [2-5] The main factors contributing to this loss to follow-up are reported to be socioeconomic, and include level of education, poverty, male gender, smoking and alcohol abuse. [6] Young individuals as well as the very elderly are prone to be lost to follow-up. Potential reasons for this vary, but are hypothesised to include an increased frequency of substance abuse in younger populations and lack of mobility in older populations. [2,7] In addition, smokers are reported to have an 80% higher risk of loss to follow-up compared with non-smokers. The reason for this is not clear, but it has been postulated that individuals with substance use may lack motivation to change their behaviour for health-related purposes. [2] Several other studies also report smokers to be at risk of not attending for follow-up as expected. [4,5,8] This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Introducing early active mobilisation following flexor tendon repair in the context of care in a developing country: A randomised feasibility study

“…The factor of distance can be linked to the finding in this research of 'lack of money for transport' arising as a reason for dropout. The distances in the present research were far less than those reported by Badenhorst et al 38 thus it is likely that poor transport infrastructure and poverty, rather than purely distance, are reasons for the high dropout rates. Affordability as a dimension of accessibility 12 is reflected here, with the constrained economic capacity of the population.…”

“…Factors influencing the follow-up of patients, however is intractably linked to their setting. In a South African Orthopaedic study, Badenhorst et al 38 identified three main factors influencing loss to follow-up, namely distance to travel, BMI and HIV status. The factor of distance can be linked to the finding in this research of 'lack of money for transport' arising as a reason for dropout.…”

Loss to follow-up among patients diagnosed with spinal tuberculosis at a tertiary hospital in Western Cape Province, South Africa: A retrospective cohort study

“…Previous studies investigating hospitalbased follow-up in orthopaedics have for the most part focused on trauma follow-up in a developed country setting, including wellresourced clinical trials. [29][30][31][32][33][34] Although Dunn et al [15] alluded to poor compliance with tertiary hospital follow-up among spinal TB patients in the Western Cape, this concern fell beyond the main objective of the present study and was not subsequently investigated.…”

“…The time period for the dataset was 1 January 2012 -31 December 2017. Finally, distance from the RESEARCH hospital was taken as the shortest distance by road between the patient's area of residence and the hospital according to Google Maps [30,34] and reported as both a continuous variable and a categorical variable, < or ≥50 km. All study data were captured by a single investigator using custom-designed electronic data capture forms in order to optimise data quality and consistency.…”

“…The definition of loss to follow-up may have a large impact on study findings and should be kept consistent between studies wherever possible. [36,37] However, existing definitions such as loss to follow-up from TB treatment [38] and loss to follow-up in orthopaedic trauma [29,31,32,34] were not suitable for the current context. The following definition was therefore developed, based on the expected frequency of visits.…”