Quality of life, functional status and cost-effectiveness of treatment after femoral shaft fractures in Malawi. A comparison of skeletal traction and intramedullary nailing in a low resource setting.
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Introduction: The incidence of femoral shaft fractures in Low- and Middle-Income Countries(LMICs) ranges from 15.7 to 45.5 per 100,000 people per year. A recent study in Malawi, a low-income country (LIC), estimated the national incidence of femoral shaft fractures to be 26.5 per 100,000 people per year, and the prevalence at 1.38 per100,000 population. The femur is one of the principal weight-bearing bones in the body. Hence fractures of the femoral shaft affect weight bearing and mobility, which in turn affects various aspects of quality of life. Furthermore, these fractures occur frequently in the economically productive age group resulting in varying degrees of economic loss both for the patients, their families and the nation. The overall aim of this thesis was to compare the quality of life and functional status of adult patients with femoral shaft fractures treated with intramedullary (IM) nailing and skeletal traction. Methods: This thesis is based on 4 studies. The first study assessed the clinimetric properties of the Chichewa EQ-5D-3L questionnaire. The questionnaire was administered to a sample of adult patients with both traumatic and non-traumatic musculoskeletal conditions. The second study translated and culturally adapted the English Short Musculoskeletal Function Assessment (SMFA) questionnaire into Chichewa using the multi-step linguistic validation (LV) method. The clinimetric properties of the Chichewa SMFA were then assessed by administering the questionnaire to adult patients with both traumatic and non-traumatic conditions. The third study assessed quality of life and functional status in adult patients with femoral shaft fractures treated with either IM nailing or skeletal traction. Quality of life and functional status were assessed using the Chichewa EQ-5D-3L and SMFA questionnaires respectively. Assessment was done at 6 weeks, 3 months, 6 months, and 1-year post injury. The fourth study assessed the cost-effectiveness of the two treatment modalities from both the government health care payer and societal perspectives. The time horizon was 1-year. This was a cost utility analysis where QALYs were calculated from EQ-5D-3L index scores and direct treatment costs calculated using time and motion analysis were obtained from a prospective costing study. Indirect costs included patient lost productivity, and patient transportation, meal, and childcare costs associated with hospital stay and follow-up visits. Results: Both the Chichewa EQ-5D-3L and SMFA versions were found to demonstrate adequate validity, internal consistency, floor/ceiling effects, and reliability. Hence, they were found to be valid and reliable tools for measuring quality of life and functional status in patients with musculoskeletal conditions in populations where Chichewa (or Chinyanja) is the primary language. Patients treated with IM nailing had better quality of life and function at 6 weeks, 3 months and 6 months after injury, compared to those treated with skeletal traction. The study also found that IM nailing patients returned to work earlier than skeletal traction patients. There were no differences in quality of life and function at 1-year post injury. However, 30% of skeletal traction patients converted to IM nailing due to failed treatment; these would have ended up with poor quality of life and function at 1 year if they had continued with skeletal traction treatment. IM nailing was found to be a dominant approach being both cost saving and more effective than skeletal traction. Furthermore, the sensitivity analysis showed more than 90% certainty of the findings. Conclusion: In summary, the studies included in this thesis have established that the Chichewa EQ-5D-3L and SMFA questionnaires are valid and reliable tools that can be used to assess quality of life and function respectively, in adults with musculoskeletal problems who use Chichewa as their primary language. IM nailing was associated with better quality of life, better function and earlier return to work, and was more cost-effective than skeletal traction in the treatment of adult femoral shaft fractures.
Has partsPaper 1: Chokotho L, Mkandawire N, Conway D, Wu H, Shearer D, Hallan G, Gjertsen JE, Young S, Lau B. Validation and reliability of the Chichewa translation of the EQ-5D quality of life questionnaire in adults with Orthopaedic injuries in Malawi. Malawi Med J. 2017 June; 29(2):84-88. The article is available in the main thesis. The article is also available at: http://dx.doi.org/10.4314/mmj.v29i2.2
Paper 2: Chokotho L, Lau B, Conway D, Wu H, Shearer D, Mkandawire N, Hallan G, Gjertsen JE, Young S. Validation of the Chichewa Short Musculoskeletal Function Assessment (SMFA) questionnaire. Malawi Medical Journal. 2019;31(1):65-70. The article is available at: https://hdl.handle.net/1956/21878
Paper 3: Chokotho L, Wu HH, Shearer D, Lau BC, Mkandawire N, Gjertsen JE, Hallan G, Young S. Outcome at 1 year in patients with femoral shaft fractures treated with intramedullary nailing or skeletal traction in a low-income country: a prospective observational study of 187 patients in Malawi. Acta Orthop. 2020; 91(6).724-731. The article is available at: https://hdl.handle.net/11250/2735153
Paper 4: Chokotho L, Donnelley C, Young S, Lau BC, Wu HH, Mkandawire N, Gjertsen JE, Hallan G, Shearer D. Cost Utility Analysis of Intramedullary Nailing and Skeletal Traction Treatment for Patients with Femoral Shaft Fractures in Malawi. The article is not available in BORA.