The state of orthopaedic trauma-related registries in Latin America: benefits, barriers, and bearings

Abstract

Fracture registries offer a valuable means to enhance understanding of musculoskeletal trauma and related care, providing information that may reduce variation in care, optimize efficiency, improve outcomes, and lower costs. Registries enable healthcare authorities to pinpoint areas of concern, such as a rise in fall-related hip fractures among older adults, and to monitor the effectiveness of public health initiatives aimed at preventing fractures, such as fall prevention programs. In addition, registries provide data for research on risk factors, treatment outcomes, and best practices in fracture management, ultimately leading to enhanced treatment protocols and patient care. Registries help identify variations in treatment practices across different hospitals or regions, facilitating the identification of best practices and ensuring all patients receive optimal care. The following article describes the state of registries in Latin America, specifically Argentina, Brazil, Colombia, Ecuador, and Mexico, all members of the International Orthopaedic Trauma Association.

1. Introduction

There is significant variation in the type of fractures treated, methods of treatment including choice of the type of surgical repair, anesthesia techniques, and hospital lengths of stay across countries related to care of musculoskeletal injuries. National fracture registries offer the opportunity to compare how national healthcare systems differ in their approach to management of injured patients, including those with similar clinical challenges. Fracture registries can enhance the understanding of the type and quality of clinical care. Furthermore, registries can inform best practice standards, optimize efficiencies, improve outcomes, and reduce costs. They provide data through which healthcare authorities and physicians identify areas of interest, monitor health programs, and address potential complications associated with injuries and treatments. The following article describes the state of registries in Latin America, specifically Argentina, Brazil, Colombia, Ecuador, and Mexico, all members of the International Orthopaedic Trauma Association (IOTA).

2. Argentina

Argentina does not currently have a mandatory regional or national data collection system concerning the care of fractures, which is now only done at each institution. The existence of institutional registries makes it difficult to share information between different institutions; each registry is designed differently according to what data each institution or orthopaedic service considers relevant.

The obstacles identified as barriers to creating or implementing these registries arise from different facets of Argentina's health system, which is broadly divided into 3 branches: social, public, and private health.¹ The absence of regional or national policy direction as well as lack of coordination between these 3 branches is one of the causes of the absence of national registries. Another area for improvement affecting the formation of registries is many institutions' use of different electronic medical records. A regional electronic system where all the institutions use the same system would be highly beneficial, with each patient having a single clinical history system. All this, combined with the absence of regional and national health policy coordination, hinders the creation and adoption of registries. Another barrier to registries is the requirement for funding by governmental or private financial investors, which is essential to creating, developing, and implementing registries.

Currently, Argentina only has general health registries at the national level, which involve specific population data, such as births and deaths, from which data, such as life expectancy, can be retrieved.² Regarding orthopaedic pathology, specifically fractures, there are various registry initiatives, some under development, and others in progress, with little or low adoption by orthopaedists.

Among those registries under development is the Argentine Hip Fracture Registry (RAFCA).³ This initiative involves multiple national medical associations and has been in development for years. The registry details and how the system will be accessed for data processing or availability have yet to be reported. Another registry related to hip and wrist fractures was developed by the Argentine Association of Orthopedics and Traumatology through its Morbidity and Mortality Committee.^4,5 It is an entirely anonymous registry with deidentified data, consisting of a brief survey that includes different demographic data, types of fractures, treatment, complications, and mortality. One limitation is that it is necessary to enter the association's web page and upload patient data individually. Every institution must perform its data inquiries, so orthopaedists generally conduct their own searches, which can be time-consuming. This registry has no accessibility limitations, and the raw data are available on the same portal. Finally, the results of the data analysis are published in the association's journal, which is freely accessible to anyone who wants to view them.^4,5

The importance and usefulness of generating fracture registries are slowly being understood in Argentina. Although most are still in development, and some are infrequently used, each academic association understands its needs. There is a need for greater coordination and collaboration between the different associations and governmental stakeholders to aid in registry development.

3. Ecuador

The Ecuadorian Healthcare System requires improvements in assisting and monitoring traumatic pathologies, as indicated by high prevalence, incidence, and mortality in trauma patients. The standard for such registries is the Swedish Healthcare System, whose path started in 1970.^6–8 Since then, 10% of orthopaedic trauma cases have been recorded. The 72nd World Health Assembly, which took place in 2019, aimed to overcome some of the main challenges countries face in caring for trauma patients, including lack of organization in prehospital care and in health centers, as well as the lack of safety measures for ER health personnel in hospitals and health centers. This remains a common challenge in many different countries.⁹

In Ecuador, healthcare units involve different entities that offer medical treatment services, distributed in the public and private sectors. These units are classified into level I (health centers), level II (primary hospitals), or level III (specialty hospitals) facilities. Surgical services are the most performed treatment in health units nationwide, which comprise 1508 unique areas. Considering all the facilities, those in the coastal region and highlands perform the highest number of surgical cases.¹⁰ As many as 70% of hospital admissions in public sector institutions are related to patients who present to emergency departments. Most admissions occur in the coastal region, followed by the highlands region.¹¹ The available national data include information on mortality rates, which showed a higher prevalence in men as a result of organic diseases (ischemic accidents, 11.2%), homicides (9.2%), and traffic accidents (7.1%), with an increase in incidence between the ages 18 and 29 years. The most significant number of deaths was registered in the Coastal region, representing 53.6% of the total number of deaths, and the highlands, representing 38.1% of the deaths.¹¹ Low-income and middle-income countries, Ecuador among them, seek to standardize data and attention to neurotrauma throughout the LATINO registry.¹²

A current, updated Ecuadorian medical registry that allows doctors nationwide to identify data variables, indicators, inclusion criteria, and specific and standardized data depictions related to orthopaedic trauma is essential, but unfortunately lacking. This registry would help measure the effectiveness of implemented treatments to improve the trauma care delivered and decrease mortality rates.

In Ecuador, a Trauma Registry would ideally be organized in association with the Sociedad Ecuatoriana de Ortopedia y Traumatología. To do so, it is necessary to legislate to obtain a private or public budget to implement and maintain programs to collect quality information and to develop plans and strategies to improve the handling of patients suffering from trauma through the entire spectrum of care: prevention, prehospital, hospital, and rehabilitation phases.

4. Colombia

The Colombian health system would benefit from efficient, accurate, and updated health information systems. Although there is legislation aimed at generating this information, such as the General System of Quality Assurance (Resolution 1446 of 2006, Decree 1011 of 2006) and the Surveillance System (Decree 3518 of 2006), it has not yet been possible to create a system that provides reliable and rapid information.^13–16 The official national data registries are limited to contagious diseases such as influenza, measles, COVID-19, and rare diseases such as multiple sclerosis, Guillain-Barre syndrome, and Von Willebrand disease, all of which require mandatory reporting.^17–19

Colombia's Information System for Social Protection has recently been strengthened as an open source of health event information.²⁰ Within this system, the Individual Registry of Health Services is the one most used for research, as it allows access to the primary recorded diagnoses and provides valuable information about the cost of medical care; however, its main limitation is the quality of information. Aside from the primary diagnoses, further clinical information is not accessible. Diagnoses are only recorded once per patient, which makes it suitable for conditions that are unique lifetime events, such as autoimmune diseases, for example, but not for fractures since it does not provide information on whether the fracture is a new or follow-up of a previous event.^21,22

For traumatology or fractures, there are no official, unified, complete, or open national registries for research or public health decision making; there are some institutional registries, scientific associations, or research groups with their own registries, but they are very limited in terms of accessibility and number of included patients due to not having a national scope. One such initiative is the National Registry of Hip Fractures due to Fragility, which was started in September 2023. Currently, only 3 health institutions from 3 different cities in the country are providing patient data, although other hospitals and clinics are in the process of joining. The Colombian Association of Osteoporosis and Mineral Metabolism initiated the project, and data are collected as specified by the Global Fragility Fracture Network Hip Fracture Audit Special Interest Group publication in 2022. This effort emerged as a continuation of the Colombian fragility fracture multicenter study published in 2021 under the leadership of the same association.^23,24 The registry includes 22 variables that encompass demographic variables (age, sex, origin, and place of residence), history of fragility fracture, osteoporosis treatment at the time of the fracture, preinjury ambulatory function, use of prefracture walking or cognitive assistive devices, date of fracture, diagnosis or type of fracture, American Society of Anesthesiology classification, date and type of surgery received, complications, treatment at discharge, mortality, date of discharge, and whether there was follow-up. For now, no summary reports have been reported with the data collected.

An internal survey was conducted and sent to the boards of directors of the affiliated societies of the Colombian Society of Orthopaedic Surgery and Traumatology to establish the importance, but also the knowledge, of national health registries related to orthopaedics. This questionnaire specifically aimed to gather opinions on key elements that such registries should include, determine whether registries existed in areas of orthopaedics other than trauma, and identify if these affiliate societies were participating in international registries. Thirty-six individuals participated. Sixty-two percent of the specialists responded that they were aware of international orthopaedic subspecialty registries, including those for anterior cruciate ligament injuries, joint replacement, and others. In descending order of importance, respondents considered the most critical features of a national registry to include the following: standardized patient data collection, outcomes, procedures, and diagnoses (50%); ability to evaluate specific outcomes and clinical, scientific, or research objectives (32%); and record of practices, results, and improvement actions that allow for professional improvements (17.6%). Only 14% are aware of and participate in any national registry, including the Anterior Cruciate Ligament, COMPASS (spine surgery), and congenital upper limb malformations registry. Among the difficulties in creating a registry in Colombia, professionals identified barriers that include a lack of knowledge of the advantages and benefits of registries (42.9%), lack of direction by a regulatory entity (37%), lack of technological tools for development (17%), and National Data Protection Law (2.9%).

In conclusion, in Colombia, national pathology registry systems exist, but they need more functionality and information completeness. Government entities and scientific associations in orthopaedics and traumatology must lead the creation and regulation of novel and official registries within our specialties.

5. Mexico

National audits are born from the need to know about patient management, clinical guideline provider compliance, and treatment results.^25,26 Quality indicators (QI) and standardized clinical instruments can document and evaluate clinical care and guideline application. QI has proven to lower complications and morbidity in the hip fracture patient.²⁶

In México, the estimated incidence of hip fractures in 2006 was 6357 in people older than 50 years. This number increased to 9028 in that population in 2019, an increase of 42%. As reported elsewhere, women are more affected than men in a ratio of 2:1.²⁷ Like in other countries, hip fractures continue to be a public health issue due to the high mortality, which is approximately 12%–27% during the first year.^28,29 A poor functional result is expected in 50% of the patients who cannot return to their prefracture activity levels.^30,31 Only 25% will be able to do their activities of daily living without assistance and another 8% will be institutionalized.^31,32 These data underscore the importance of a national registry for hip fractures in Mexico, where the epidemiology and impact of the condition, documentation of clinical care quality indicators, and compliance with treatment guidelines are recorded. In 2023, a systematic review and meta-analysis were performed, followed by a collaborative position statement by 9 Mexican medical societies. This work is currently under review for publication.

Mexico's national public healthcare services are divided into 7 healthcare systems, each of which cares for a specific subset of the population (those on social security, federal employees, department of defense, and others).³³ Of the 128 million inhabitants, only 117 million have access to public healthcare systems.³⁴ In addition, some systems have restrictive data-sharing privacy policies that do not allow data sharing outside of institutions. Therefore, creating a national universal hip fracture registry in these circumstances is extremely difficult.

Thus, two initiatives are currently under development. The first is through the Mexican Institute of Social Security (IMSS) as the Multicenter Mexican Registry of Hip Fractures IMSS, which is meant to register all hip fractures presenting to the IMSS network. This system treats almost 50% of the Mexican population. The other was led by the Mexican Federation of Orthopedics and Traumatology (FEMECOT) and the other 6 medical societies. This initiative is called REMFRAC: “Mexican Registry of Hip Fractures,” which started as a national registry and now attempts to include the private sector that treats approximately 7% of the cases nationally and other health systems. The goal is to share and publish data from across institutions. The registry, coordinated by FEMECOT, will enable a multicentric observational epidemiologic study with a patient follow-up of 30 days and will include all the low-energy trauma hip fracture patients 65 years and older. REMFRAC used the MCD (Minimum Common Dataset) as a frame for the database and made custom modifications, keeping the 22 essential variables.³⁵ The data fields include 29 multiple-choice questions for the initial assessment and 7 multiple-choice questions for the 30-day follow-up (Table 1).³⁶ An audit committee of 9 members was made, including members from the other 6 societies, and an advisory board will give insight and proposals to the registry committee. The pilot phase started in 10 centers, and the protocol was sent to the national ethics committee for approval.

Table 1.

Variables in the REMFRAC database during the first assessment and 30-day follow-up.

Patient Data	Hospital Management	Hospital Discharge
1. Residence (prefracture)	15. Time from the emergency admission to the surgical management	27. Secondary osteoporosis prevention
2. Number of comorbidities	16. Type of surgical procedure	28. Destination at discharge
3. Low energy fracture after 50 YO?	17. Type of anesthesia	29. Thromboprophylaxis at discharge
4. Time since the last fracture	18. Surgical duration
5. Functional ambulation categories, prefracture	19. Mobilization out of bed in the first 48 h
6. Use of a walking aid device	20. Walk before hospital discharge (before day 4)	Follow-up at day 30
7. Katz index	21. Medical treatment team (select all the involved specialties)	1. Is the patient alive?
8. Previously diagnosed with dementia	22. Did the patient suffer delirium?	2. Did the patient suffer any complication that required hospital stay
9. Prefracture osteoporosis treatment?	23. Pressure ulcers	3. Did the patient suffer a complication that required surgical management
10. ASA preoperative score	24. Did the patient suffer any medical complications?	4. Postfracture mobility functional ambulation categories
11. Fracture type	25. Length of hospital stay	5. Secondary osteoporosis prevention currently
12. Side	26. In-house mortality	6. Did the patient receive fall prevention and physical therapy
13. Pathologic fracture		7. Katz score
14. Incident-associated fractures (at the same time as the hip fracture)

5.1. Multicenter Mexican Registry of Hip Fractures—IMSS

This registry is supported by IMSS as a multicenter, observational, longitudinal study. All patients with a diagnosis of hip fracture are included. Time to surgery of 36 hours from hospital admission was established as the cutoff point for defining surgical delay. The type of fracture and surgery type were documented. The discharge and follow-up variables are the same as in the REMFRAC. The follow-up is documented at 30 and 120 days through medical consultations or phone calls. This registry has included 24 centers, and up to 1042 cases have been reported. In these 24 centers, an orthogeriatric care program called “OrthogeriatrIMSS” is also set to implement the strategies necessary to improve patient outcomes through established quality initiative programs.

In México, several barriers have been found to developing national fracture registries, including hip fracture audits, such as restrictive data sharing policies, the number of health systems, and limited resources. However, some solutions have been identified and used for hip fracture registries. Such solutions include making registries accessible for health systems to capture most hip fracture patients and using data sets with consistent variables to make them comparable and adherable.

6. Brazil

Brazil is the largest and easternmost country in South America and Latin America, with a total population of 212,775,161, according to the Worldometer elaboration of the latest United Nations data.³⁷ The latest World Bank classification ranked Brazil as an upper middle-income country, with a current gross domestic product per capita of US $10,294.9.³⁸ According to the Federal Council of Medicine, Brazil currently has 575,930 active doctors, a proportion of 2.81 professionals for every 1000 people.³⁹ This number has grown 8 times more than the general population since 1990, an increased average of 5 percent a year, compared with an average increase of one percent a year in the general population.³⁹ Despite this optimistic scenario, there needs to be a better distribution of doctors in the country. The average number of doctors per 1000 inhabitants in the capital is 7.03, compared with 1.89 in the countryside.³⁹ This disproportion distribution greatly complicates patient care, generating diagnostic and treatment delays and increasing patient morbidity and mortality, especially in emergencies such as traumatic injuries.

The burden of acute trauma is exceptionally high in Brazil, with traumatic injuries representing the third leading cause of death and 12.5% of deaths from all causes.³³ Between the ages of 1 and 39 years, trauma is the leading cause of death, with a mortality rate of 70.5 cases per 100,000 inhabitants and male sex comprising 83.1% of the deaths.⁴⁰ This makes Brazil the fifth highest death rate in the world due to traffic injuries, with 28% resulting from motorbike accidents.⁴¹ As determined by the Brazilian Federal Constitution and managed by the country's Unified Health System (SUS), responsibility for health is divided between the Ministry of Health (MH), a federal body, the states, and municipalities. In this structure, most of the trauma care in small and medium-sized cities is provided by municipally administered hospitals, without an established or organized trauma registry (TR) or even, sometimes, without standardized care protocols for high-energy trauma patients.^39,42 Therefore, many patients with traumatic injuries are unable to achieve immediate and appropriate management with suitable protocols or be included in trauma registries.

In 2022, the Brazilian MH launched the TRAUMA project (Tecnologia de Rápido Acesso Unificado para Mitigação da Acidentalidade—Unified Rapid Access Technology for Accident Mitigation), a database that gathers data on injuries caused by violence and accidents, and which will enable the creation of management panels with more qualified information. This project emerged within the scope of the Support Program for the Institutional Development of the Unified Health System (Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde—PROADI-SUS), an alliance between 6 reference hospitals in Brazil and the MH.⁴³ The objective is to improve care and support public health policies in managing trauma victims.⁴⁴ Owing to the short period since its implementation, there are still no data to assess the initial results of this registry. Although very localized, other initiatives have been performed in institutions organized to gradually establish health policies and collect data on the traumatic injuries they treat. One of these initiatives took place at Hospital João XXIII, a Brazilian public hospital in Minas Gerais, starting in January 2013.⁴⁵ A TR was implemented, and the initial results of the first 1000 patients were evaluated using its database. The initial data evaluation revealed interesting results, such as aggression being the predominant cause of injuries, causing 47.5% of hospital visits, which surpassed those for traffic accidents. The average length of stay was 6 days, and the mortality rate was 13.7%. Among the most significant difficulties in implementing, the TR were obtaining resources to finance the project and the lack of information in the medical records.⁴⁵

These and other difficulties in establishing the TR, such as high costs, low follow-up rates, and problems with buy-in from surgeons and hospitals, have been highlighted in different studies, which showed an overall small number of trauma registries in developing countries and a significant variation in the data collection and analysis processes.^44,45 Two years ago, Nguyen et al⁴⁶ reported the status of orthopaedic trauma registries in 21 countries represented by 20 member societies of the IOTA. During the study period, Brazil had only one active registry, but not dedicated to high-energy trauma. Furthermore, although the authors showed that the data collected by these records resulted in 1847 publications reported independently of the journal, the SUS Information Technology Department did not make the numbers available in Brazil. This finding corroborates the degree of difficulty and challenges of developing TR in developing countries while also demonstrating the opportunity for this tool to be finally implemented in a country where traumatic injuries are endemic. The situation for registries in Brazil is similar to that of other countries in Latin America. Despite having a high prevalence of intentional and nonintentional injuries, most of the countries in the region lacked public trauma registries, preventing them from quantifying and addressing key problems.

Brazilian medical associations that coordinate both skeletal trauma and nonskeletal trauma face an enormous challenge in the coming years to the development and implementation of nationwide registries. The task is complex, given the discrepancies pointed out at the beginning of this section regarding the poor distribution of doctors across the country and the financial, technological, and human resource gaps between the public systems coordinated by the SUS and private supplementary healthcare systems. Despite the difficulties and obstacles recognized in advance, these registries should emerge soon.

7. Conclusions

There needs to be an adequately established fracture registry in the various countries representing Latin America. The most developed registries are those for hip fractures, which are critical given the injury's socioeconomic consequences. Hip fractures serve as an ideal condition to audit the care of geriatric populations. The region's most significant barriers are coordination between public and private health sectors, a healthcare system needing more electronic resources to capture data, a shortage of personnel for data entry and analysis, and orthopaedists' unawareness of the benefits of having registry systems. National registries provide a unique opportunity to compare how different countries' healthcare systems respond to the same clinical conditions. Establishing standard norms and data sets would benefit the orthopaedic trauma community greatly, and registry development represents challenges to academic societies and government agencies to facilitate their development.