Changing Health Systems One Step at a Time: Former OrACORe/PIVOT Fellow Organizes Ankle Fracture Educational Program in Partnership with Malawian Providers

Former OrACORe/PIVOT and COMET T-32 fellow and current orthopaedic surgery resident Dr. Kiran Agarwal-Harding has been traveling to Malawi for over two years now, adding to his research portfolio on global orthopaedic trauma care. In early October, Dr. Agarwal-Harding traveled there again, this time to Lilongwe with a small team of Boston orthopaedic surgeons, including Dr. George Dyer from Brigham and Women’s Hospital and Dr. John Kwon from Beth Israel Deaconess Medical Center. In partnership with Malawian orthopaedic surgeons, they led an educational conference on ankle fracture for local orthopaedic clinical officers (OCO’s).

Organizers and participants of the ankle fracture conference gathered for a group photo to mark the occasion. Malawian and U.S. orthopaedic faculty worked closely in designing and leading the conference (photo courtesy of Agarwal-Harding).

Ankle Fracture: The Start of a “Vicious Cycle”

Over the course of his many trips to Malawi, Dr. Agarwal-Harding came to see ankle fractures as problematic, both for their prevalence and lack of surgical treatment. “Surgical care is the standard of care for most ankle fractures in the U.S.,” he said. “Going to a place like Malawi and seeing so many ankle fractures treated nonoperatively raised a lot of questions and concerns.”

One case in particular stuck with Dr. Agarwal-Harding. He was invited into the operating room by Dr. Leonard Banza, an orthopaedic surgeon at Kamuzu Central Hospital in Malawi. The patient had a trimalleolar ankle fracture dislocation, “basically a bad ankle fracture with dislocation of the joint.” Ankle dislocation can usually be detected even without imaging and should be treated immediately. This patient’s ankle had remained dislocated for five weeks, though. By the time he made it to the central hospital, it was too late to fix the fracture, and Dr. Banza was left no choice but to fuse the ankle, significantly reducing the patient’s range of motion in that joint.

You enter this kind of vicious cycle. If you don’t take care of things well at the beginning, they become much more complicated, and it’s harder to take care of them later on.

Dr. Agarwal-Harding

“You enter this kind of vicious cycle,” Dr. Agarwal-Harding said. “If you don’t take care of things well at the beginning, they become much more complicated, and it’s harder to take care of them later on. So in fact it’s easier and more efficient for the system if you invest in taking care of these things earlier.”

With further research, Dr. Agarwal-Harding confirmed that ankle fractures were indeed common and treated primarily nonoperatively in Malawi. Why, though, were these patients not getting surgery? Was a lack of resources to blame? A knowledge gap? According to Dr. Agarwal-Harding, both are true. There are certainly issues at the health systems level that lead to resource shortages at different times and places. But there is also a more fundamental difference in the understanding of best practices for ankle fracture treatment. For some cases, Malawian providers would’ve still chosen nonoperative treatment even if resources weren’t limited. “It seemed like there was a mismatch in knowledge of evidence-based guidelines for treatment of ankle fractures between surgeons in the US and surgeons in Malawi,” Dr. Agarwal-Harding said.

Orthopaedic Clinical Officers: On the “Frontlines of Orthopaedic Care”

These findings and his own experience in Malawian clinics and operating rooms inspired Dr. Agarwal-Harding to organize an educational conference on ankle fracture identification and treatment. When deciding who the target audience for this educational intervention should be, OCO’s were the obvious answer.

There are less than a dozen orthopaedic surgeons in Malawi serving a population of nearly 20 million — OCO’s help to balance these numbers. Established in the 1980’s as a solution to the problem of unmet need for orthopaedic and trauma care, OCO’s are trained in basic nonoperative care for musculoskeletal conditions and traumas, though some can do wound debridements and amputations as well.

“They manage 90 percent of orthopaedic trauma in the country,” Dr. Agarwal-Harding said. “For some of the older OCO’s, they’ve been in the district hospitals longer than the orthopaedic surgeons have.” And, in practice, they do more than just manage orthopaedic trauma. In many district hospitals, OCO’s are the only staff trained in trauma care. “Any poly-trauma that comes in — they could have a head injury, an abdominal injury, all these different things — it’s the OCO who’s there managing all of it.”

If you, as a complete foreigner, go to a country, drive around, assess the capacity, write a paper, and try to make a change, that change won’t happen.

Dr. Agarwal-Harding

Because of the high volume and complexity of cases they see, OCO’s are under a lot of pressure, Dr. Agarwal-Harding said. “You get OCO’s who have spent years and years out there working in these conditions without a lot of resources but who are dedicated to providing whatever care they can,” he said. “What little we can do is provide education and advocacy for what they do. We can provide support and be there for them.”

OCO’s weren’t only the audience for Dr. Agarwal-Harding’s educational conference but were also co-creators, in a way. From the beginning, stakeholder involvement in designing the conference was a priority. “If you, as a complete foreigner, go to a country, drive around, assess the capacity, write a paper, and try to make a change, that change won’t happen,” Dr. Agarwal-Harding said. “The people that should be contributing the insights are not being identified or included in the process.” And so, OCO’s and Malawian orthopaedics faculty members were integral in providing contextual information for and designing the conference.

The Conference: “Slowly Moving the Needle”

The conference began with a knowledge assessment, taken by all 61 of the OCO’s in attendance. The multiple-choice test was closed-book and a surprise to attendees. It covered anatomy, injury identification, and treatment recommendation as they relate to ankle fractures. The rest of the day was spent sharing the data that led to the creation of the conference and the impact its organizers hoped it would have.

The day was filled with lectures on topics ranging from reading x-rays to managing open fractures, case-based group discussions, and practical tutorials, such as a splinting workshop. Each module was designed in partnership with orthopaedics faculty in Malawi and informed by prior research. “Using all these data we collected, we could use evidence to create an effective module that was addressing the knowledge gaps that we knew existed and was feasible within the context of Malawi,” Dr. Agarwal-Harding said.

The highlight of the course, though, was a standardized protocol for ankle fracture treatment, jointly developed by the U.S. and Malawian faculty and printed on pocket-sized water-resistant paper. Every OCO in attendance was given copies to bring back to their hospitals. (In fact, all materials, including case-study packets, drills, and textbooks, were given to the OCO’s to share with their hospitals.)

I think we moved the needle. It’s not a complete transformation, but I think this is a change we should be proud of.

Dr. Agarwal-Harding

Before heading home, the OCO’s were given a post-conference assessment, the same test they’d taken prior to the ankle fracture module. Everyone who had taken the first assessment took the second one, and more than 80 percent improved their scores. The average change in score was an 11-percent improvement, with scores going up by as much as 20 points on the 49-question test. Improvement was greatest among OCO’s with less than 10 years of experience and those in the first and second quintiles (with the lowest scores) for the baseline assessment.

For Dr. Agarwal-Harding, these results translate into improved care of ankle fracture in Malawi. “I think we moved the needle,” he said. “It’s not a complete transformation, but I think this is a change we should be proud of.”

His work is far from done, though. Dr. Agarwal-Harding has plans to return to Malawi in the coming year and give a refresher course and follow-up assessment to the OCO’s who attended the conference. He’s also planning to assess adherence to the standardized protocol that was distributed.

Beyond ankle fractures in Malawi, Dr. Agarwal-Harding hopes to expand this educational approach to other orthopaedic injuries and countries. Through implementing and evaluating interventions, he hopes to bring lasting change. “That’s the whole purpose,” he said. “This iterative process is how you change a system.”