title: Referral patterns and predictors of referral delays for patients with traumatic injuries in rural Rwanda.
abstract: In developing countries, 9 out of 10 patients lack access to timely operative care. Most patients seek care at district hospitals that often lack operative capacity, creating a need for referral. Delays in referrals contribute to substantial disability and death. This study assessed the predictors of delayed referrals for injured patients.
  
  
  
  This retrospective cohort study included injured patients, recommended for referral between January 1, 2013, and December 31, 2013, from 3 rural district hospitals in Rwanda. We defined delay as nonexecution of referral 2 days after referral recommendation. We performed a multivariate logistic regression using stepwise backward selection to identify the predictors of delayed referral.
  
  
  
  Of the 1,227 injured patients, 23.0% (n = 282) were recommended for referral. Of these, 36.5% (n = 103) had road traffic injuries and 53.6% (n = 151) were diagnosed with closed fractures/dislocation. Among 231 patients, 108 (46.8%) had a delay in referral execution. The predictors of delay included age >35 years (odds ratio = 2.45, 95% confidence interval: 1.09-5.50), closed fractures/dislocation (odds ratio = 16.37, 95% confidence interval: 3.13-85.78), admission to surgical wards (odds ratio = 10.25, 95% confidence interval: 2.70-38.82), and a duration ≥7 days from admission to referral recommendation (odds ratio = 4.80, 95% confidence interval: 1.38-16.63).
  
  
  
  Over 50% of referrals were completed in a timely fashion due to a strong referral system and a patient support program. Empowering district hospitals with trained staff and appropriate equipment could reduce the need for referral, and increasing surgeons at referral hospitals could reduce referral delays.
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda. Electronic address: theonkrz@gmail.com.
authors.forename: Theoneste
authors.initials: T
authors.lastname: Nkurunziza
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA.
authors.forename: Gabriel
authors.initials: G
authors.lastname: Toma
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.
authors.forename: Jackline
authors.initials: J
authors.lastname: Odhiambo
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA; Department of Surgery, University of California, San Francisco, CA.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Maine
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Boston, MA; University Teaching Hospital, Kigali, Rwanda.
authors.forename: Robert
authors.initials: R
authors.lastname: Riviello
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda; Brigham and Women's Hospital, Boston, MA.
authors.forename: Neil
authors.initials: N
authors.lastname: Gupta
authors.affiliation: Ministry of Health, Kigali, Rwanda.
authors.forename: Caste
authors.initials: C
authors.lastname: Habiyakare
authors.affiliation: Ministry of Health, Kigali, Rwanda.
authors.forename: Tharcisse
authors.initials: T
authors.lastname: Mpunga
authors.affiliation: University Teaching Hospital, Kigali, Rwanda; University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda.
authors.forename: Alex
authors.initials: A
authors.lastname: Bonane
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA.
authors.forename: Bethany
authors.initials: B
authors.lastname: Hedt-Gauthier
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D003906:Developing Countries; D005260:Female; D006760:Hospitalization; D006767:Hospitals, District; D006780:Hospitals, Rural; D006801:Humans; D016015:Logistic Models; D008297:Male; D012017:Referral and Consultation; D012189:Retrospective Studies; D019035:Rural Health Services; D012432:Rwanda; D012959:Socioeconomic Factors; D061665:Time-to-Treatment; D014947:Wounds and Injuries / Q000628:therapy*; D055815:Young Adult