American Society of Regional Anesthesia and Pain Medicine August 2016 - 12
Current Research on Anesthesia for Hip Fracture Surgery: Pragmatic
Randomized Trials as a Key Next Step Toward Improving Care
H
ip fractures are a major public health problem in the United
States and around the world, occurring 250,000 times
annually in this country1 and more than1.5 million times
globally.2 Outcomes after hip fracture are poor-at 1 year, 20%-
30% of patients will have died and nearly half of all patients who
were living independently before fracture will have been newly
admitted to a long-term nursing home.3
Outcomes after hip fracture are highly multifactorial. Research
conducted over the past 3 decades has shown patient
comorbidities, prefracture function, cognitive status, and fracture
characteristics to be key determinants of an individual's likelihood
of both functional recovery and survival after fracture.4 Yet, while
anesthesiologists have debated the relative advantages and
disadvantages of common approaches to providing anesthesia for
hip fracture surgery-most typically with spinal anesthesia with
sedation or with general anesthesia-major gaps in evidence
persist in this area, with consequences for patient and provider
decision making about care.
Available randomized trials offer inconclusive evidence of the
relative advantages of spinal versus general anesthesia for hip
fracture surgery; in a Cochrane review of 22 randomized studies
published between 1977 and 2000, Parker and colleagues5
observed spinal anesthesia to be associated with lower rates of
mortality, deep venous thrombosis, and confusion after surgery.
Nonetheless, interpretation of these studies has been limited
by methodologic concerns.
For example, definitions
of key endpoints, such as
postoperative confusion, varied
markedly across studies;
elsewhere, reviewers have
noted that changes in practice
over time may have made
results from these studies less
applicable to choices currently
faced by hip fracture patients.6
studies on this topic share a
common limitation in that they all
may be affected, to a greater or
lesser degree, by selection bias.
Moreover, existing observational
and randomized studies have
largely been unable to assess
key outcomes of importance
to patients, such as recovery
of ambulation, functional
independence, and pain.
Mark D. Neuman, MD, MSc
These limitations in the literature
Assistant Professor of
are reflected in heterogeneity in
Anesthesiology and Critical Care
how anesthesia care is currently
University of Pennsylvania
delivered for patients. In the
Director, Penn Center for
United Kingdom, spinal anesthesia
Perioperative Outcomes Research
represents the primary anesthetic
and Transformation
modality in about half of all hip
Senior Fellow, Leonard Davis
fracture cases, with general
Institute for Health Economics
anesthesia being used in the
Philadelphia, PA
other half.14 The best available
data from the United States
Section Editor: Melanie Donnelly, MD
suggest that regional anesthesia
represents the primary
anesthetic modality for only about 25% of all hip fracture cases.15
In both instances, patterns of anesthesia care vary widely across
hospitals.
"...the extent of heterogeneity that
now exists in current practice highlights
the degree to which more definitive,
randomized trial-level evidence is still
needed to guide care ..."
More recently, retrospective observational studies have emerged
to explore the relative advantages and disadvantages of common
anesthesia techniques for hip fracture surgery. Work published
by my group in Anesthesiology in 2012 suggested potentially
large benefits of spinal versus general anesthesia in terms of
in-hospital mortality and postoperative pulmonary complications,
using administrative health data from New York state.7 Since
then, several other papers, including additional work from our
group, have explored this question with a range of databases and
statistical methodologies. Such work has yielded heterogeneous
findings, with spinal anesthesia being associated with improved
outcomes, compared to general anesthesia, in certain studies,8-10
and similar outcomes in others.11-13 Nonetheless, all retrospective
12
2
What lessons can we take
from these numbers? On the
most basic level, they highlight
a need for better information
to guide practice regarding
anesthesia for hip fracture
care. In a classic definition,
Benjamin Friedman16
characterized "clinical
equipoise" as a state in which "there is a split in the clinical
community, with some clinicians favoring [treatment] A and others
favoring [treatment] B." While individual practitioners may hold
weaker or stronger beliefs about the advantages and disadvantages
of spinal versus general anesthesia,17 the heterogeneity of care
observed in practice argues that an overall state of clinical
equipoise exists regarding the optimal approach to anesthesia for
hip fracture surgery. And while some bioethicists have questioned
the value of equipoise alone as a required criterion for justifying
whether a randomized trial should be done,18 the extent of
heterogeneity that now exists in current practice highlights the
degree to which more definitive, randomized trial-level evidence is
still needed to guide care. Further insights are particularly needed
to characterize differences in the results of anesthesia care with
American Society of Regional Anesthesia and Pain Medicine
2016
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http://www.brightcopy.net/allen/asra/18-04
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http://www.brightcopy.net/allen/asra/16-1
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https://www.nxtbook.com/allen/asra/15-2
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