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Hip Fracture Outcomes: Two New Studies

More Evidence Needed on Comparative Effectiveness of Regional vs. General Anesthesia

Newly-published studies by Senior Fellows Mark Neuman, Jeffrey Silber, Rachel Werner, and colleagues have direct implications for the management of hip fractures, which afflict more than 300,000 older adults each year.

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LDI Senior Fellows Mark Neuman, Jeffrey Silber and Rachel Werner.

The first study, published earlier this week in JAMA Internal Medicine, focuses on outcomes in a particularly vulnerable and understudied population: long-term residents of nursing homes, who are at twice the risk of sustaining a hip fracture as community dwellers. This retrospective cohort analysis of more than 60,000 nursing home residents found that 36% died by 180 days after fracture, including about half of all men. The combined risk of death or new total dependence in walking (i.e., never regaining the ability to walk unassisted) was 53.5% within 180 days. In adjusted analyses, the greatest decreases in survival after fracture occurred with age older than 90 years, nonoperative fracture management, and advanced comorbidity. The combined risk of death or new total dependence in walking within 180 days was greatest among patients with very severe cognitive impairment, patients receiving nonoperative management, and patients older than 90 years.

This study both confirms and extends findings from smaller studies. While the risk factors are no surprise, the high probabilities of death and disability have not been previously quantified. The authors discuss the implications for treating hip fractures among nursing home residents:

In particular, the extreme rates of mortality and functional disability documented herein suggest that counseling regarding prognosis for survival and recovery, explicit discussions of goals of care, and aggressive efforts to control pain and other distressing symptoms represent essential components of management for nursing home residents with HF. At the same time, our observation of substantially worse risk-adjusted outcomes among patients receiving nonoperative management suggests that indicated operative fracture treatment may be reasonable even in the presence of advanced comorbidity, cognitive impairment, or baseline functional dependence if it is consistent with patients’ overall goals of care. More generally, our findings emphasize the importance of continued efforts to prevent HFs among nursing home residents, and they stress the need for further research on the potential for quality improvement initiatives, potentially including specialized inpatient geriatric fracture programs, to improve outcomes among nursing home residents who sustain HFs.

In an invited commentary, Ko and Morrison argue that these results support consideration of palliative care at the onset of hip fracture, as a complement to standard postfracture management. They explain:

In the most vulnerable nursing home residents including the oldest-old and those with advanced comorbidity and cognitive impairment, operative management should be considered if it is consistent with the patients’ care goals. However, the decision to pursue operative management needs to be carefully considered in the context of benefits and risks of orthopedic surgery, symptom management, and the patients’ life expectancy. In patients with life-limiting diseases such as advanced dementia, patient-centered comprehensive interdisciplinary palliative and hospice care without concurrent operative management may be a more suitable model of care.

The second study, published yesterday in JAMA, compares surgical outcomes in hip fracture patients receiving general anesthesia vs. regional (i.e., spinal or epidural) anesthesia. This is an extremely well-done retrospective cohort analysis of more than 56,000 hip fracture patients over 50 in New York State hospitals over a seven-year period. It features an innovative “near-far” instrumental variable match that paired patients who lived at different distances from hospitals that specialized in regional or general anesthesia.

They found that 72% of patients received general anesthesia, and 28% received regional anesthesia. Overall, 5.3% of patients died within 30 days. The median length of stay was 6.2 days. The near-far matched analysis of more than 10,000 patient pairs found that regional anesthesia was associated with a significant 0.6 day shorter length of stay. Although the match showed a slightly lower 30-day mortality with regional anesthesia, this finding did not reach statistical significance.

The authors conducted supplementary analyses using a within-hospital match that paired patients who received regional and general anesthesia within the same hospital, and an across-hospital match that paired patients using standard propensity scores. These supplemental analyses confirmed shorter lengths of stay for patients receiving regional anesthesia.

What do we make of these findings? The authors note that the association between regional anesthesia and shorter length of stay could relate to reductions in complications or more effective rehabilitation. The jury is still out on whether the type of anesthesia affects 30-day mortality. Nevertheless, the results of this and other observational studies warrant a randomized clinical trial to provide more definitive evidence about the comparative effectiveness of regional vs. general anesthesia in hip fracture surgery. Current guidelines suggest offering patients the choice of anesthesia type; a clinical trial would yield a critical piece of information to help make that decision.