Regional anesthesia for hip fracture surgery, advocated as a safer alternative to general anesthesia, wasn't associated with fewer deaths after the procedure, a population-based study showed.
The 30-day mortality rate after hip fracture was 5.4% among patients who lived around centers specializing in spinal or epidural blockade plus sedation, compared with 5.8% for those who resided around centers doing general anesthesia for the surgery ( P=0.20 for difference), Mark D. Neuman, MD, of the University of Pennsylvania in Philadelphia, and colleagues found.
A comparison of the two approaches within hospitals using both likewise turned up no significant difference in early survival, the researchers reported in the June 25 issue of the Journal of the American Medical Association.
But analysis of that data from the New York Statewide Planning and Research Cooperative System (SPARCS) did show a modestly shorter length of stay associated with regional anesthesia.
Matched analysis showed 0.6-day's shorter stays among patients near a regional anesthesia-specialized center versus near a general anesthesia-specialized center ( P<0.001).
These findings play into the ongoing debate over what type of anesthesia is best for hip fracture patients more broadly, commented Andrew Rosenberg, MD, chair of anesthesiology at NYU Langone Medical Center in New York City.
'For many years people believed that regional anesthesia was better for patients undergoing elective hip surgery but the literature on type of anesthesia for hip fracture did not indicate any difference in mortality based on type of anesthesia the patient received,' he told MedPage Today.
These findings affirm that the same applies for hip fracture surgery, he noted.
It's good to have options without worrying about compromising patient outcomes, commented Kevin Grant, MD, orthopedic trauma surgeon at Beaumont Health System in Royal Oak, Mich.
'It allows the surgeon and anesthesiologist to work together to chose the best anesthetic for that patient,' he told MedPage Today. 'Different patients have different comorbidities, whether it's heart disease or lung disease, that might preclude one anesthetic option versus another.'
Also, 'some fracture patterns might require more relaxation or it might be a longer case that maybe a regional or spinal anesthetic wouldn't be appropriate for,' he added.
Regional anesthesia has remained in the minority for hip fracture procedures, despite a push from practice guidelines calling for broader use of regional anesthesia for hip fracture surgery as a strategy to improve quality of care and cut postoperative complications, Neuman's group pointed out.
In their retrospective study, regional anesthesia was used for 28% of all 56,729 patients ages 50 and older getting open reduction, internal fixation, hemiarthroplasty, or total hip arthroplasty for hip fracture at general acute care hospitals in New York state from July 1, 2004, through Dec. 31, 2011.
Because less morbidity has been believed to occur with regional anesthesia, the retrospective, observational studies done previously have all faced considerable confounding from nonrandom selection of older and sicker patients for regional anesthesia, the researchers noted.
Neuman's study attempted to get around this limitation with instrumental variable analysis, 'which capitalizes on differences in practice patterns across providers or facilities to approximate the structure of a randomized trial within the setting of an observational study,' the group explained.
Hospitals were categorized as specializing in regional or general anesthesia based on the percentage of their patients with a hip fracture who received regional anesthesia over the full study period.
The 63 out of 159 hospitals reporting anesthesia data to the database who used regional anesthesia for more than the median of one-third of hip fracture surgeries were considered specialized in that approach.
The main analysis matched patients with a near-far instrumental variable, pairing those who lived at different distances from hospitals that specialized in regional or general anesthesia.
That analysis showed a nonsignificant 30-day mortality estimate of risk difference of -1.1% for regional versus general anesthesia (95% confidence interval -2.8 to 0.5).
Early mortality results came out likewise similar between types of anesthesia in supplementary analyses of within and across hospital patient matches.
Supplementary analyses of length of stay showed patients went home slightly earlier after spinal or epidural anesthesia, but with smaller magnitudes of difference than the 0.6 days seen in the main near-versus-far analysis.
While Rosenberg called the study 'well-conducted' and 'an important addition to the literature,' he cautioned about the large number of patients with hip fracture who could not be included in the final data analysis due to no documentation of the type of anesthesia.
'Hopefully in the future, automated record keeping will include all patients with a specific medical issue,' he said.
Other limitations were the single state studied and its retrospective nature, Grant added.
'The next step, if they wanted to, would be use a larger database with more than one state ... a large chart review going across the country,' he suggested.
The study was funded by the Foundation for Anesthesia Education and Research, the National Institute on Aging, and by the National Science Foundation.
The researchers disclosed no relevant relationships with industry.
Primary source: Journal of the American Medical Association Source reference: Neuman MD, et al 'Anesthesia technique, mortality, and length of stay after hip fracture surgery' JAMA 2014; 311(24): 2508-2517.
