Skip to main content

The influence of mode of anaesthesia on perioperative outcomes in people with hip fracture: a prospective cohort study from the National Hip Fracture Database for England, Wales and Northern Ireland

Abstract

Background

Delirium is common after hip fracture surgery, affecting up to 50% of patients. The incidence of delirium may be influenced by mode and conduct of anaesthesia. We examined the effect of spinal anaesthesia (with and without sedation) compared with general anaesthesia on early outcomes following hip fracture surgery, including delirium.

Methods

We used prospective data on 107,028 patients (2018 to 2019) from the National Hip Fracture Database, which records all hip fractures in patients aged 60 years and over in England, Wales and Northern Ireland. Patients were grouped by anaesthesia: general (58,727; 55%), spinal without sedation (31,484; 29%), and spinal with sedation (16,817; 16%). Outcomes (4AT score on post-operative delirium screening; mobilisation day one post-operatively; length of hospital stay; discharge destination; 30-day mortality) were compared between anaesthetic groups using multivariable logistic and linear regression models.

Results

Compared with general anaesthesia, spinal anaesthesia without sedation (but not spinal with sedation) was associated with a significantly reduced risk of delirium (odds ratio (OR)=0.95, 95% confidence interval (CI)=0.92–0.98), increased likelihood of day one mobilisation (OR=1.06, CI=1.02–1.10) and return to original residence (OR=1.04, CI=1.00–1.07). Spinal without sedation (p<0.001) and spinal with sedation (p=0.001) were both associated with shorter hospital stays compared with general anaesthesia. No differences in mortality were observed between anaesthetic groups.

Conclusions

Spinal and general anaesthesia achieve similar outcomes for patients with hip fracture. However, this equivalence appears to reflect improved perioperative outcomes (including a reduced risk of delirium, increased likelihood of mobilisation day one post-operatively, shorter length of hospital stay and improved likelihood of returning to previous residence on discharge) among the sub-set of patients who received spinal anaesthesia without sedation. The role and effect of sedation should be studied in future trials of hip fracture patients undergoing spinal anaesthesia.

Peer Review reports

Background

Over 70,000 hip fractures occur each year in the United Kingdom (UK) and almost all receive urgent surgery [1]. These often frail, older patients face substantial morbidity; 6–10% die within 1 month [1] or experience reduced health-related quality of life [2]. The commonest post-operative complication is delirium, often under-detected despite its deleterious effect on patient experience and recovery [3,4,5]. Delirium occurs in between a quarter and half of patients [1, 6, 7]. People with hip fractures commonly require prolonged admissions, are often less mobile than pre-operatively and need more care post-discharge. Patients recovering from hip fracture occupy over 4000 hospital beds in the UK [8], with annual hospital costs of £1.1 billion (1% of the National Health Service (NHS) budget) [9].

Surgery can be performed under general or regional (usually spinal) anaesthesia. A Cochrane analysis of 28 randomised controlled trials (RCTs) (n=2976) [10], highlighted low-quality evidence and no difference between general or spinal anaesthesia for 30-day mortality, pneumonia, myocardial infarction, cerebrovascular accident, and acute confusional state [10]. Trials were noted to not reflect current practice; patients were often sedated before spinal anaesthesia but this was not considered in analyses. Observational studies report contrasting findings regarding mortality, readmissions, complications, and length of stay [11,12,13,14,15,16,17]. Most studies have limited detail on anaesthesia technique and co-interventions (e.g. sedation), and focus on outcomes 30 days or more after surgery, rather than on important, distressing short-term outcomes like post-operative delirium. The recent Regional versus General Anesthesia for Promoting Independence after Hip Fracture (REGAIN) study [18] found no difference in outcomes, including delirium, when patients with hip fracture were randomised to general or spinal anaesthesia, but the effects of sedation were not examined within this RCT.

The National Institute for Health and Care Excellence (NICE) have made a high-priority recommendation for a three-arm RCT to compare general anaesthesia versus spinal anaesthesia without sedation versus spinal anaesthesia with sedation on postoperative outcomes after hip fracture [19]. In addition, the fragility fractures James Lind Alliance priority setting partnership, undertaken by patients and healthcare professionals, highlighted two important research questions for hip fracture patients (identifying the optimal pain relief during anaesthesia and post-operatively; and finding the best treatments to prevent/treat delirium post-operatively) [20, 21].

The National Hip Fracture Database (NHFD) for England, Wales and Northern Ireland is a mandatory national clinical audit of hip fracture care, with hospitals continually assessed against Key Performance Indicators (KPIs) [1]. These include two measures of acute peri-operative care: success in getting patients out of bed by the day after surgery and post-operative delirium assessment. These important short-term outcomes are missing from previous observational data and RCTs [10], including recent trials [22, 23]. Delirium is a common complication of surgery in frail and older people, distressing to patients, family and carers, and associated with increased mortality or institutional care placement. The 4 ‘A’s Test (4AT) is a rapid delirium screen, in patients with or without cognitive impairment, and can predict immobility, prolonged length of stay, mortality and change in residence on discharge [6].

The NHFD dataset includes details of casemix including an admission cognitive assessment (Abbreviated Mental Test Score (AMTS)) and details of the care, fracture type, surgery and anaesthesia. We hypothesised that mode of anaesthesia would be associated with risk of post-operative delirium. We used the NHFD to assess the effect of spinal anaesthesia (with and without sedation) and general anaesthesia on early postoperative outcomes, including delirium and mobilisation by the day after surgery, and other relevant postoperative outcomes including length of stay, discharge destination and 30-day mortality.

Methods

Study design and data sources

A prospective cohort study was performed using NHFD data. It contains data on over 97% of all hip fractures in patients aged 60 years or above in England, Wales and Northern Ireland [1]. These include patient characteristics, hip fracture type, surgery, details of the care patients receive and relevant outcomes. Data are collected and submitted by clinical teams in 175 trauma units. Patients’ details and NHS number are passed to the NHS Personal Demographics Service, which provided the date of death from the Office for National Statistics (ONS).

The Healthcare Quality Improvement Partnership (HQIP) is commissioned by NHS England to commission and manage the National Clinical Audit and Patient Outcomes Programme (NCAPOP). As part of this programme, the NHFD is a quality improvement initiative commissioned by HQIP/NHS England. NHFD data is collected under section 251 of the NHS Act 2016 following approval by the Health Research Authority (HRA) Confidentiality Advisory Group (CAG 8-03(PR11)/2013). Only pseudonymised data are sent to the University of Oxford for this project. This research project was reviewed by HQIP and approved as an extended analysis and output of the NHFD clinical audit programme. Ethical approval was not sought in line with Governance Arrangements for Research Ethics Committee (GAfREC) guidance for this secondary analysis of administrative data.

Study selection criteria

We included patients who presented over a 2-year period (1st January 2018 to 31st December 2019; n=135,685). The following exclusions were made: (1) patients who did not undergo surgery (n=2748); (2) patients who received anaesthesia other than the defined exposures (see below; n=7977); (3) patients with missing data for one or more of the covariates (n=17,932). After these exclusions, there were 107,028 patients (58,727 (55%) general anaesthesia and 48,301 (45%) spinal anaesthesia) available for the complete case analysis (Fig. 1). For each individual analysis of the outcomes of interest, patients were excluded if they did not have data available for that outcome (Fig. 1).

Fig. 1
figure 1

Study selection criteria using data from the National Hip Fracture Database for England, Wales and Northern Ireland during 2018–2019

Exposure

The NHFD collects data on anaesthesia type, including the use of sedation and nerve blocks. The data available for both of these variables are binary; for example, the patient either did or did not receive sedation. The primary anaesthetic exposure of interest was binary: general or spinal anaesthesia (with or without sedation). Patients who received both general and spinal anaesthesia were excluded, as were any who received epidural anaesthesia [24]. These primary anaesthetic groupings made no distinction regarding the use of nerve blocks (which were adjusted for in the statistical models).

Covariates

Potential confounding factors for the outcomes being assessed were chosen a priori to be adjusted for in the subsequent analyses [8, 11, 25,26,27,28]. These covariates were patient age at surgery, sex, American Society of Anesthesiologists (ASA) physical status, year of presentation to hospital, fracture type, pathological fracture or not, hospital geographical region, pre-injury residence from which patient was admitted, cognitive state (admission AMTS), pre-injury mobility, whether the patient received a nerve block in the Emergency Department or on the ward pre-operatively, time from admission to theatre, grade of senior surgeon in theatre, grade of senior anaesthetist present in theatre, the use of a nerve block in theatre, and operation performed. The NHFD uses ASA physical status rather than a measure specifically focused on frailty. The ASA physical status ranges from 1 (healthy patient) to 5 (moribund patient not expected to live for more than 24 h with or without surgery) [29]. AMTS is scored from 0 to 10 and grouped according to clinically relevant classifications (0 to 7 represents abnormal cognition, and 8 to 10 represents normal cognition) [30].

Outcomes

Outcomes of interest included postoperative delirium in the week after surgery, mobilisation by the day after surgery, length of acute hospital stay, discharge destination, and 30-day mortality. The result of a delirium assessment performed using the 4AT score [31] in the week after surgery is a KPI for the NHFD. The 4AT score ranges from 0 to 12; a score of 0 suggests unlikely delirium or cognitive impairment; 1 to 3 suggests possible chronic cognitive impairment without excluding the possibility of delirium; 4 or more suggests delirium with or without chronic cognitive impairment [6, 31].

The 4AT score is calculated from the summation of its 4 subscales: alertness (scored 0=normal, with mild sleepiness for <10 seconds after waking, or 4=abnormal), Abbreviated Mental Test 4 (AMT4) (0=no mistakes; 1=one mistake; 2=two or more mistakes or untestable), attention (0=reciting ≥7 months backwards correctly; 1=starts but lists <7 months or refuses to start; 2=untestable), and acute change or fluctuating course (0=no or 4=yes). The AMT4 tests for recall of age, date of birth, place (name of hospital or building) and current year. Attention is tested by instructing the patient to list months in reverse order, starting from December. Acute change or fluctuating course is the evidence of significant change or fluctuation in mental status within the last 2 weeks and persisting in the last 24 h.

Statistical analysis

Analyses were conducted using STATA version 15.1 (StataCorp, TX, USA), with 95% confidence intervals (CIs). Descriptive statistics were used to summarise patients’ demographic and clinical factors stratified by the anaesthesia exposure variable. The standardised mean difference (SMD) for each covariate by anaesthetic type was used to measure covariate imbalance. SMDs of 0.10 or more for any covariate were suggestive of imbalance [32, 33], with only one covariate (pre-operative cognitive state) having evidence of imbalance (Table 1).

Table 1 Baseline characteristics of hip fracture patients treated in England, Wales and Northern Ireland during 2018–2019, as recorded in the National Hip Fracture Database

Multivariable regression models were used to assess the effect of anaesthesia on each outcome of interest. All regression models were a priori adjusted for the covariates described above, including admission AMTS, with analyses conducted using a complete case analysis. For delirium, analyses were performed using the 4AT score (grouped 0, 1 to 3, and 4 or more). Additional file 1: Appendix 1 details the types of regression models used for each outcome, tests of assumptions and sensitivity analysis.

Results

General anaesthesia versus spinal anaesthesia (Tables 2 and 3)

In the adjusted regression models, use of spinal anaesthesia was associated with a significantly reduced odds of delirium (4AT), when compared with general anaesthesia (odds ratio (OR)=0.96, 95% CI=0.94–0.99; p=0.007). More patients returned to their original residence with spinal anaesthesia (OR=1.04, CI=1.01–1.06; p=0.013), which also had a significantly shorter length of hospital stay (coefficient −0.46 days, CI= −0.66 to −0.26 days; p<0.001). There were no differences in mobilisation by the day after surgery (OR=1.02, CI=0.99–1.06; p=0.156), or in 30-day mortality (OR=1.03, CI=0.98–1.09; p=0.248).

Table 2 Outcomes of hip fracture patients after surgery by anaesthetic type for those treated in England, Wales and Northern Ireland during 2018–2019, as recorded in the National Hip Fracture Database
Table 3 Multivariable regression analysis results for the effect of anaesthetic type (general anaesthetic vs. spinal anaesthetic) on outcome following surgery for hip fracture patients in England, Wales and Northern Ireland during 2018-19, as recorded in the National Hip Fracture Database

General anaesthesia versus spinal anaesthesia without sedation versus spinal anaesthesia with sedation

The above adjusted regression analyses were repeated with the spinal anaesthesia group subdivided into those who did and did not receive sedation; 58,727 (55%) received general anaesthesia, 31,484 (29%) received spinal without sedation, and 16,817 (16%) received spinal with sedation. Baseline characteristics (Additional file 2: Table S1) and outcomes (Additional file 2: Table S2) for these three different anaesthetic exposure groups are provided. In most cases, the beneficial clinical effects associated with spinal anaesthesia (compared with general anaesthesia) in the previous analyses were only seen in the sub-group of patients who received spinal anaesthesia without sedation (Table 4).

Table 4 Multivariable regression analysis results for the effect of anaesthetic type (general anaesthetic vs. spinal anaesthetic with no sedation vs. spinal anaesthetic with sedation) on outcome following surgery for hip fracture patients in England, Wales and Northern Ireland during 2018–2019, as recorded in the National Hip Fracture Database

Compared with general anaesthesia, spinal without sedation (but not spinal with sedation) was associated with a 5% reduced odds of delirium (OR=0.95, CI=0.92–0.98; p=0.001), a 6% increased odds of mobilisation by the day after surgery (OR=1.06, CI=1.02–1.10; p=0.004), a 4% increased odds of return to original residence (OR=1.04, CI=1.00–1.07; p=0.025), and a significantly shorter length of hospital stay (without sedation coefficient −0.45 days, CI= −0.68 to −0.23 days, p<0.001; with sedation coefficient −0.48 days, CI= −0.77 to −0.19 days, p=0.001). To illustrate the differences observed in length of hospital stay, if the 58,727 patients receiving general anaesthesia had actually received spinal anaesthesia without sedation, this may have potentially reduced the total length of hospital stay for these patients by 26,427 days (CI 13,507 to 39,934 days), which we would consider to be of clinical importance. There were no differences observed in 30-day mortality between the three groups. Additional file 1: Appendix 1 provides more information on the results of the sensitivity analysis.

Discussion

Whether mode of anaesthesia has a causal role in differences in outcomes following hip fracture surgery remains controversial. A Cochrane review reported no difference between general or spinal anaesthesia, but emphasised the available evidence was low quality with trials not reflecting current clinical practice [10]. Large observational studies have been limited by the heterogeneous nature of the spinal anaesthesia group, and have focussed on outcomes 30 days or more after surgery [11,12,13,14,15,16,17]. Such time frames for outcome assessment when assessing the effect of anaesthesia are no longer considered relevant by national clinical bodies, with a preference for more immediate, temporally related, and plausible perioperative outcomes such as post-operative delirium [34].

Delirium is the commonest complication of hip fracture and is associated with increased mortality, morbidity and healthcare costs [1, 6, 7]. Despite this it is often under-recognised. Little is known about how anaesthesia effects delirium especially in the short-term [10], although a recently completed trial in China is using delirium within 7 days of hip fracture surgery as the primary outcome and will help address this [35]. The recent REGAIN trial provides powerful reassurance that the choice of general or spinal anaesthesia is something that anaesthetists and their patients can safely decide between themselves, since neither approach had significantly better outcomes, including risk of post-operative delirium [18].

Our work has demonstrated that compared with general anaesthesia, the use of spinal anaesthesia without sedation was associated with a significantly reduced risk of delirium reflecting improved scores in the 4AT domains of ‘Alertness’ and AMT4 (four items testing orientation in time and place) [31], but not those of ‘Attention’, and ‘Acute change’. The observed delirium risk was reduced by 5% (CI=2% to 8%) with spinal without sedation (compared with general anaesthesia), which we consider to be of clinical relevance given that only 30% of patients currently receive spinal without sedation in this frail population, and especially given the known morbidity associated with delirium. Our work therefore suggests that spinal without sedation may therefore be the regimen most suitable for patients with hip fracture. Both a Cochrane review [10] and NICE [19] have previously postulated that the use of sedation with spinal anaesthesia may affect outcomes after hip fracture surgery. It was noted that previous trials often included patients sedated before spinal anaesthesia, which might reduce any short-term benefits [10].

Recent work demonstrated that the 4AT predicts a number of adverse outcomes following hip fracture surgery, including immobility, prolonged length of hospital stay, and change in residence on discharge [6]. The improvements seen for these outcomes in the spinal without sedation group of our study may reflect the reduced risk of delirium that we observed in these patients. These clinical benefits should not be underestimated in the frail and vulnerable hip fracture patient population. Immobility is associated with significant morbidity and often mortality, including pulmonary and urine sepsis, pressure ulcers, and venous thromboembolism [36, 37], therefore prompt mobilisation after surgery is extremely advantageous. Shorter hospital stay and successful return to pre-admission residence have substantial resource and financial implications for healthcare systems as well as benefits for patients who return to familiar surroundings. Our data suggests the potential reduction in length of hospital stay would be of clinical importance and have the potential for large healthcare savings.

A study strength is the granularity of NHFD observational data, which was lacking in previous observational studies. This includes examining the specific effect of using sedation with spinal anaesthesia; adjusting the analysis for important and clinically relevant variables including fracture classification and pre-operative residence, cognition, and mobility; and assessing important early post-operative outcomes reflecting the quality of acute peri-operative care, including post-operative delirium (including the 4AT subscales) and mobilisation on post-operative day-one. This provided a unique opportunity to examine the effect of anaesthesia on post-operative outcomes in a large population, which captures over 97% of all hip fractures nationwide. Using a nationwide cohort also helps increase the external validity and generalisability of our findings.

A limitation of this work is that causality cannot be inferred from observational data. The reduced risk of delirium in patients receiving spinal anaesthesia without sedation compared with general (22% vs. 28% having 4AT score of 4 or more), suggests an interaction between anaesthesia choice and early delirium following hip fracture surgery. The NHFD data does not collect information regarding why each anaesthetic method was selected, about the specific anaesthetic administered (drugs, dose, depth of sedation), the length of operation and anaesthesia, or the use of specific sedative, opioid or other analgesic agents; factors which may all influence outcomes. We adjusted our models for numerous patient and surgical factors relevant to hip fracture patients including their ASA physical status and admission cognitive status (AMTS); however, we were unable to adjust for other potentially important variables (e.g. frailty and specific medical comorbidities) or unknown confounders.

A research study specifically designed to examine influences on the incidence of delirium would ideally use multiple assessments on each shift of each post-operative day [38]. Any national audit collecting data on 70,000 people a year must be pragmatic and limit the data collection burden on clinical staff, and the NHFD confines its recording of post-operative delirium assessment to the results of a single 4AT in the week following surgery. We recognise that this inevitably means that some episodes of delirium will have been missed from our analysis. Therefore we cannot comment on the severity or duration of delirium in each case, however, this should not affect our comparison of different anaesthetic approaches when exploring the NHFD dataset.

Missing data for some variables may have influenced the findings. We cannot rule out whether patient factors are the link between use of sedation and adverse outcomes (an agitated patient might be more likely to receive sedation and more likely to have adverse outcomes), or anaesthetist factors (anaesthetists who routinely avoid sedation may provide, or work within teams that provide, conditions less likely to result in adverse outcomes). Data from Canada [39, 40], and the inter-unit variation seen within NHFD suggest that patient factors are not as important as hospital and anaesthetist tradition and preference. The Steroids To Reduce the Impact on DElirium (STRIDE) randomised trial compared two levels of propofol sedation in older people having spinal anaesthesia for hip fracture surgery and found no difference overall [5]. However, this did not answer the question of whether avoiding sedation entirely makes a difference. Until formal trials of sedation versus no sedation are performed we are left with suggestive but inconclusive evidence of benefit.

Sedation was not examined in the REGAIN study [18] but common practice was to provide some sedation. The regional with general anaesthesia on postoperative delirium (RAGA-delirium) study avoided sedation in the regional anaesthesia arm. Results suggest no difference in rates of delirium, albeit with very low rates (5-6%) [41]. The iHOPE study does not preclude sedation but does advocate avoidance of deep levels of sedation [22, 23, 35].

The role and outcomes of sedation will require further assessment in ongoing trials, and the future trials recommended by NICE [19]. Our work helps to inform the planning of such studies. However, the effect size that we demonstrate suggests that such studies will need to be very large. A conservative estimate of trial size to demonstrate a reduction in delirium from 30% to 25% is of the order of 1700 participants per group. This means that such an RCT will be challenging to justify and run in the UK, unless it could be embedded within a well-established prospective cohort study [42] that is representative of the general hip fracture population [43].

Conclusions

Spinal and general anaesthesia may achieve similar outcomes for patients with hip fracture, but within this, it appears that spinal without sedation was associated with improved perioperative outcomes—including a reduced risk of delirium, an increased likelihood of mobilisation by the day after hip fracture surgery, an increased likelihood of returning to admission residence on discharge, and a shorter length of hospital stay. Most of these benefits were not observed in spinal anaesthesia with sedation, suggesting sedation may influence perioperative outcomes in hip fracture surgery. The role and effect of sedation should be assessed in future RCTs of hip fracture patients undergoing spinal anaesthesia.

Availability of data and materials

The study is based on data from the National Hip Fracture Database and was provided within the terms of an NHS Digital sharing agreement. The data do not belong to the authors and may not be shared by the authors, except in aggregate form for publication. Data can be obtained by submitting a research request through the NHS Digital Data Access Request Service.

Abbreviations

4AT:

4 ‘A’s Test

AMT4:

Abbreviated Mental Test 4

AMTS:

Abbreviated Mental Test Score

ASA:

American Society of Anesthesiologists

CAG:

Confidentiality Advisory Group

CI:

Confidence interval

GAfREC:

Governance Arrangements for Research Ethics Committee

iHOPE:

Improve hip fracture outcome in the elderly patient

HRA:

Health Research Authority

HQIP:

Healthcare Quality Improvement Partnership

IQR:

Interquartile range

KPI:

Key Performance Indicators

NCAPOP:

National Clinical Audit and Patient Outcomes Programme

NHS:

National Health Service

NHFD:

National Hip Fracture Database

NICE:

National Institute for Health and Care Excellence

OR:

Odds ratio

ONS:

Office for National Statistics

RCT:

Randomised controlled trial

RAGA-delirium:

Regional with general anaesthesia on postoperative delirium

REGAIN:

Regional versus General Anesthesia for Promoting Independence after Hip Fracture

SD:

Standard deviation

SMD:

Standardised mean difference

STRIDE:

Steroids To Reduce the Impact on DElirium

UK:

United Kingdom

References

  1. The National Hip Fracture Database Annual Report 2019. Data from January to December 2018. Available at: https://www.nhfd.co.uk/files/2019ReportFiles/NHFD_2019_Annual_Report_v2101.pdf. Accessed 21 Aug 2022.

  2. Griffin XL, Parsons N, Achten J, Fernandez M, Costa ML. Recovery of health-related quality of life in a United Kingdom hip fracture population. The Warwick Hip Trauma Evaluation--a prospective cohort study. Bone Joint J. 2015;97-B(3):372–82.

    Article  CAS  Google Scholar 

  3. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc. 2001;49(5):516–22.

    Article  CAS  Google Scholar 

  4. Clemmesen CG, Lunn TH, Kristensen MT, Palm H, Foss NB. Effect of a single pre-operative 125 mg dose of methylprednisolone on postoperative delirium in hip fracture patients; a randomised, double-blind, placebo-controlled trial. Anaesthesia. 2018;73(11):1353–60.

    Article  CAS  Google Scholar 

  5. Sieber FE, Neufeld KJ, Gottschalk A, Bigelow GE, Oh ES, Rosenberg PB, et al. Effect of Depth of Sedation in Older Patients Undergoing Hip Fracture Repair on Postoperative Delirium: The STRIDE Randomized Clinical Trial. JAMA Surg. 2018;153(11):987–95.

    Article  Google Scholar 

  6. Lisk R, Yeong K, Enwere P, Jenkinson J, Robin J, Irvin-Sellers M, et al. Associations of 4AT with mobility, length of stay and mortality in hospital and discharge destination among patients admitted with hip fractures. Age Ageing. 2020;49(3):411–7.

    Article  Google Scholar 

  7. Bellelli G, Morandi A, Di Santo SG, Mazzone A, Cherubini A, Mossello E, et al. "Delirium Day": a nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool. BMC Med. 2016;14:106.

    Article  Google Scholar 

  8. Johansen A, Tsang C, Boulton C, Wakeman R, Moppett I. Understanding mortality rates after hip fracture repair using ASA physical status in the National Hip Fracture Database. Anaesthesia. 2017;72(8):961–6.

    Article  CAS  Google Scholar 

  9. Leal J, Gray AM, Prieto-Alhambra D, Arden NK, Cooper C, Javaid MK, et al. Impact of hip fracture on hospital care costs: a population-based study. Osteoporos Int. 2016;27(2):549–58.

    Article  CAS  Google Scholar 

  10. Guay J, Parker MJ, Gajendragadkar PR, Kopp S. Anaesthesia for hip fracture surgery in adults. Cochrane Database Syst Rev. 2016;2:CD000521.

    PubMed  Google Scholar 

  11. Neuman MD, Rosenbaum PR, Ludwig JM, Zubizarreta JR, Silber JH. Anesthesia technique, mortality, and length of stay after hip fracture surgery. JAMA. 2014;311(24):2508–17.

    Article  CAS  Google Scholar 

  12. Qiu C, Chan PH, Zohman GL, Prentice HA, Hunt JJ, LaPlace DC, et al. Impact of Anesthesia on Hospital Mortality and Morbidities in Geriatric Patients Following Emergency Hip Fracture Surgery. J Orthop Trauma. 2018;32(3):116–23.

    Article  Google Scholar 

  13. Tung YC, Hsu YH, Chang GM. The Effect of Anesthetic Type on Outcomes of Hip Fracture Surgery: A Nationwide Population-Based Study. Medicine (Baltimore). 2016;95(14):e3296.

    Article  CAS  Google Scholar 

  14. Patorno E, Neuman MD, Schneeweiss S, Mogun H, Bateman BT. Comparative safety of anesthetic type for hip fracture surgery in adults: retrospective cohort study. BMJ. 2014;348:g4022.

    Article  Google Scholar 

  15. Neuman MD, Silber JH, Elkassabany NM, Ludwig JM, Fleisher LA. Comparative effectiveness of regional versus general anesthesia for hip fracture surgery in adults. Anesthesiology. 2012;117(1):72–92.

    Article  CAS  Google Scholar 

  16. Ahn EJ, Kim HJ, Kim KW, Choi HR, Kang H, Bang SR. Comparison of general anaesthesia and regional anaesthesia in terms of mortality and complications in elderly patients with hip fracture: a nationwide population-based study. BMJ Open. 2019;9(9):e029245.

    Article  Google Scholar 

  17. Morgan L, McKeever TM, Nightingale J, Deakin DE, Moppett IK. Spinal or general anaesthesia for surgical repair of hip fracture and subsequent risk of mortality and morbidity: a database analysis using propensity score-matching. Anaesthesia. 2020;75(9):1173–9.

    Article  CAS  Google Scholar 

  18. Neuman MD, Feng R, Carson JL, Gaskins LJ, Dillane D, Sessler DI, et al. Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults. N Engl J Med. 2021;385(22):2025–35.

    Article  CAS  Google Scholar 

  19. National Institute for Health and Care Excellence. Hip fracture: the management of hip fracture in adults. NICE clinical guideline 124. 2011. Available at: https://www.nice.org.uk/guidance/cg124. Accessed 21 Aug 2022.

  20. Fernandez MA, Arnel L, Gould J, McGibbon A, Grant R, Bell P, et al. Research priorities in fragility fractures of the lower limb and pelvis: a UK priority setting partnership with the James Lind Alliance. BMJ Open. 2018;8(10):e023301.

    Article  Google Scholar 

  21. Boney O, Bell M, Bell N, Conquest A, Cumbers M, Drake S, et al. Identifying research priorities in anaesthesia and perioperative care: final report of the joint National Institute of Academic Anaesthesia/James Lind Alliance Research Priority Setting Partnership. BMJ Open. 2015;5(12):e010006.

    Article  Google Scholar 

  22. Kowark A, Adam C, Ahrens J, Bajbouj M, Bollheimer C, Borowski M, et al. Improve hip fracture outcome in the elderly patient (iHOPE): a study protocol for a pragmatic, multicentre randomised controlled trial to test the efficacy of spinal versus general anaesthesia. BMJ Open. 2018;8(10):e023609.

    Article  Google Scholar 

  23. Neuman MD, Ellenberg SS, Sieber FE, Magaziner JS, Feng R, Carson JL, et al. Regional versus General Anesthesia for Promoting Independence after Hip Fracture (REGAIN): protocol for a pragmatic, international multicentre trial. BMJ Open. 2016;6(11):e013473.

    Article  Google Scholar 

  24. White SM, Moppett IK, Griffiths R, Johansen A, Wakeman R, Boulton C, et al. Secondary analysis of outcomes after 11,085 hip fracture operations from the prospective UK Anaesthesia Sprint Audit of Practice (ASAP-2). Anaesthesia. 2016;71(5):506–14.

    Article  CAS  Google Scholar 

  25. Shah A, Prieto-Alhambra D, Hawley S, Delmestri A, Lippett J, Cooper C, et al. team REs. Geographic variation in secondary fracture prevention after a hip fracture during 1999-2013: a UK study. Osteoporos Int. 2017;28(1):169–78.

    Article  CAS  Google Scholar 

  26. Shah A, Matharu GS, Inman D, Fagan E, Johansen A, Judge A. Variation in timely surgery for hip fracture by day and time of presentation: a nationwide prospective cohort study from the National Hip Fracture Database for England, Wales and Northern Ireland. BMJ Qual Saf. 2021;30(7):559–66.

    Article  Google Scholar 

  27. Whitehouse MR, Berstock JR, Kelly MB, Gregson CL, Judge A, Sayers A, et al. Higher 30-day mortality associated with the use of intramedullary nails compared with sliding hip screws for the treatment of trochanteric hip fractures: a prospective national registry study. Bone Joint J. 2019;101-B(1):83–91.

    Article  CAS  Google Scholar 

  28. Sheehan KJ, Sobolev B, Villan Villan YF, Guy P. Patient and system factors of time to surgery after hip fracture: a scoping review. BMJ Open. 2017;7(8):e016939.

    Article  Google Scholar 

  29. Dripps RD, Lamont A, Eckenhoff JE. The role of anesthesia in surgical mortality. JAMA. 1961;178:261–6.

    Article  CAS  Google Scholar 

  30. Abbreviated Mental Test Score (AMTS). Available at: https://www.oxfordmedicaleducation.com/geriatrics/amts/. Accessed 21 Aug 2022.

  31. 4AT. Rapid Clinical Test for Delirium. Available at: https://www.the4at.com. Accessed 21 Aug 2022.

  32. Austin PC. Some methods of propensity-score matching had superior performance to others: results of an empirical investigation and Monte Carlo simulations. Biom J. 2009;51(1):171–84.

    Article  Google Scholar 

  33. Austin PC. Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Stat Med. 2009;28(25):3083–107.

    Article  Google Scholar 

  34. Griffiths R, Babu S, Dixon P, Freeman N, Hurford D, Kelleher E, et al. Guideline for the management of hip fractures 2020: Guideline by the Association of Anaesthetists. Anaesthesia. 2021;76(2):225–37.

    Article  CAS  Google Scholar 

  35. Li T, Yeung J, Li J, Zhang Y, Melody T, Gao Y, et al. Comparison of regional with general anaesthesia on postoperative delirium (RAGA-delirium) in the older patients undergoing hip fracture surgery: study protocol for a multicentre randomised controlled trial. BMJ Open. 2017;7(10):e016937.

    Article  Google Scholar 

  36. Cserhati P, Kazar G, Manninger J, Fekete K, Frenyo S. Non-operative or operative treatment for undisplaced femoral neck fractures: a comparative study of 122 non-operative and 125 operatively treated cases. Injury. 1996;27(8):583–8.

    Article  CAS  Google Scholar 

  37. Goh EL, Lerner RG, Achten J, Parsons N, Griffin XL, Costa PML. Complications following hip fracture: Results from the World Hip Trauma Evaluation cohort study. Injury. 2020;51(6):1331–6.

    Article  Google Scholar 

  38. Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Audisio R, Borozdina A, et al. European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol. 2017;34(4):192–214.

    Article  Google Scholar 

  39. McIsaac DI, Wijeysundera DN, Bryson GL, Huang A, McCartney CJL, van Walraven C. Hospital-, Anesthesiologist-, and Patient-level Variation in Primary Anesthesia Type for Hip Fracture Surgery: A Population-based Cross-sectional Analysis. Anesthesiology. 2018;129(6):1121–31.

    Article  Google Scholar 

  40. McGinn R, Talarico R, Hamiltoon GM, Ramlogan R, Wijeysundra DN, McCartney CJL, et al. Hospital-, anaesthetist-, and patient-level variation in peripheral nerve block utilisation for hip fracture surgery: a population-based cross-sectional study. Br J Anaesth. 2022;128(1):198–206.

    Article  Google Scholar 

  41. Li T, Li J, Yuan L, Wu J, Jiang C, Daniels J, et al. Effect of Regional vs General Anesthesia on Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery: The RAGA Randomized Trial. JAMA. 2022;327(1):50–8.

    Article  CAS  Google Scholar 

  42. Costa ML, Griffin XL, Achten J, Metcalfe D, Judge A, Pinedo-Villanueva R, et al. World Hip Trauma Evaluation (WHiTE): framework for embedded comprehensive cohort studies. BMJ Open. 2016;6(10):e011679.

    Article  Google Scholar 

  43. Metcalfe D, Costa ML, Parsons NR, Achten J, Masters J, Png ME, et al. Validation of a prospective cohort study of older adults with hip fractures. Bone Joint J. 2019;101-B(6):708–14.

    Article  CAS  Google Scholar 

Download references

Funding

One of the authors [GSM] was supported by the Academy of Medical Sciences, the Wellcome Trust, the Medical Research Council, the British Heart Foundation, Versus Arthritis, Diabetes UK, the British Thoracic Society (Helen and Andrew Douglas bequest), and the Association of Physicians of Great Britain and Ireland) to carry out the work presented [SGL023\1021]. This study was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care.

Author information

Authors and Affiliations

Authors

Contributions

GSM, MRW, and AJ2 (Judge) conceived the study. GSM, AS, SM, AJ1 (Johansen), DI, IM, MRW and AJ2 were involved in the study design. AS, SH and AJ2 analysed the data. GSM and AS wrote the initial manuscript draft. GSM, AS, SM, AJ1, DI, IM, MRW and AJ2 interpreted the data. All authors read and approved the final manuscript. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. AJ2 is the guarantor for this study and had final responsibility for manuscript submission.

Corresponding author

Correspondence to Gulraj S. Matharu.

Ethics declarations

Ethics approval and consent to participate

The Healthcare Quality Improvement Partnership (HQIP) is commissioned by NHS England to commission and manage the National Clinical Audit and Patient Outcomes Programme (NCAPOP). As part of this programme, the NHFD is a quality improvement initiative commissioned by HQIP/NHS England. NHFD data is collected under section 251 of the NHS Act 2016 following approval by the HRA Confidentiality Advisory Group (CAG 8-03(PR11)/2013). Only pseudonymised data are sent to the University of Oxford for this project. This research project was reviewed by HQIP and approved as an extended analysis and output of the NHFD clinical audit programme. Ethical approval was not sought in line with Governance Arrangements for Research Ethics Committee (GAfREC) guidance for this secondary analysis of administrative data.

Consent for publication

Not applicable.

Competing interests

All authors declare: funding was received for the submitted work as described in the Funding statement; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years, and no other relationships or activities that could appear to have influenced the submitted work.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1: Appendix 1.

Multivariable regression and sensitivity analysis.

Additional file 2: Table S1.

Baseline characteristics of hip fracture patients by anaesthetic type. Table S2. Outcomes of hip fracture patients after surgery by anaesthetic type.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Matharu, G.S., Shah, A., Hawley, S. et al. The influence of mode of anaesthesia on perioperative outcomes in people with hip fracture: a prospective cohort study from the National Hip Fracture Database for England, Wales and Northern Ireland. BMC Med 20, 319 (2022). https://doi.org/10.1186/s12916-022-02517-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12916-022-02517-8

Keywords

  • Anaesthesia
  • Spinal
  • General
  • Outcomes
  • Hip fracture
  • Delirium