Anaesthesia 2014, 69, 640–652
Correspondence Outcome by mode of anaesthesia for hip fracture surgery The biggest question raised by White et al. in their recent publication on spinal versus general anaesthesia for hip fracture surgery [1] is why the national 30-day mortality rate has remained largely unchanged from the first National Hip Fracture Database (NHFD) Report in 2009 (8.3%) to the latest NHFD Report in 2013 (8.2%) [2]. We agree with the authors that significant improvements in performance will not be made by advocating one mode of anaesthesia over another for this group of patients. In the ten years from 2002 to 2012, the 30-day mortality rate for all hip fractures (operated and nonoperated) in the Royal Victoria Hospital, Belfast has fallen incrementally from 7.2% to 5.4%. This has been increasingly difficult to achieve and has not been made possible by any single intervention. Instead, we have achieved this using our mantra of ‘performance by the aggregation of marginal gains’ in our medical, surgical and anaesthetic management
for hip fractures [3]. Each patient with hip fracture is evaluated, managed and treated as an individual case. Accountability lies with the consultant orthogeriatrician, consultant anaesthetist and consultant surgeon for each case. Hospitals in England are currently paid a Best Practice Tariff (BPT) of £1335 (€1706; $2102) above base tariff for each hip fracture patient undergoing surgery within 36 hours of admission if other orthogeriatric assessments of falls and bone health are also fulfilled. The Royal Victoria Hospital in Belfast does not work under BPT incentives and in the NHFD 2013 Report it is second from bottom of the table classifying hospitals by the proportion of patients undergoing surgery within 36 hours of admission (26%), yet still has a 30-day mortality of 5.4%, more than three standard deviations below the average (8.2%) for our size of unit (approximately 900 hip fractures per year) [2]. We are concerned that the current BPT incentives influence hospitals in England to expose certain patients to surgery and anaesthesia before it is in the patients’ best interests to do so. The current Scottish
Intercollegiate Guidelines Network 2009 publication on hip fracture management states: “there is no consistent evidence of an improvement in mortality from early surgery for hip fracture. . . Surgery should be performed as soon as the medical condition of the patient allows” [4]. The only study showing a detrimental effect of delay to hip fracture surgery on 30-day mortality that attempted to correct for confounding factors, including co-morbidities, was a retrospective analysis by Bottle and Aylin of 129 552 admissions with hip fracture in England between 2001and 2004 [5]. That study only enrolled patients who had been admitted from their own home (not institutions), effectively selecting a cohort with fewer co-morbidities than expected. The reported 30-day (inhospital) mortality rate for the all patients was 14.3%. Yet this study has been repeatedly used to promote universal and indiscriminate use of time targets to theatre for all hip fracture patients. The problem with the BPT is that it is based on ensuring a standard of process (timing and tick boxes) and not of performance (outcomes and patient satisfaction). Obviously, good
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Correspondence
process contributes to good performance, but good performance requires more than just process. In addition, if the standard of process is not evidence-based then it may, in fact, lead to poor performance. We still do not know what patients with hip fracture die from within 30 days of surgery, but we know that heart failure and chest infection are major contributors [6]. It is likely that there are subgroups of patients who may benefit from early surgery (younger, fitter patients, those prone to chest infection including those with chronic obstructive pulmonary disease, asthma, obesity, carcinomatosis), while there are subgroups that may benefit from delay and optimisation (patients with heart failure, myocardial ischaemia/acute coronary syndrome, hyptotension, tachyarrhythmias, requirement for high-dose inspired oxygen, acute renal dysfunction, anaemia). Similarly, there are likely to be subgroups of patients who may benefit from spinal anaesthesia instead of general anaesthesia, and vice versa, with a large group in whom it may make no difference. Excellence in intra-operative management centres on the maintenance of adequate blood pressure throughout the operation (as close to pre-induction levels as possible), avoidance of long-acting opioids, use of nerve blocks and attention to detail in fluid management. Although not ideal, the 30-day mortality rate currently remains the best indicator of how a hip fracture unit is performing and since the introduction of BPT, many units have seen significant improvements in performance, but this does not mean that it is as a result of reduced
Anaesthesia 2014, 69, 640–652
times to theatre for all patients. In addition to funding increased operating capacity, BPT finances have helped ensure provision of orthogeriatric services throughout hospitals in England, thereby enabling improved peri-operative management. Which leaves the question of why the overall 30-day mortality rate has remained largely unchanged from the first NHFD Report in 2009 (8.3%) to the latest NHFD Report in 2013 (8.2%). Further significant improvements are unlikely unless a more subtle and individual approach to each patient is adopted. This cannot be achieved with a financial incentive for all patients to have surgery within 36 hours of admission, nor by advocating a ‘magic bullet’ recipe for anaesethesia. We disagree strongly that a ‘Sprint Audit of Practice’ that has been carried out with no set aims or standards before data collection will answer any questions of how to produce improvements in national 30-day mortality rates, or indeed of what is best practice in this area [7]. The recent letter by Maddock and Jack in Anaesthesia highlighted the incorrect labeling of audits presented as posters at the AAGBI Annual Congress in Dublin that did not involve a comparison made to a defined standard [8] and it would appear this mistake is being made yet again. The role of medical optimisation and aftercare, which is the cornerstone of peri-operative management at the Royal Victoria Hospital, will be ignored in this survey. Publication of the results, with no set standards, runs the risk of illinforming the anaesthetic community and reversing progress in a
© 2014 The Association of Anaesthetists of Great Britain and Ireland
public health area on which we should be leading. M. E. McBrien M. O. Shields G. Heyburn Royal Victoria Hospital Belfast, UK Email:
[email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References 1. White SM, Moppett IK, Griffiths R. Outcome by mode of anaesthesia for hip fracture surgery. An observational audit of 65 535 patients in a national dataset. Anaesthesia 2014; 69: 224–30. 2. The National Hip Fracture Database. National Report 2013. http://www.nhfd. co.uk/20/hipfractureR.nsf/0/CA920122A 244F2ED802579C900553993/$file/NHFD %20Report%202013.pdf?OpenElement (accessed 11⁄03⁄2014). 3. Heyburn G, McBrien ME. Pre-operative echocardiography for hip fractures: time to make it a standard of care. Anaesthesia 2012; 67: 1189–93. 4. Scottish Intercollegiate Guidelines Network. Management of hip fracture in older people. National Clinical Guideline 111. 2009. http://www.sign.ac.uk/pdf/ sign111.pdf (accessed 07/10/2013). 5. Bottle A, Aylin P. Mortality associated with delay in operation after hip fracture. British Medical Journal 2006; 332: 947–51. 6. Roche JJW, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and post operative complications on mortality after hip fracture in elderly people: prospective observational cohort study. British Medical Journal 2005; 331: 1374. 7. Hip Fracture Anaesthesia Sprint Audit Project (ASAP). http://www.networks. nhs.uk/nhs-networks/hip-fracture-anaes thesia/hip-fracture-anaesthesia-sprintaudit-project-asap (accessed 15/03/2014). 8. Maddock A, Jack E. When is an audit not an audit? Anaesthesia 2014; 69: 193–4. doi:10.1111/anae.12718 641
