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We may have improved but we must get better still

The never-ending story of the elderly with fractured neck of femur

Coburn, Mark; Sanders, Robert; Neuman, Mark; Rossaint, Rolf; Matot, Idit

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European Journal of Anaesthesiology: March 2017 - Volume 34 - Issue 3 - p 115-117
doi: 10.1097/EJA.0000000000000560
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The aim of this Editorial is to shed some light on recent developments based on literature published in 2015/2016 and remaining challenges in the perioperative care of elderly hip-fracture patients. In Europe, we are faced with a wide range of healthcare performances in the perioperative management of hip-fracture patients. The recently published EuroHOPE patient database covered 59 605 hip-fracture patients across seven European countries. The hip fracture prevalence of patients older than 50 years ranged from 307/100 000 in Finland to 1269/100 000 in Italy. The 30-day and 1-year mortality rates peaked at 11.7 and 34.8% in Hungary and were lowest in Italy with 4.0 and 19.7%, respectively. Length of hospital stay was longest in Italy (18.9 days) and shortest in Norway (9.8 days).1 In contrast, a retrospective cohort study from New York State including 188 208 hip-fracture patients revealed a 4.5% 30-day mortality rate for surgically treated and 10.7% for non-surgically-treated hip-fracture patients. In the United Kingdom, 30-day mortality is approximately 8.5% and although the rate is decreasing, it remains unacceptably high.2 Hospital stays shorter than 10 days were associated with increased odds of survival 30 days after discharge.3 Obviously, there are large differences in the perioperative care of elderly hip-fracture patients between the United States of America, Europe and within Europe.1,3 Annually in Europe, hip fracture affects about 628 000 patients, accounting for approximately 200 000 deaths. More than three-quarters of the patients are older than 65 years.4 These data underline the enormous humanitarian and socio-economic need to improve the quality and effectiveness of care for patients with hip fracture.

Hip-fracture patients frequently present with complex comorbidities including impaired hepatic and renal function, diabetes mellitus, dementia, delirium, frailty, coronary artery disease, heart failure and patient polypharmacy. These are all individually linked to increases in postoperative complications and mortality. Virtually, the entire hip-fracture population (95%) arrive at hospital with at least one major comorbidity. Additional risk factors such as residential status, functional and cognitive impairment prior to fracture, male sex, poor nutrition status and anaemia have been identified and are associated with increased mortality.4 Complications such as pneumonia or deep vein thrombosis are associated with worse outcome. It is not surprising that patients with multiple comorbidities are at highest risk of death.4 Further discharge to a hospice facility, older age, metastatic disease and nonsurgical management were associated with increased 30-day mortality.3 In a study population of 234 314 patients in France matched for age, gender and comorbidities, acute hip-fracture patients showed a much higher relative risk of in-hospital mortality compared with elective total hip replacement, Relative Risk 5.8 [95% CI 5.26 to 6.58].5

Not surprisingly, the number of comorbidities negatively influences the psychological outcomes of elderly patients with hip fracture.6–8 The occurrence of postoperative delirium has been identified as a risk factor for increased mortality and for posttraumatic stress disorder.9,10 A large international, multi-centre, randomised controlled trial (HIPELD study) is evaluating at present whether xenon may reduce the incidence of delirium in elderly hip-fracture patients ( NCT01199276).11 However, to be able to identify patients at risk, valid screening tools for postoperative delirium that fit daily clinical challenges are required. The properties of a 2-min bedside 10-point Cognitive Screener (three-item temporal orientation, category fluency and three word recall) has shown promise to stratify the risk of delirium in older fracture patients.12 Risk stratification models aim to predict outcomes and optimise the efficacy, clinical and cost-effectiveness of perioperative interventions. However, these models require external validation and will always be subject to some error. For example, the Nottingham Hip Fracture Score (NHFS) and the Surgical Outcome Risk Tool (SORT) were evaluated and re-calibrated from a multi-centre, national dataset including 9017 hip-fracture cases. Both the NHFS and the SORT show moderate discrimination for 30-day mortality after hip fracture surgery. Further studies are required to discern the accuracy of the NHFS as a risk stratification tool internationally.13

So far, anaesthesia care for hip fracture varies markedly in practice. Although spinal and general anaesthesia for hip fracture have been previously compared in retrospective studies and small randomised trials, much of the available prospective data are old. In a current matched retrospective cohort study including 56 729 patients, regional anaesthesia (spinal or epidural) was associated with a shorter length of hospital stay but there was no difference in the 30-day mortality between the groups.14 In 2016, a Cochrane Library review summarised randomised trials comparing regional versus general anaesthesia for hip-fracture surgery. There was no difference in 1-month mortality, pneumonia, myocardial infarction, cerebrovascular accident, acute confusional state, congestive heart failure, acute kidney injury, pulmonary embolism, number of patients transfused with red blood cells, length of surgery and length of hospital stay. Furthermore, there is uncertainty about optimal doses of spinally administered drugs in these elderly patients.15 However, without prophylaxis with potent anticoagulant drugs, the risk of deep venous thrombosis was less in the neuraxial block group. Yet, the level of evidence in the reported studies was low, and the power of the studies insufficient.16 This underlines the need to further address this topic in large-scale studies. At present, the University of Pennsylvania is carrying out a multi-centre randomised controlled trial ‘regional versus general anaesthesia for promoting independence after hip fracture surgery (REGAIN)’ to assess whether one type of standard care anaesthesia leads to better outcomes in recovery of walking, overall health and disability, pain and survival in approximately 1600 patients ( NCT02507505).

Perioperative pain management is crucial and requires a multi-modal approach including regional anaesthesia as early as in the prehospital period and in the emergency room. However, evidence from randomised controlled trials is sparse.17 Further, it appears that implementing fast-track care pathways and early surgery improves 30-day mortality rate.18

Advanced methods for perioperative fluid volume optimisation following hip fracture are available. However, a recent Cochrane Review provided no evidence that fluid strategies improve outcomes in hip-fracture patients, although the results of the Cochrane Review are based on only five studies including 403 patients in total. These studies were under-powered, and the level of evidence was low or very low.19 For hip fracture (and probably other high-risk procedures), intraoperative haemodynamic stability seems to improve outcome. Data collected by anaesthetists in the Anaesthesia Sprint Audit of Practice were re-analysed for 11 085 patients. The mortality rate increased within 5 days postoperatively for each 5 mmHg of intraoperative decrease in SBP [odds ratio 0.983 (0.973 to 0.993)].20 Further, anaemia on admission has been shown to be an independent risk factor for long-term mortality in hip-fracture patients.21 The currently available Cochrane Library evidence does not support the use of liberal red blood cell transfusion thresholds based on a 10 g dl−1 haemoglobin trigger in preference to more restrictive transfusion thresholds or symptoms of anaemia in hip-fracture patients. However, the reliability of the studies included in the Cochrane review is limited and the evidence was of low quality.22 Further, dedicated geriatric care with an emphasis on comprehensive medical assessment and treatment, initiation of rehabilitation through mobilisation and planning of discharge early in hip-fracture patients improved mobility at 4 months compared with the usual orthopaedic care.23

The perioperative care of hip-fracture patients includes consecutive stages of preoperative, intraoperative and postoperative care. At all stages, a multi-disciplinary team of Trauma and Emergency Surgeons, of Anaesthesiologists, of Geriatricians and of Physiotherapists treat the highly frail hip-fracture patients. During perioperative care, an array of interventions needs to be employed to address the complex healthcare problems. Yet, despite all efforts so far, the health and socio-economic outcome of this patient population is dramatic. Comparative effectiveness research (CER) may provide an alternative. A fundamental concept of CER is to study distinctions in care and outcome in observational studies, thus turning natural variability into an asset.24 We see an enormous potential for CER in the elderly hip-fracture population because of its unique features. First, there are large between-centre and between-country differences in both outcome and management. Second, advanced statistical models that take into account random effects are available to analyse differences between centres. There is an urge for real-world approaches to improve outcome of elderly hip-fracture patients. CER may address many questions that will be complex to address in randomised controlled trials. Nonetheless, the need to establish a clear understanding of how to care for these vulnerable patients will probably require large randomised studies, conducted on the foundation of CER.

Acknowledgements relating to this article

Assistance with the Editorial: none.

Financial support and sponsorship: none.

Conflicts of interest: MC, RS and RR are members of the steering committee of the HIPELD study. MN is the Principal Investigator of the REGAIN trial. The trial is funded by the US Patient Centred Outcomes research Institute (PCORI) under contract #PCS 1406-18876.

Comment from the Editor: this article was checked and accepted by the Editors, but was not sent for external peer-review.


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