Title: What is the clinical effectiveness of regional anaesthesia compared with general anaesthesia for post-operative complications in patients with hip fractures?
Funder: The Academy of Medical Sciences

Abstract: This research will determine the clinical effectiveness of regional anaesthesia compared with general anaesthesia for post-operative complications in hip fracture patients. The National Institute for Health and Care Excellence (NICE) and the James Lind Alliance (Priority Setting Partnership of patients, carers and clinicians) recommend prioritising this research topic. A systematic review and meta-analysis will be performed with evidence synthesis experts using Cochrane guidance. Eligible randomised controlled trials (RCTs) will include hip fracture surgery patients randomised to general or regional anaesthesia, which report post-operative complications and mortality. A prospective nationwide cohort study will be performed using data from The Natonal Hip Fracture Database (NHFD). The NHFD collects data on post-operative delirium and mobility, which reflect the quality of acute peri-operative care, but have not been assessed in previous studies. Over 180,000 patients undergoing hip fracture surgery between 2017-2019 will be studied. The effect of anaesthesia (general anaesthesia, spinal anaesthesia, or spinal anaesthesia with sedation) on post-operative outcomes (delirium, mobilisation on day-one after surgery, length of stay, and thirty-day mortality) will be assessed. Analyses will account for relevant patient (including age, sex) and surgical (including fracture type, surgeon, centre/hospital) covariates using either adjusted regression models, propensity score matching or instrumental variable analysis. This work will inform design of an efficient three-arm RCT, comparing the effectiveness of anaesthesia (general, spinal, spinal with sedation) in hip fracture patients, which will be embedded in an ongoing prospective cohort study. An NIHR HTA grant application will be prepared with an experienced team and Clinical Trials Unit.

Lay abstract: Each year 70,000 elderly people fall and break (fracture) their hip due to weak bones, and require emergency surgery to reduce serious complications. Despite this, patients have long hospital stays, and serious medical problems, including death (1-in-17 die within 30-days). Immediately before surgery, patients receive medications (anaesthetic) to reduce pain and discomfort. Anaesthetics can be general (patient is completely unconcious) or regional (patient is awake but numb below the waist). Regional anaesthetics may improve patient outcomes. Finding out which anaesthetic works best has been highlighted as an important research area. First, we will find out which anaesthetic has better outcomes for patients by looking at evidence available from research studies that have already been done (a process called “systematic review”). Specifically, we will look at how the anaesthetic (general versus regional) effects outcomes after surgery, like complications, length of hospital stay, and death. Second, we will use data on 180,000 patients from the National Hip Fracture Database (records over 95% of all broken hips) to compare these same outcomes between different anaesthetic types. In addition we will look at whether patients become confused (delirium), and whether they walk the day after surgery. These latter patient-centred outcomes are lacking in previous studies comparing different anaesthetics. Finally, we will use the results of this project to design a larger study where patients with broken hips are randomly assigned to receive different types of anaesthetics. This nationwide study will establish the most effective and safest type of anaesthesic for patients with broken hips.

Research activity codes: 6.1 PHARMACEUTICALS;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MUSCULOSKELETAL