Title: What is a 'good anaesthetic? Producing evidence in complex settings: the case of fractured neck of femur.
Funder: Department of Health and Social Care

Abstract: Approximately 70000 cases of hip fracture occur in England every year, and this is projected to rise to around 100000 cases over the next two decades. The majority of hip fractures are sustained by elderly people, with a mean age of incidence of 82 years. Hip fracture is a major cause of mortality, and it is estimated that the mortality associated with hip fracture is between 6 and 10 per cent within the 30 days following injury. However, there is also a great burden of morbidity following surgical treatment, including loss of physical and cognitive function. Though 74.5% of hip fracture patients are resident at their own home at the time of their injury, only 46.4% of patients are discharged to their own home. Two broad anaesthetic strategies can be adopted to facilitate surgical treatment of hip fracture, general anaesthesia in which the patient is unconscious throughout surgery, and regional (neuraxial) anaesthesia in which the patients lower limbs are numbed. It has long been suspected that the type of anaesthesia that is provided has an impact on the rate of morbidity and mortality, however meta-analysis of randomized controlled trials and a large observational case series have failed to demonstrate that this is the case. This may be because the anaesthetic technique does not matter, however it is likely that simply classifying anaesthesia as general' or regional' provides insufficient resolution given the variety of anaesthetic practice: examination of the available data suggests that anaesthesia providers vary considerably in the techniques they employ, and different drugs, doses and medical equipment may mean that one anaesthetic is very different from another despite being classified under the same broad strategy. Furthermore, approximately three-quarters of patients undergoing regional anaesthesia for fixation of hip fracture are sedated to some degree, and approximately one-half of patients undergoing general anesthesia have local anaesthetic injected around a major nerve to numb the hip. Anaesthetics are therefore complex interventions and this provides major challenges in drawing conclusions from the statistical analysis of morbidity and mortality.In considering these issues, the authors of the most recent large-scale observational study of anaesthesia for hip fracture surgery suggested that it may be more important to consider what constitutes a good' or a bad' anaesthetic than to simply focus on the broad anaesthetic strategy, and the NICE guidelines on hip fracture suggest that qualitative research would be valuable to investigate patients preference for anaesthetic technique. We therefore propose to investigate the concept of a good anaesthetic' for hip fracture surgery from the perspective of all three key stakeholders in the operation: the patient, the anaesthetist, and the surgeon. In order to gain a deep understanding of the issues we will adopt an ethnographic approach to qualitative research: using observation, discussion and interviews to build a rich understanding of the factors that influence the quality and safety of anaesthetic provision for this unique patient group.

Lay abstract: Approximately 70,000 cases of hip fracture occur in England every year, and this is projected to rise to around 100,000 cases over the next twenty years. The majority of hip fractures are sustained by elderly people, and the average age of a hip fracture patient is 82 years. People who sustain a hip fracture have a 10 percent chance of death within the 30 days following injury, and it is likely that those who survive a hip fracture will experience a substantial deterioration in their general health. As a consequence of this, over a third of patients with hip fractures who are admitted from their own home are unable to return to independent living on discharge from hospital. The high risk of death or significant deterioration in health means that doctors must find ways to provide the best possible care for this group of patients. In order to allow a hip fracture to be fixed, nearly all patients have an operation, and this requires an anaesthetic. Two types of anaesthetic can be used for hip fracture surgery: general anaesthesia in which the patient is unconscious throughout surgery, and regional anaesthesia in which the patient's legs are numbed temporarily, but the patient remains awake. Considerable research effort has focussed on determining if some types of anaesthesia are safer than others, however high-quality scientific studies have so far failed to demonstrate that this is the case. Whilst this could indicate that the anaesthetic technique does not matter, existing studies' division of anaesthesia into general' or regional' provides insufficient information about what treatment each patient is actually undergoing, and this makes existing data unreliable. For example, there are at least five different injections and three different gases in use in the UK that can all induce general anaesthesia, and these drugs are often used in different ways and different combinations by different anaesthetists, for different patients. In short, one anaesthetic of a given type is not the same as the next. In considering these issues, the authors of the most recent large study of anaesthesia for hip fracture surgery suggested that it is important to obtain further information about what a good' or a bad' anaesthetic involves, rather than to simply focus on the type of anaesthetic given. In addition, NICE has noted that there is not enough scientific information about what is important in hip fracture anaesthesia from the patients' perspective, and has suggested that this should be a priority for research. We therefore propose to investigate the concept of a good anaesthetic' for hip fracture surgery from the perspective of all three key stakeholders in the operation: the patient, the anaesthetist, and the surgeon. In order to gain a deep understanding of the issues we will use a number of research techniques including interviews with patients and staff, direct observation of anaesthetic practice, and focus group discussions to build an in-depth understanding of the factors that influence the quality and safety of the anaesthetic management of this challenging patient group.

Research activity codes: 6.1 PHARMACEUTICALS
Health categories: MUSCULOSKELETAL;GENERIC HEALTH RELEVANCE