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Interpreting national hip fracture data

We commend White et al.’s recent paper about the type of anaesthesia used for patients with hip fracture [1]. Whilst it is encouraging that these data are being used to help us understand key influences affecting outcome, we have some questions on the reporting and interpretation of the analysis. The primary aim was to analyse any differences in 30-day mortality between general (GA) and spinal (SA) anaesthesia. Although no significant difference was found (p = 0.53), when patients receiving both GA and SA were included in the ‘GA’ group, there was a statistically significant reduction in 30-day mortality using GA (7.5%) compared with SA (8.0%, p = 0.04). One of the secondary aims involved analysis of time-related events. The abstract reports increased 24-hour mortality after cemented arthroplasty (1.6%) compared with uncemented arthroplasty (1.2%), but the discussion fails to acknowledge that the 30-day mortality reported by the National Institute of Health and Care Evidence (NICE) clinical guideline 124 relating to hip fracture management in adults [2] was significantly lower for cemented than with uncemented arthroplasty (7.4% vs 8.9%, respectively, p < 0.0001). The authors suggest that the evidence in favour of spinal anaesthesia informs all guidelines, yet NICE did not recommend its use over GA in either its 2011 guidelines [2] or its 2013 evidence update [3]. Throughout their paper, the authors have questioned whether the data are accurate or can be believed, but a number of equally valid interpretations could have been made based on the data presented. For example, there is a significant reduction in reported 30day mortality between patients of ASA physical status 4 having GA compared with SA (22.2% vs 26.5%, respectively, p = 0.008). The authors suggest that anaesthesia has only a small effect on 30-day mortality, yet we know this complex patient group is affected by a multitude of interventions, of which anaesthesia and surgery must be major players. It is also suggested that future research concentrates on ‘anaesthesia-sensitive’ outcomes, but we have learnt from orthopaedic practice, for example, that reviewing radiological results has little impact on patient experience, which must surely be the prime outcome when analysing medical interventions. Given our alternative interpretations of the data presented, we wonder whether the authors have interpreted their data fairly and accurately.