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Pain Medicine 2012; 13: 948–956
Wiley Periodicals, Inc.
Regional Anesthesia as Compared with General
Anesthesia for Surgery in Geriatric Patients
with Hip Fracture: Does It Decrease Morbidity,
Mortality, and Health Care Costs? Results of a
Single-Centered Study
pme_1402
948..956
Linda Le-Wendling, MD,* Azra Bihorac, MD,†
Tezcan Ozrazgat Baslanti, PhD,* Stephen Lucas,
MD,* Kalia Sadasivan, MD,‡ Adam Wendling, MD,*
H. James Heyman, MD,* and Andre Boezaart,
MD, PhD§
Departments of *Anesthesiology,
†
Anesthesiology, Surgery, and Medicine,
‡
Orthopaedics and Rehabilitation and
§
Anesthesiology and Orthopaedics and Rehabilitation,
University of Florida College of Medicine, Gainesville,
Florida, USA
Reprint requests to: Linda Le-Wendling, MD,
Department of Anesthesiology, University of Florida
College of Medicine, PO Box 100254, Gainesville, FL
32610-0254, USA. Tel: 352-294-5076; Fax:
352-265-8013; E-mail: [email protected].
Disclosure: All authors have read and approved the
manuscript. Dr. Boezaart is a consultant for Teleflex
Medical and receives royalties for Arrow International
for his invention of the “stimulating catheter.” Azra
Bihorac (AB) was supported by Award Number
K23GM087709 from the National Institute of General
Medical Sciences.
All other authors have no conflicts of interest to
disclose.
to July 2007) on morbidity, mortality and hospitalization costs.
Methods. This retrospective cohort study involved
data collection from electronic and paper charts of
308 patients who underwent surgery for hip fracture
from September 2006 to December 2008. Data on
postoperative morbidity, in-patient mortality, and
cost of hospitalization (as estimated from data on
hospital charges) were collected and analyzed.
Seventy-three patients received regional anesthesia
and 235 patients received general anesthesia.
During July 2007, approximately halfway through
the study period, a regional anesthesia and analgesia program was introduced.
Results. The average cost of hospitalization in
patients who received surgery for hip fracture was no
different between patients who receive regional or
general anesthesia ($16,789 + 631 vs $16,815 + 643,
respectively, P = 0.9557). Delay in surgery and intensive care unit (ICU) admission resulted in significantly higher hospitalization costs. Age, male
gender, African American race and ICU admission
were associated with increased in-hospital mortality.
In-hospital mortality and rates of readmission are not
statistically different between the two anesthesia
groups.
Conclusions. There is no difference in postoperative morbidity, rates of rehospitalization, in-patient
mortality or hospitalization costs in geriatric
patients undergoing regional or general anesthesia
for repair of hip fracture. Delay in surgery beyond 3
days and ICU admission both increase cost of
hospitalization.
Abstract
Introduction. Hip fracture in geriatric patients has a
substantial economic impact and represents a major
cause of morbidity and mortality in this population.
At our institution, a regional anesthesia program
was instituted for patients undergoing surgery for
hip fracture. This retrospective cohort review examines the effects of regional anesthesia (from mainly
after July 2007) vs general anesthesia (mainly prior
948
Key Words. Acute Pain; Aged; Analgesic; Anesthesiology; Elderly
Introduction
Hip fracture is a common, potentially devastating event for
geriatric patients with approximately 1.6 million hip fractures occurring annually worldwide [1] and a projected 6.2
Regional Anesthesia for Geriatric Patients
million hip fractures annually by the year 2050 [1]. In 2004
in the US alone, an estimated 387,000 patients older than
65 were hospitalized due to falls and about 37% of these
patients sustained hip fractures [2]. The mean cost of
hospitalization for patients with hip fractures was $18,638
with an average length of hospital stay of 7 days [2]. Hip
fracture has consistently been found to be associated with
a high morbidity and mortality [3–5] with reported mortality
remaining stable in the last 40 years [6]. A higher mortality
has been associated with increasing age and male gender
[7,8].
At the University of Florida and Shands Hospital
(UF&Shands), we have performed an increasing number
of surgeries for geriatric patients with fragility hip fractures
since the opening of our level I trauma center in 2005.
Prior to July 2007, most surgeries for hip fractures were
performed using general anesthesia. A shift in the involvement of the Acute Pain Medicine Service in July 2007
resulted in a change in intraoperative anesthetic management of geriatric, debilitated patients, which involved
placement of single injection spinals, continuous spinal
catheters, or epidural catheters for intraoperative anesthesia and femoral nerve blocks or lumbar paravertebral
blocks for postoperative analgesia. We also introduced a
specialized team of medical personnel dedicated to postoperative analgesia. Subsequently, we conducted a retrospective cohort study to examine patient characteristics,
cost of hospitalization (estimated from charges of hospitalization), readmission rates, and in-hospital mortality for
these patients. Our hypothesis was that the use of
regional anesthesia would reduce pulmonary morbidity,
and therefore reduce the need for critical care intervention
postoperatively, length of hospital stay, and cost of
hospitalization.
Methods
Data Source
Investigators received institutional review board approval
and a waiver of informed consent prior to gathering and
analyzing data. Patients who underwent surgery for hip
fractures (percutaneous pinning, open reduction internal
fixation, or bipolar arthroplasty) from September 2006 to
December 2008 were identified using current procedure
terminology codes. We arbitrarily chose this period of time
for the equal number of months before and after institution
of regional anesthesia for hip fracture repair, and to allow
for up to at least 1 year follow-up after the last discharge
date to assess 1 year mortality. The hospital’s decision
support services analyst provided the authors with demographic data, charges for surgery and hospitalization, hospital characteristics, outcomes (e.g., in-hospital mortality,
length of stay, number of intensive care unit (ICU) days,
ICU charge, and discharge facility), and insurance status.
Hospital charge data included physician fees, procedural
charges, and equipment charges. Cost of hospitalization
was estimated by applying the ratio of cost-to-charge for
urban hospitals in the South Atlantic division (Healthcare
Cost and Utilization Project, 2008 National Statistics) [9] to
the amount charged for hospitalization. International Classification of Diseases, ninth edition (ICD-9) codes for up to
15 diagnoses and procedures are listed for each admission. We reviewed the perioperative anesthesia records
and recorded type of intraoperative anesthesia (general vs
regional) and postoperative analgesia (systemic opioids vs
peripheral or neuraxial continuous nerve block). General
anesthesia included the use of inhalational with or without
intravenous agents for induction and maintenance of
anesthesia. Regional anesthesia included the use of a
neuraxial technique (single injection spinal, continuous
spinal, or continuous epidural anesthesia) with or without
the use of a continuous peripheral nerve block. Of note,
patients with failed neuraxial blockade who subsequently
underwent surgery using general anesthesia were
included in the general anesthesia (GA) group for analysis.
Patient Population
All surgeries were performed at a single hospital in an
academic setting. Patients were included in the retrospective review if their age was greater than or equal to 65
and if they sustained a low-impact hip fracture requiring
surgical stabilization.
We identified 319 patients who underwent a total of 324
surgeries for fragility hip fracture at UF&Shands between
September 2006 and December 2008. Patients who subsequently had a second low-impact hip fracture requiring
stabilization during the time period of the study who may
or may not have the same type of intraoperative anesthetic (N = 5) were not included in the analysis. Patients
with preexistent end-stage renal disease requiring dialysis
(N = 6) were not included in the analysis. Of the 308
patients included in the statistical analysis, 73 received
regional anesthesia and 235 received general anesthesia
intraoperatively.
Outcomes
We reviewed admission and discharge summaries from
the hospital’s electronic records to acquire information
about hospital readmission within 30 days of discharge
and reason for readmission. Information regarding number
of days of hospitalization, days from admission to surgical
stabilization, ICU length of stay, days on mechanical ventilation, in-patient mortality, ICD-9 codes for admission
diagnoses, condition and disposition at discharge, and
discharge facility were provided by the hospital’s decision
support services analyst.
Statistical Analysis
The primary outcomes of interest in this study were
in-hospital mortality, in-hospital complications, hospital
length of stay, and total costs (as estimated from hospital
charges). All categorical outcomes were adjusted using
multiple logistic regression models that included age,
race, gender, anesthesia type, day of admission (weekend
949
Le-Wendling et al.
vs weekday), admitting service, surgery delay, length of
stay, ICU admission, presence of cardiovascular disease,
chronic obstructive pulmonary disease, cancer, diabetes,
and dementia. For continuous outcomes, we used linear
regression models adjusted for the same factors as
above. In addition, because this was an observational
study, to adjust for the lack of randomization that could
result in large differences on the observed and unobserved patient characteristics between the general anesthesia and regional anesthesia groups, we used a
propensity scoring method to create an analysis that
resembled what would occur if the anesthesia had been
randomly assigned. This method allowed us to reduce the
bias that would result due to the lack of randomization of
subjects into anesthesia groups to properly estimate the
effect of anesthesia type on length of stay and hospital
charges. A propensity score, which is the probability of the
patient being assigned to general anesthesia rather than
regional anesthesia conditional on the patient’s demographic characteristics and comorbidities, was calculated
for each patient using the logistic regression. The propensity score weights, which are the inverse of the propensity
scores, were calculated and used in the analyses as
weight [10]. Propensity score-weighted linear regression
models were fitted to compare the effect of anesthesia
type on the cost of hospitalization and length of stay. Least
squares means were compared for the propensity score
adjusted and the unadjusted multiple regression models.
Linear regressions were performed using untransformed
Table 1
groups
costs because mean estimates obtained were similar to
those of alternative approaches that better account for
skewed data. The coefficient of determination, R2, was
calculated as an indicator of the proportion of variability
explained by each model. Length of stay and hospital
charges were compared among subgroups with analysis
of variance and Kruskal–Wallis test, then modeled in linear
regressions. For univariate analysis of categorical variables, we used Pearson c2 analyses or Fisher’s exact test
as appropriate. The goodness of fit of the logistic regression models was assessed with the Hosmer–Lemeshow
test, and c-statistics evaluated the discriminatory capability of the models. All significance tests were two-sided,
with an a of 0.05, which we considered to be statistically
significant. Statistical analyses were performed with SAS
(v.9.2, Cary, NC).
Results
We enrolled a total of 323 patients who underwent hip
fracture surgery for fragility hip fracture of whom 308 were
eventually submitted to the analysis. Univariate analysis
comparing patient characteristics between the GA and
regional anesthesia (RA) group are presented in Table 1.
Proportions of in-hospital mortality, nursing home discharge, and rehospitalization and median length of stay,
and estimated cost of hospitalization among subgroups
that are determined by baseline demographics and clinical
Comparison of demographics and comorbidities of patients in general and regional anesthesia
No. (%) of Patients
Overall
Age (years) (ⱖ80)
Male gender
African American race
Weekend admission
Medicine admitting service
Cardiovascular disease
Diabetes
Chronic obstructive pulmonary disease
Cancer
Dementia
Chronic renal disease
Postoperative ICU
Postoperative mechanical ventilation
Postoperative regional analgesia
Surgery day delay (days)
0–1
2–3
>3
ICU = intensive care unit.
950
Overall
General Anesthesia
(N = 235)
Regional Anesthesia
(N = 73)
308
186
79
22
83
88
151
66
85
20
36
53
64
18
128
132
64
18
74
68
119
57
66
13
30
40
53
17
64
54
15
4
9
20
32
9
19
7
6
13
11
1
64
236
55
17
175 (75%)
46 (20%)
14 (6%)
(56%)
(27%)
(8%)
(31%)
(29%)
(51%)
(24%)
(28%)
(6%)
(13%)
(17%)
(23%)
(6%)
(27%)
(74%)
(21%)
(5%)
(12%)
(27%)
(44%)
(12%)
(26%)
(10%)
(8%)
(18%)
(15%)
(1%)
(88%)
61 (85%)
9 (12%)
3 (4%)
P Value
0.0066
0.2532
0.5275
0.0013
0.7993
0.3098
0.0301
0.7312
0.2742
0.2909
0.8763
0.1686
0.0841
<0.0001
0.2748
Regional Anesthesia for Geriatric Patients
Table 2
Measures of health care use related to hip stabilization surgery, patients aged 65 or older
No. (%) of Patients
Overall
Age (years)
65–79
ⱖ80
Gender
Female
Male
Race
African American
Other
Anesthesia type
General anesthesia
Regional anesthesia
Admission day of week
Weekend
Weekday
Admitting service type
Medicine
Surgery
Cardiovascular disease
Yes
No
Diabetes
Yes
No
COPD
Yes
No
Cancer
Yes
No
Dementia
Yes
No
CKD
Yes
No
ICU
Yes
No
Surgery day delay (days)
0–1
2–3
>3
Median (Q1, Q3)
Overall
In-hospital
Mortality
Nursing Home
Discharges
(N = 297)
Rehospitalization
(N = 297)
308
11 (3.57)
173 (58.25)
59 (19.87)
5 (4, 7)
14,689 (11,823, 18,697)
122
186
2 (1.64)
9 (4.84)
55 (45.83)*
118 (66.67)
23 (19.17)
36 (20.34)
6 (4, 8)
5 (4, 7)
15,163 (12,378, 20,095)
14,161 (11,677, 17,923)
229
79
4 (1.75)*
7 (8.86)
126 (56.00)
47 (65.28)
44 (19.56)
15 (20.83)
5 (4, 7)
6(4, 8)
13,958 (11,731, 17,764)*
16,039 (12,948, 21,133)
22
286
3 (13.64)*
8 (2.80)
11 (57.89)
162 (58.27)
2 (10.53)
57 (20.50)
6 (4, 8)
5 (4, 7)
16,780 (13,571, 20,067)
14,601 (11,731, 18,642)
235
73
9 (3.83)
2 (2.74)
125 (55.31)
48 (67.61)
42 (18.58)
17 (23.94)
5 (4, 7)
5 (4, 7)
14,724 (11,731, 18,866)
13,812 (12,151, 18,480)
83
225
4 (4.82)
7 (3.11)
40 (50.63)
133 (61.01)
19 (24.05)
40 (18.35)
5 (4, 8)
6 (4, 7)
14,333 (10,884, 19,511)
14,718 (12,246, 18,646)
88
220
7 (7.95)*
4 (1.82)
51 (62.96)
122 (56.48)
21 (25.93)
38 (17.59)
7 (5, 10)*
5 (4, 6.5)
17,017 (14,106, 21,492)*
13,681 (11,463, 16,551)
151
157
8 (5.30)
3 (1.91)
91 (63.64)
82 (53.25)
32 (22.38)
27 (17.53)
6 (4, 9)*
5 (4, 7)
16,039 (13,299, 21,133)*
13,085 (10,921, 16,312)
66
242
0 (0)
11 (4.55)
41 (62.12)
132 (57.14)
20 (30.30)*
39 (16.88)
6 (4, 10)*
5 (4, 7)
15,371 (12,929, 21,331)
14,537 (11,710, 18,365)
85
223
3 (3.53)
8 (3.59)
50 (60.98)
123 (57.21)
23 (28.05)*
36 (16.74)
5 (4, 7)
5 (4, 8)
14,902 (12,286, 19,174)
14,623 (11,677, 18,646)
20
288
0 (0)
11 (3.82)
10 (50.00)
163 (58.84)
1 (5.00)
58 (20.94)
7.5 (5, 14)*
5 (4, 7)
19,923 (14,127, 24,423)*
14,459 (11,766, 18,082)
36
272
1 (2.78)
10 (3.68)
26 (74.29)
147 (56.11)
9 (25.71)
50 (19.08)
5 (4, 7)
5 (4, 7)
15,119 (11,776, 18,973)
14,647 (11,823, 18,697)
53
255
2 (3.77)
9 (3.53)
32 (62.75)
141 (57.32)
13 (25.49)
46 (18.70)
6 (4, 9)*
5 (4, 7)
15,306 (12,659, 20,646)
14,553 (11,710, 18,286)
64
244
8 (12.5)*
3 (1.23)
35 (62.50)
138 (57.26)
17 (30.36)*
42 (17.43)
9 (6, 13.5)*
5 (4, 7)
22,025 (17,539, 30,807)*
13,594 (11,398, 16,375)
236
55
17
5 (2.12)*
3 (5.45)
3 (17.65)
135 (58.44)
31 (59.62)
7 (50.00)
43 (18.61)
52 (25.00)
3 (21.43)
Length of
Stay (days)
5 (4, 7)*
7 (6, 10)
12 (9, 13)
Hospital Cost ($)
13,767 (11,398, 16,509)*
17,287 (13,795, 21,902)
22,868 (20,095, 25,488)
* Significant differences among subgroups, P value < 0.05.
COPD = chronic obstructive pulmonary disease; CKD = chronic kidney disease; ICU = intensive care unit.
characteristics are presented in Table 2. Of the 308
patients, 73 received regional anesthesia and 235
received general anesthesia. Frequency and type of
regional anesthesia and analgesia as well as surgical procedure is presented in Tables 3 and 4. The majority of RA
patients (96%) received continuous spinal anesthesia.
There were predominantly more females (N = 229) than
males (N = 79), and 188 patients were older than 80 years
of age.
The odds ratios (ORs) for in-hospital mortality, nursing
home discharge, and rehospitalization rates obtained by
multiple logistic regression (c-statistic = 0.949) are
reported in Table 5. A higher in-hospital mortality was
Table 3
Frequency of anesthesia
Frequency (%)
Type of Anesthesia
General anesthesia
Failed regional anesthesia, conversion
to general anesthesia
Continuous spinal catheter
Local with sedation
Single injection spinal
Combined spinal/epidural
222 (72%)
13 (4%)
70
1
1
1
(23%)
(0.3%)
(0.3%)
(0.3%)
951
Le-Wendling et al.
Table 4
Propensity score-weighted linear regression models on hospital cost and length of stay
R 2 = 75.4%
Hospital Cost ($)
R 2 = 33.18%
Length of Stay (days)
Predictors
Estimate (SE)
P Value
Estimate (SE)
P Value
Age (years)
Male gender (vs female)
African American race (vs other)
General anesthesia (vs regional)
Weekend admission (vs weekday)
Medicine admitting service (vs surgery)
Cardiovascular disease (yes vs no)
COPD (yes vs no)
Dementia (yes vs no)
Cancer (yes vs no)
Diabetes (yes vs no)
ICU (yes vs no)
In-hospital mortality (yes vs no)
Surgery day delay (hours) (2–3 vs 0–1)
(>3 vs 0–1)
Length of stay (day)
65
460
28
25
429
-1,128
410
921
645
2,290
-563
4,389
2,873
NA
NA
1,360
0.2140
0.3947
0.9759
0.9557
0.4159
0.0407*
0.4161
0.0850
0.3630
0.0358*
0.3339
<0.0001*
0.0365*
NA
NA
<0.0001*
0.05
0.93
-1.10
0.19
-1.27
0.36
0.75
-0.72
-0.88
2.46
0.85
2.95
-0.32
6.87
1.52
NA
0.3190
0.0562
0.1860
0.6438
0.0075*
0.5205
0.0974
0.1231
0.1710
0.0116*
0.1036
<0.0001*
0.7947
<0.0001*
0.0168*
NA
(52)
(539)
(925)
(457)
(527)
(549)
(504)
(521)
(708)
(1,086)
(582)
(655)
(1,368)
(61)
(0.05)
(0.49)
(0.83)
(0.41)
(0.47)
(0.56)
(0.45)
(0.47)
(0.64)
(0.97)
(0.52)
(0.56)
(1.23)
(1.04)
(0.63)
* Significant differences among subgroups, P value < 0.05.
COPD = chronic obstructive pulmonary disease; ICU = intensive care unit; NA = not applicable; SE = standard error.
Table 5
Regression on overall complications, pulmonary complications, and cardio complications
c-statistic
Hosmer-Lemeshow
goodness-of-fit test
0.7290
0.8592
0.7730
0.4780
0.8210
0.9513
Complications
Pulmonary Complications
Cardio Complications
Predictors
OR (CI for OR)
P Value
OR (CI for OR)
P Value
OR (CI for OR)
P Value
Age (years)
Male gender (vs female)
African American race
(vs other)
General anesthesia
(vs regional)
Weekday admission
(vs weekend)
Surgery admitting
service (vs medicine)
Cardiovascular disease
(yes vs no)
COPD (yes vs no)
Dementia (yes vs no)
Cancer (yes vs no)
Diabetes (yes vs no)
Surgery day delay
(hours) (2–3 vs 0–1)
(>3 vs 0–1)
1.0 (0.9, 1.1)
1.8 (0.9, 3.6)
0.7 (0.2, 2.6)
0.5822
0.0972
0.5462
1.0 (0.9, 1.1)
2.3 (1.0, 5.2)
1.5 (0.4, 6.2)
0.9472
0.0520
0.5752
1.0 (0.8, 1.1)
1.7 (0.6, 4.8)
0.4 (0.0, 3.9)
0.4485
0.2799
0.4409
1.7 (0.7, 4.1)
0.2056
2.2 (0.7, 7.2)
0.1751
1.7 (0.4, 6.3)
0.4534
2.1 (0.9, 4.8)
0.0712
1.9 (0.7, 5.1)
0.2287
1.8 (0.6, 5.7)
0.3069
1.4 (0.7, 3.2)
0.3730
2.0 (0.7, 5.3)
0.1758
2.4 (0.7, 8.0)
0.1427
3.1 (1.5, 6.4)
0.0019*
5.1 (1.9, 13.7)
0.001*
8.1 (2.2, 30.4)
0.0019*
1.5
2.1
1.1
0.8
1.2
0.2609
0.1165
0.9153
0.5211
0.6670
1.2
1.9
2.4
0.7
1.2
0.7336
0.2811
0.2152
0.5180
0.8012
2.3
1.9
1.5
1.1
0.7
0.0883
0.3465
0.6577
0.8728
0.6801
0.0387*
2.4 (0.5, 10.8)
0.2419
6.4 (1.5, 28.5)
(0.8,
(0.8,
(0.3,
(0.3,
(0.5,
3.0)
5.2)
3.9)
1.7)
3.0)
3.6 (1.1, 12.2)
(0.5,
(0.6,
(0.6,
(0.3,
(0.4,
2.8)
5.8)
9.6)
1.9)
3.4)
* Significant differences among subgroups, P value < 0.05.
CI = confidence interval; COPD = chronic obstructive pulmonary disease; OR = odds ratio.
952
(0.9,
(0.5,
(0.3,
(0.4,
(0.2,
6.1)
7.0)
8.1)
3.3)
3.1)
0.0143*
Regional Anesthesia for Geriatric Patients
Table 6
Propensity score-weighted linear regression models on hospital cost and length of stay
R 2 = 75.4%
Hospital Cost ($)
R 2 = 33.18%
Length of Stay (days)
Predictors
Estimate (SE)
P Value
Estimate (SE)
P Value
Age (years)
Male gender (vs female)
African American race (vs other)
General anesthesia (vs regional)
Weekend admission (vs weekday)
Medicine admitting service (vs surgery)
Cardiovascular disease (yes vs no)
COPD (yes vs no)
Dementia (yes vs no)
Cancer (yes vs no)
Diabetes (yes vs no)
ICU (yes vs no)
In-hospital mortality (yes vs no)
Surgery day delay (hours) (2–3 vs 0–1)
(>3 vs 0–1)
Length of stay (day)
65
460
28
25
429
-1,128
410
921
645
2,290
-563
4,389
2,873
NA
NA
1,360
0.2140
0.3947
0.9759
0.9557
0.4159
0.0407*
0.4161
0.0850
0.3630
0.0358*
0.3339
<0.0001*
0.0365*
NA
NA
<0.0001*
0.05
0.93
-1.10
0.19
-1.27
0.36
0.75
-0.72
-0.88
2.46
0.85
2.95
-0.32
6.87
1.52
NA
0.3190
0.0562
0.1860
0.6438
0.0075*
0.5205
0.0974
0.1231
0.1710
0.0116*
0.1036
<0.0001*
0.7947
<0.0001*
0.0168*
NA
(52)
(539)
(925)
(457)
(527)
(549)
(504)
(521)
(708)
(1086)
(582)
(655)
(1,368)
(61)
(0.05)
(0.49)
(0.83)
(0.41)
(0.47)
(0.56)
(0.45)
(0.47)
(0.64)
(0.97)
(0.52)
(0.56)
(1.23)
(1.04)
(0.63)
* Significant differences among subgroups, P value < 0.05.
COPD = chronic obstructive pulmonary disease; ICU = intensive care unit; NA = not applicable; SE = standard error.
associated with increasing age (OR, 1.6), male gender
(OR, 8.1), African American race (OR, 16.1), and ICU
admission (OR, 24.2). Anesthesia type was not found to
be significantly associated with in-hospital mortality. The
OR of nursing home discharge was significantly higher for
patients with dementia (OR, 2.6), whereas the OR of
rehospitalization was significantly higher for patients with
COPD (OR, 2.3) or diabetes (2.5). Cardiovascular disease
was associated with a higher overall complication rate and
higher cardiovascular and pulmonary complication rate.
Delay in surgery beyond 3 days was associated with
higher overall complication rate and a higher cardiovascular complication rate (Table 5).
Table 6 shows the propensity score-weighted regression
analysis results for estimated hospital cost and length of
stay. Although the median estimated cost of hospitalization was higher for patients admitted to the medicine
service (as compared with surgical admitting service),
admission by the department of internal medicine
Table 7
resulted in a lower cost of hospitalization after adjusting
for the demographic characteristics and comorbidities
than the admitting service of the department of surgery.
Patients with a diagnosis of cancer, patients who require
an admission to the ICU and patients who died or
stayed longer during hospitalization had higher estimated
costs of hospitalization. The mean estimated cost of
hospitalization ($16,789 vs $16,815) and mean length of
stay (6.4 vs 6.6 days) were not significantly different
between the patients undergoing hip fracture surgery
under regional anesthesia and general anesthesia
(Tables 7 and 8). Table 9 summarizes the effect of anesthesia type on complications and health care use; there
are no significant differences between the two anesthesia groups.
Discussion
In this study, we found that there is no added cost to the
institution for use of regional anesthesia, predominantly
Mean hospital cost ($) by anesthesia type: unadjusted vs propensity score adjusted models
Model
Anesthesia Type
Hospital
Cost ($)
Propensity score
adjusted model
Unadjusted model
General anesthesia
Regional anesthesia
General anesthesia
Regional anesthesia
16,815
16,789
16,816
16,877
95%
Confidence
Limits
16,172
16,158
16,246
15,835
17,457
17,420
17,386
17,919
P Value for
Difference
Difference
between
Means
95% Confidence
Limits for the
Difference
0.9557
25
-875
925
0.9209
-61
-1,263
1,142
953
Le-Wendling et al.
Table 8
Mean length of stay (days) by anesthesia type: unadjusted vs propensity score adjusted models
Model
Anesthesia Type
Length
of Stay
(days)
Propensity score
adjusted model
Unadjusted model
General anesthesia
Regional anesthesia
General anesthesia
Regional anesthesia
6.6
6.4
6.7
6.8
95%
Confidence
Limits
6.0
5.8
6.2
6.0
consisting of continuous spinal anesthesia for hip fracture
repair. Patients with continuous spinal anesthesia were
more likely to receive RA via continuous femoral and
lumbar paravertebral blocks, and these continuous blocks
remained in situ an average of two postoperative days.
Our group considers the use of RA in elderly patients to be
opioid sparing and thus desirable, though we did not
study this issue [11–13]. The fact that there was no significant increase in morbidity or mortality associated with
implementing RA for hip fracture repair [14] makes RA an
attractive modality for perioperative pain control, especially important during the preoperative period. Neuraxial
anesthesia, especially continuous spinal anesthesia
should be considered an option for the geriatric population
undergoing hip fracture surgery because of its ease of use
and relative safety in addition to the fact that it offers
optimal flexibility in the timing and duration of the surgery.
The potential to decrease intraoperative hypotension [15]
was also subjectively perceived to have been avoided.
Fragility hip fractures in the geriatric population can pose an
economic burden to the health care system because this
patient population is at risk for significant postoperative
morbidity and mortality. Most published studies investigate
perioperative parameters and their effects on postoperative morbidity and mortality with inconsistent results [16].
Table 9
Difference
between
Means
95% Confidence
Limits for the
Difference
0.6438
0.2
-0.6
1.0
0.7331
-0.2
-1.2
0.8
Little data exist on the economic impact of the type of
anesthesia used for hip surgery in the geriatric population.
One study noted a lower cost of intraoperative anesthesia
associated with using a single-injection spinal anesthesia
for intraoperative management. This study looked at only
the intraoperative period, not at cost for the entire hospital
stay [17]. Our average estimated cost of hospital stay for
hip fracture in the geriatric population is consistent with
literature published in the United States and similar to costs
published in Europe [2,17,18]. Kates et al. published a
lower median cost of hospitalization than the current study
($11,417), but they did not add surgeon and geriatrician
costs of care [19]. The current study includes all estimated
costs of hospitalization, including labor, procedures, and
equipment.
Continuous spinal anesthesia was felt to provide good
anesthesia with judicious dosing of local anesthetic to
allow for improved hemodynamic control and avoidance
of an invasive airway [14]. It also provided optimal flexibility
in scheduling, as patients with hip fractures are almost
always unscheduled and emergency surgery. The timing
of the end of surgery is usually not predictable, especially
in a large very busy training hospital and continuous spinal
anesthesia provided optimal timing flexibility and added
little, or in the case of this study, no additional risk. Patients
Complications and health care use as a function of anesthesia type
Hospital cost, adjusted mean (US $)
Length of stay, adjusted mean (days)
Complications (yes/no)
Pulmonary complications (yes/no)
Cardio complications (yes/no)
In-hospital mortality (yes/no)
Nursing home discharges (yes/no)
Rehospitalization (yes/no)
CI = confidence interval; OR = odds ratio.
954
7.1
6.9
7.1
7.7
P Value for
Difference
Regional anesthesia
General anesthesia
Regional anesthesia
General anesthesia
General vs regional
General vs regional
General vs regional
Regional vs general
Regional vs general
Regional vs general
Adjusted Mean
95% CI
16,789
16,815
6.38
6.57
(16,158, 17,420)
(16,172, 17,457)
(5.81, 6.93)
(5.99, 7.14)
OR
95% CI
1.7
2.2
1.7
1.0
1.7
2.0
(0.7,
(0.7,
(0.4,
(0.1,
(0.9,
(1.0,
4.1)
7.2)
6.3)
6.7)
3.1)
4.0)
Regional Anesthesia for Geriatric Patients
undergoing general anesthesia who failed tracheal extubation did so because of hemodynamic instability and
poor postoperative ventilation, especially in the presence
of preexistent pulmonary comorbidities. This study was
thus performed on the premise that the patients who
received RA would have lower incidences of postoperative
ventilator requirements as they would require less systemic anesthetic and analgesics, and thus have reduced
postoperative respiratory depression. Because ventilator
dependence would necessitate postoperative ICU admission, avoidance of postoperative respiratory depression
was believed to result in decreased cost of hospitalization,
and an intuitive notion that these patients would have
decreased morbidity and mortality. However, RA did not
influence morbidity, in-patient mortality, or the number of
patients who required postoperative ventilation via an
endotracheal tube, which was low in both the GA and RA
group. One patient in the RA group (1%) vs 10 patients in
the GA group (4%) required postoperative mechanical
ventilation. This makes it difficult to draw meaningful conclusions about this hypothesis. However, consistent
with results from previous publications, this study finds
that cost of hospitalization increased with delay in surgery.
ICU admission expectedly also increased the cost of
hospitalization.
This study differs from current literature in several ways. A
recent Cochrane review of randomized controlled trials
prescribing GA vs RA showed borderline improvement of
short-term mortality and decreased postoperative delirium
with regional anesthesia, but no long-term differences [20].
Radcliff retrospectively reviewed a large database of Veterans Administration patients with hip fractures and showed
increased short-term mortality associated with intraoperative GA (vs RA). However, they did not investigate any role
for peripheral nerve blockade for postoperative pain relief
[21]. Pedersen assessed the implementation of a pathway,
which included early anesthesia evaluation, optimization of
fluid and electrolyte balance, nutritional assessment, and a
social service consult in addition to postoperative pain
management with a peripheral nerve block [22], and demonstrated a reduction in opioid requirements, postoperative complications and mortality. None of the cited studies
used continuous intrathecal catheters for intraoperative
anesthesia nor did they look at the financial implications of
different treatments.
A weakness of this study includes its retrospective nature.
Furthermore, the authors did not adjust the estimated cost
of hospitalization data for inflation, but because the patient
cohort was selected over a period of less than 2 years, it
was felt that inflation would not alter the data significantly.
Hospital charge data were collected instead of cost data,
however, because cost-to-charge ratio for hospitals can
be inferred using the cost-to-charge ratio from the Healthcare Cost and Utilization Project, this number was felt to
adequately reflect cost of hospitalization of these patients.
Data collected with regard to complications and comorbid
conditions were based on ICD-9 codes, and therefore, the
accuracy of the information collected is subject to the
accuracy of the actual coding itself.
The fact that the type of surgical anesthesia did not alter
the patient’s cost of hospitalization or postoperative morbidity and mortality may be a result of the complexity of
the patients’ medical history and the number of surgical
and medical factors that all can contribute to the outcomes or it may simply reflect the natural coarse of life in
this population, which consisted of 188 of 306 patients
older than 80 years.
Conclusion
There is no difference in cost of hospitalization, rehospitalization rates, postoperative morbidity, and in-patient
mortality in geriatric patients, the majority being older than
80 years, undergoing regional vs general anesthesia for
hip fracture repair. Delay in surgery beyond 3 days and
ICU admission both increase the cost of hospitalization in
geriatric patients that receive surgery for hip fracture.
Acknowledgment
A special thanks to Christine Bono, PhD, decision support
services analyst for the acquisition of financial data.
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