• Mark D Neuman, Paul R Rosenbaum, Justin M Ludwig, Jose R Zubizarreta, and Jeffrey H Silber.
• Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia2Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania.
• JAMA. 2014 Jun 25; 311 (24): 2508-17.

ImportanceMore than 300,000 hip fractures occur each year in the United States. Recent practice guidelines have advocated greater use of regional anesthesia for hip fracture surgery.ObjectiveTo test the association of regional (ie, spinal or epidural) anesthesia vs general anesthesia with 30-day mortality and hospital length of stay after hip fracture.Design, Setting, And PatientsWe conducted a matched retrospective cohort study involving patients 50 years or older who were undergoing surgery for hip fracture at general acute care hospitals in New York State between July 1, 2004, and December 31, 2011. Our main analysis was a near-far instrumental variable match that paired patients who lived at different distances from hospitals that specialized in regional or general anesthesia. Supplementary analyses included a within-hospital match that paired patients within the same hospital and an across-hospital match that paired patients at different hospitals.ExposuresSpinal or epidural anesthesia; general anesthesia.Main Outcomes And MeasuresThirty-day mortality and hospital length of stay. Because the distribution of length of stay had long tails, we characterized this outcome using the Huber M estimate with Huber weights, a robust estimator similar to a trimmed mean.ResultsOf 56,729 patients, 15,904 (28%) received regional anesthesia and 40,825 (72%) received general anesthesia. Overall, 3032 patients (5.3%) died. The M estimate of the length of stay was 6.2 days (95% CI, 6.2 to 6.2). The near-far matched analysis showed no significant difference in 30-day mortality by anesthesia type among the 21,514 patients included in this match: 583 of 10,757 matched patients (5.4%) who lived near a regional anesthesia-specialized hospital died vs 629 of 10,757 matched patients (5.8%) who lived near a general anesthesia-specialized hospital (instrumental variable estimate of risk difference, -1.1%; 95% CI, -2.8 to 0.5; P = .20). Supplementary analyses of within and across hospital patient matches yielded mortality findings to be similar to the main analysis. In the near-far match, regional anesthesia was associated with a 0.6-day shorter length of stay than general anesthesia (95% CI, -0.8 to -0.4, P < .001). Supplementary analyses also showed regional anesthesia to be associated with shorter length of stay, although the observed association was smaller in magnitude than in the main analysis.Conclusions And RelevanceAmong adults in acute care hospitals in New York State undergoing hip repair, the use of regional anesthesia compared with general anesthesia was not associated with lower 30-day mortality but was associated with a modestly shorter length of stay. These findings do not support a mortality benefit for regional anesthesia in this setting.

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