Comparative Effectiveness of Regional versus General Anesthesia for Hip Fracture Surgery in Adults Mark D. Neuman, M.D., M.Sc.,* Jeffrey H. Silber, M.D., Ph.D.,† Nabil M. Elkassabany, M.D.,‡ Justin M. Ludwig, M.A.,§ Lee A. Fleisher, M.D. ABSTRACT Background: Hip fracture is a common, morbid, and costly event among older adults. Data are inconclusive as to whether epidural or spinal (regional) anesthesia improves outcomes after hip fracture surgery. Methods: The authors examined a retrospective cohort of patients undergoing surgery for hip fracture in 126 hos- pitals in New York in 2007 and 2008. They tested the association of a record indicating receipt of regional versus general anesthesia with a primary outcome of inpatient mortality and with secondary outcomes of pulmonary and cardiovascular complications using hospital fixed-effects logistic regressions. Subgroup analyses tested the associa- tion of anesthesia type and outcomes according to fracture anatomy. Results: Of 18,158 patients, 5,254 (29%) received re- gional anesthesia. In-hospital mortality occurred in 435 (2.4%). Unadjusted rates of mortality and cardiovascular complications did not differ by anesthesia type. Patients receiving regional anesthesia experienced fewer pulmo- nary complications (359 [6.8%] vs. 1,040 [8.1%], P  0.005). Regional anesthesia was associated with a lower adjusted odds of mortality (odds ratio: 0.710, 95% CI 0.541, 0.932, P = 0.014) and pulmonary complications (odds ratio: 0.752, 95% CI 0.637, 0.887, P  0.0001) relative to general anesthesia. In subgroup analyses, re- gional anesthesia was associated with improved survival and fewer pulmonary complications among patients with intertrochanteric fractures but not among patients with femoral neck fractures. Conclusions: Regional anesthesia is associated with a lower odds of inpatient mortality and pulmonary complications among all hip fracture patients compared with general anes- thesia; this finding may be driven by a trend toward im- proved outcomes with regional anesthesia among patients with intertrochanteric fractures. * Assistant Professor, Department of Anesthesiology and Crit- ical Care, University of Pennsylvania School of Medicine, Phila- delphia, Pennsylvania, and Senior Fellow, Leonard Davis Insti- tute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania. † Professor, Departments of Pediat- rics and Anesthesiology and Critical Care, University of Pennsyl- vania School of Medicine; Director, Center for Outcomes Re- search, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania. ‡ Assistant Pro- fessor, Department of Anesthesiology and Critical Care, Univer- sity of Pennsylvania School of Medicine. § Statistical Program- mer, Center for Outcomes Research, Children’s Hospital of Philadelphia.  Professor and Chair, Department of Anesthesiol- ogy and Critical Care, University of Pennsylvania School of Med- icine, and Senior Fellow, Leonard Davis Institute of Health Eco- nomics, University of Pennsylvania. Received from the Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania. Submitted for publication July 21, 2011. Accepted for publication February 27, 2012. Supported by Foundation for Anesthesia Ed- ucation and Research, Rochester, Minnesota, grant MRTG-02/15/ 2011 (to Dr. Neuman), and by the Department of Anesthesiology, University of Pennsylvania. The funding source did not play a role in the study design, the collection, analysis, and interpreta- tion of data, or the writing of the article and the decision to submit it for publication. This work was presented at the 58th Annual Meeting of the Association of University Anesthesiolo- gists, Philadelphia, Pennsylvania, May 12, 2011, and at the Meet- ing of the Orthopedic Anesthesia Pain Rehabilitation Society, Chicago, Illinois, October 14, 2011. Address correspondence to Dr. Neuman: Department of Anes- thesiology and Critical Care, University of Pennsylvania, 1117 Block- ley Hall, 423 Guardian Drive, Philadelphia, Pennsylvania 19104. neumanm@mail.med.upenn.edu. This article may be accessed for personal use at no charge through the Journal Web site, www. anesthesiology.org. Copyright © 2012, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology 2012; 117:72–92  This article is featured in “This Month in Anesthesiology.” Please see this issue of ANESTHESIOLOGY, page 9A. What We Already Know about This Topic • Some prospective and observational studies demonstrate re- duced major morbidity and mortality with regional compared with general anesthesia for hip fractures • No large observational study in the general, nonveteran popu- lation, has examined this issue What This Article Tells Us That Is New • In a review of more than 18,000 patients having surgery for hip fracture in New York in 2007 and 2008, use of regional anes- thesia was associated with a 25–29% reduction in major pul- monary complications and death Anesthesiology, V 117 • No 1 July 2012 72