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HIP ATTACK TRIAL

This trial has not demonstrated that a major redesign of the pathway for patients with hip fractures and allocation of additional resources to achieve a reduced time to surgery would provide significant benefit in terms of mortality, major complication or long term morbidity. Increased utility of regional anaesthesia may provide an alternative method of reducing pain and the stress response associated with a hip fracture whilst improving patient satisfaction.

HIP ATTACK Study

Background

Management of hip fractures is an important issue for health systems worldwide. Hip fractures associated with high morbidity and mortality.

The main aim of the study was to assess whether reducing the time from diagnosis to surgery could reduce morbidity and mortality.

 

Study design

Prospective, multinational, multicentre, randomised trial with unblinded treating clinicians and blinded analysing clinicians due to the nature of the intervention.

Intervention – accelerated surgery group with a goal of 6hr from diagnosis to treatment. Facilitated by early assessment from perioperative physicians and priority theatre booking.

Control – Standard care

Positive aspects of study design

  • Large, well powered study
  • Multi-centre, multi-national
  • Primary outcomes, secondary outcomes and subgroup analysis pre-defined, relevant and patient centred.
  • Good statistical methods for analysis and management of potential effect of having coprimary outcomes by using a fallback procedure
  • Well powered with nearly complete recruitment of intended sample size
  • Analysis of effect of time from fracture to presentation on outcome also included.
  • ‘Intention to treat analysis’ arguably not a true intention to treat analysis – will be discussed later

 

Limitations of study design

  • 58.1% of all patients screened excluded simply because of time of presentation. To be used as a guideline, any new standard needs to be applicable to the majority of the affected population particularly if it is to be linked to hospital remuneration. Any intervention that is targeted at a subgroup of hip fracture patients risks compromising care for those outside the intervention group as surgery may be delayed to accommodate the target population.
  • 21.2% of the remaining eligible patients were not enrolled due to lack of available theatre space – arguably these should have been included in any intention to treat analysis.
  • Treating clinicians unblinded – unavoidable
  • Potential solution would be to have an intervention arm with a target of 12 hr from diagnosis to surgery and allow operating including from 0800-2200 although in the UK this would likely require increased consultant presence for these high risk patients.

 

 

Results – key summary

 

27701 screened, 7780 deemed eligible, 1643 excluded due to lack of resource, 1009 not identified before surgery.

1487 in accelerated care group, 1483 in standard care group.

Intervention and control group demographics/comorbidities well matched.

Significant difference in time to surgery from diagnosis between the groups, median difference 18hr.

No significant difference in either of the coprimary outcomes (mortality or major complication) between either of the groups

Of the 20 pre-defined secondary outcomes only the rates of stroke and delirium showed a statistically significant reduction in the intervention group. This difference was not then reflected in the number of patients requiring new placement in a nursing home.

 

Discussion

Important topic for patient outcomes, resource allocation and health economics.

Intervention not easily applicable to a UK population of hip fractures. Alternative study design may have been more pragmatic. Difficult to apply to UK population as significant investment in resources required to deliver intervention and potential negative impact on other groups of surgical patients both emergency and elective (and out-of-hours presentations of hip fractures).

No significant effect on coprimary outcomes.

Reduction in stroke and delirium potentially not reflected in long term morbidity of patients represented by no difference in new nursing home placements.

Patients presenting with low energy hip fractures remain a complex group with significant morbidity and mortality.  This trial has not demonstrated that a major redesign of the pathway for patients with hip fractures and allocation of additional resources to achieve a reduced time to surgery would provide significant benefit in terms of mortality, major complication or long term morbidity. Increased utility of regional anaesthesia may provide an alternative method of reducing pain and the stress response associated with a hip fracture whilst improving patient satisfaction.

 

Summary by

Dr Rob Golding

ST 4 Anaesthesia

Sandwell and West Birmingham Hospitals NHS Trust