International Journal for Quality in Health Care, 2018, 1–7

doi: 10.1093/intqhc/mzy233
Article

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Article

Comparison of regional with general anesthesia

on mortality and perioperative length of stay in
older patients after hip fracture surgery
TAKUMI NISHI1, TOSHIKI MAEDA2, TAKUYA IMATOH3,
and AKIRA BABAZONO4
1
Department of Research Planning and Information Management, Fukuoka Institute of Health and Environmental
Sciences, 39 Mukaizano, Dazaifu-shi, Fukuoka 818-0135, Japan, 2Department of Preventive Medicine and Public
Health, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan, 3Division of Medicinal Safety
Science, National Institute of Health Sciences, 3-25-26 Tonomachi, Kawasaki-ku, Kanagawa 210-9501, Japan, and 4
Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu
University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan

Address reprint requests to: Takumi Nishi, Department of Research Planning and Information Management, Fukuoka
Institute of Health and Environmental Sciences, 39 Mukaizano, Dazaifu-shi, Fukuoka 818-0135, Japan. Tel: +81-92-921-
9941; Fax: +81-92-928-1203; E-mail: nishi@fihes.pref.fukuoka.jp
Editorial Decision 16 October 2018; Accepted 29 October 2018

Abstract
Objective: The aim of this study was to examine whether anesthetic technique is associated with
30- or 90-day mortality and perioperative length of stay (LOS).
Design: We used a retrospective cohort design using a healthcare insurance claims database.
Setting: The Fukuoka Prefecture’s claims database of older patients who underwent hip fracture
surgery under general or regional (spinal or epidural) anesthesia from April 2012 to March 2016
was used for analyses.
Participants: The database under analyses contained 16 125 participants of hip fracture surgery
under general or regional anesthesia.
Main Outcome Measure: We measured 30- and 90-day mortalities and perioperative LOS.
Results: In a propensity score-matched cohort, we found no significant differences in 30- and 90-
day mortalities after adjusting for confounding factors. The reconverted perioperative LOS for the
general and regional anesthesia groups was, respectively, 29.7 (29.1–30.4) and 28.0 (27.4–28.6) days
in the matched cohort. Therefore, the perioperative LOS in the regional anesthesia group was sig-
nificantly shorter by 1.7 days than in the general anesthesia group (P < 0.001).
Conclusions: This study demonstrated that the use of regional anesthesia was not associated with
30- or 90-day mortality, but it was associated with slightly shorter perioperative LOS. Since Japan
has much longer LOS than other countries, our findings have implications for more efficient
healthcare resource utilization and quality assurance in geriatric care.

Key words: anesthetic technique, mortality, length of stay, claims data, propensity score matching

© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved.
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2 Nishi et al.
Introduction
Internationally, hip fracture is a common injury in geriatric popula-
tions: the estimated worldwide incidence of hip fracture was 1.66
million cases in 1990 and it is expected to increase to 4.5–6.26 mil-
lion cases by 2050 [1, 2]. Japan has a rapidly aging population,
with 34.61 million people (27.3% of the total population) having
been aged 65 years or older in 2016 [3]; there, the estimated number
of new hip fracture patients increased from 53 200 in 1987 to
175 700 in 2012 [4]. As well as the increased incidence, it has been
reported that the average length of stay (LOS) for hip fracture in
Japanese hospital general wards was 41.4 days in 2014—much
longer than in USA (5.8 days for acute femoral neck fracture in
2010) and UK (20.2 and 15.9 days for acute care in 2014) [5–7].
However, hip fracture is treated mainly by orthopedic surgery; it
has been observed that in Japan, 94.1% of patients were treated by
hip fracture surgery within 5 days after hospitalization [8]. Several
studies have examined postoperative prognosis: mortality was report-
edly 9.6% at 30 days in the UK [9]; overall in-hospital mortality was
3.3% (2.1% in patients undergoing surgical treatment) in Japan [10].
Various factors have been examined regarding their effect on
prognosis and healthcare resource utilization following hip fracture
surgery; however, the impact of anesthetic techniques on the out-
comes is still controversial. Also in Japan, clinical practice guideline
for femoral neck and trochanteric fractures states that either general
or regional anesthesia is appropriate [11]. As yet, no studies have
been undertaken in this area and the effect of anesthetic technique
on prognosis and healthcare resource utilization remains unclear in
Japan. Accordingly, the present study aimed to clarify whether anes-
thetic technique is associated with 30- or 90-day mortality and peri-
operative LOS using Japanese regional claims database.
Methods
Participant selection
We used claims data from the Fukuoka Prefecture Regional
Association for Late-Stage Healthcare for Older People for fiscal
2012–15. We obtained claims data on insurance beneficiaries hospi-
talized between 1 April 2012 and 31 March 2016. We extracted the
data from 34 344 inpatient records involving a primary diagnosis,
or dominant care resource use, of hip fracture according to the
International Classification of Diseases, 10th revision (ICD10;
codes: S72.0-2). Claims data contain information about all proce-
dures, drugs and devices indexed in the national fee schedule; stand-
ard codes are assigned to each [12]. From those records, we
extracted data for 22 324 patients who had undergone hip fracture
surgery under general or regional (spinal or epidural) anesthesia.
After excluding duplicate or inappropriate admission records,
we eliminated the following insurance beneficiaries: (i) those who
underwent multiple anesthesia; (ii) those admitted to wards other
than general or acute care wards; (iii) those aged 65–74 years at first
admission (only individuals aged ≥75 or 65–74 years with a specific
disability, such as hemodialysis recipients are eligible for Japan’s
late-stage older people’s health care); (iv) those with multiple frac-
tures and (v) those who underwent mixed anesthesia.
Ethical approval for this study (No. 27-15) was obtained from the
Ethics Committee of Life Science, Fukuoka Institute of Health and
Environmental Sciences, Fukuoka, Japan, on 5 October 2015. The
study used anonymized claims data, so the need to obtain informed
consent was waived in line with the Ethical Guidelines for Medical
and Health Research Involving Human Subjects in Japan [13].
Measured variables
We categorized the subjects into the general or regional anesthesia
group. Clinical practice guideline in Japan recommends total hip
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arthroplasty (THA) for active patients with femoral neck fracture;
bipolar hip arthroplasty (BHA) is indicated for inactive or older
patients [11]. Furthermore, one study in Japan has excluded few
patients underwent THA due to fracture to select elective surgery
cases to minimize case-mix heterogeneity [14]. Therefore, we sepa-
rated patients into three surgical procedure groups: osteosynthesis,
THA and BHA. Additionally, we classified the timing of surgery for
patient case-mix adjustment as follows: admission day or next day
and ≥2 days after admission.
Fracture types were categorized into subtrochanteric, intertro-
chanteric and femoral neck fracture groups. The types of claims
data included both the diagnosis procedure combination/per diem
payment system (DPC/PDPS) and fee for-service system. In Japan,
the DPC/PDPS has been adopted by almost all acute hospitals and is
a case-mix patient classification system [15].
We categorized other complications and comorbidities using
ICD10 codes, and we used the Charlson comorbidity index (CCI) to
evaluate severity [16, 17]. Based on the CCI, we categorized patients
into four groups: 0, 1, 2 and 3 or higher [18]. The fee schedule is
revised every 2 years, so we divided the fiscal year of admission into
two periods: fiscal 2012–13 and fiscal 2014–15.
Outcome measurement
We calculated perioperative LOS by summing LOS in DPC/PDPS
wards and the number of charged days in general wards. The date
of death was obtained from the administrative list of deceased bene-
ficiaries with lost qualification. We defined 30- and 90-day mortal-
ities from the dates of death and surgery.
Propensity score matching
We conducted 1:1 propensity score matching in order to reduce the
effects of confounding factors including gender, age, type of claim,
procedure, timing of procedure, admission day, fracture types,
admission fiscal year and comorbidities. And we compared mortality
and perioperative LOS between regional and general anesthesia
groups after matching. In accordance with previous studies on vari-
able selection with propensity score matching [19–21], we calculated
propensity scores using a logistic regression model. We aimed to
identify the relationship between regional anesthesia and history
within 1 year before admission of the following: hip fracture sur-
gery; chronic obstructive pulmonary disease and treatment with psy-
choactive agents, antiplatelets or anticoagulants. As practice style
differed by regions or hospitals, we introduced dummy variables for
62 residential municipalities in Fukuoka Prefecture (i.e. 61 variables)
and the interaction terms of residential municipalities and types of
claims in propensity score estimation model, in addition to age, sex
and the other covariates listed earlier. We employed the Hosmer
−Lemeshow test and C statistic as indicators of how well the logistic
regression model fitted the data. The C statistic was 0.753, and the
Hosmer−Lemeshow test did not reject the null hypothesis
(P = 0.263). Finally, each patient of the regional anesthesia group
was matched with a unique control in the general anesthesia group
within a caliper width of 0.02 [22]. As shown in Fig. 1, the number
of subjects was 9520 (59.0%) in the general anesthesia group and
6605 (41.0%) in the regional anesthesia group; we obtained 4708
pairs from them.
Anesthesia for hip surgery
Initial participants
34,344 admission records
Study subjects
16,125 beneficiaries
General anesthesia group Regional anesthesia group
9,520 beneficiaries (59.0%) 6,605 beneficiaries (41.0%)
4,708 matched
Figure 1 Flowchart of inclusion and exclusion criteria.
Statistical analyses
We summarized the characteristics of the study subjects using fre-
quency and proportions for categorical variables and mean and
standard deviation (SD) for continuous variables. We employed
standardized differences to check the balance between the regional
and general anesthesia groups. We set 0.10 as the threshold value
for acceptable standardized differences. We compared mortality
between the regional and general anesthesia groups using Pearson’s
Chi-square test. We made comparisons of perioperative LOS using
the unpaired t-test and assumed unequal variance.
Multiple logistic regression analyses were used to estimate the
adjusted effects on mortality. We employed a generalized linear
model (GLM) with a log-link function and gamma distribution to
estimate the effects of anesthetic techniques on perioperative LOS
and to control for other confounding factors. We used exponential
transformed coefficients of those models, the odds ratio in logistic
models and a multiplicative effect in GLM to evaluate the relative
effects of covariates. Furthermore, we reconverted coefficients to the
original units of mortality (%) and perioperative LOS (days) by esti-
mating marginal effects and 95% confidence intervals (CIs).
All statistical analyses used STATA for Windows, version 15.1
(StataCorp, College Station, TX, USA). The level of statistical sig-
nificance was set at 0.05.
Results
Descriptive statistics
As evident in Table 1, the mean age was significantly higher in the
regional anesthesia than in the general anesthesia group: mean (SD)
for general anesthesia, 86.1 (5.7), and for regional anesthesia, 86.7
(5.8) (P < 0.001). The proportions for DPC/PDPS claims, osteo-
synthesis and intertrochanteric fracture were higher in the regional
anesthesia group; the proportions for femoral neck fracture, hip
fracture surgery performed ≥2 days after admission, CCI ≥2 and
3
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Exclusion criteria
Without surgery: 12,020 (35.0%)
Inappropriate or duplicated admission records: 1,255 (3.7%)
Patients underwent multiple anesthesia: 458 (1.3%)
Patients admitted to wards other than general or acute-care
wardst: 2,676 (7.8%)
Patients aged 65–74 years at first admission: 423 (1.2%)
Patients with multiple fractures: 164 (0.5%)
Patients underwent mixed anesthesia: 1,223 (3.6%)
Total: 18,219 records were excluded.
4,708 matched
subjects admitted in fiscal 2014–15 were higher in the general anes-
thesia group. The mean CCI was higher in the general anesthesia
than in the regional anesthesia group: mean (SD) for general anes-
thesia, 1.1 (1.3), and for regional anesthesia, 1.0 (1.2) (P < 0.001).
Other than sex, there were significant imbalances between the two
groups.
The patient characteristics after propensity score matching
appear in Table 2. All imbalances that existed before propensity
score matching disappeared and the standardized differences of cov-
ariates were at an acceptable level.
Comparison of outcomes
Table 3 shows the comparison of outcomes in the unmatched and
matched cohorts. In the unmatched cohort, 98 (1.0%) subjects died
within 30 days after hip fracture surgery in the general anesthesia
group and 77 (1.2%) subjects did so in the regional anesthesia group.
Within 90 days after hip fracture surgery, 364 (3.8%) subjects died in
the general anesthesia group and 265 (4.0%) subjects did so in the
regional anesthesia group. There were no significant differences in 30-
and 90-day mortalities. However, the regional anesthesia group had a
significantly shorter perioperative LOS (2.1 days) than the general
anesthesia group: mean (95% CI), 30.4 (29.9–30.8) days in the gen-
eral anesthesia group and 28.3 (27.8–28.7) days in the regional anes-
thesia group (P < 0.001). After adjusting for confounding factors,
there were no significant differences in 30- and 90-day mortalities.
The reconverted perioperative LOS for the general and regional anes-
thesia groups was 29.9 (29.5–30.4) and 28.9 (28.4–29.4) days,
respectively. Thus, the regional anesthesia group had a significantly
shorter perioperative LOS (1.0 days) than the general anesthesia
group (P = 0.002).
Similarly, even after adjusting for confounding factors, there were
no significant differences in 30- and 90-day mortalities in the matched
cohort. The unadjusted perioperative LOS was significantly shorter
by 1.7 days in the regional anesthesia than in the general anesthesia
4 Nishi et al.

Table 1 Baseline characteristics of subjects by anesthetic technique for hip fracture surgery

Anesthetic technique Absolute standardized P-value

difference

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General Regional
(N = 9520) (N = 6605)

Age
Mean (SD) 86.1 (5.7) 86.7 (5.8) 0.104 <0.001
Sex
Male 1642 (17.2%) 1125 (17.0%) 0.006 0.721
Female 7878 (82.8%) 5480 (83.0%)
Type of claim
FFS 2648 (27.8%) 1264 (19.1%) 0.206 <0.001
DPC 6872 (72.2%) 5341 (80.9%)
Procedure
Osteosynthesis 6066 (63.7%) 4873 (73.8%) 0.014 <0.001
Total hip arthroplasty 59 (0.6%) 12 (0.2%) 0.153
Bipolar hip arthroplasty 3395 (35.7%) 1720 (26.0%) 0.150
Timing of procedure
Admission day or day after 2869 (30.1%) 2645 (40.0%) 0.209 <0.001
≥2 days after admission 6651 (69.9%) 3960 (60.0%)
Type of fracture
Subtrochanteric 191 (2.0%) 120 (1.8%) 0.014 <0.001
Intertrochanteric 4879 (51.3%) 3887 (58.8%) 0.153
Femoral neck 4450 (46.7%) 2598 (39.3%) 0.150
Charlson comorbidity index
Mean (SD) 1.1 (1.3) 1.0 (1.2) 0.066 <0.001
0 4008 (42.1%) 2922 (44.2%) 0.043 0.001
1 2851 (29.9%) 2015 (30.5%) 0.012
2 1529 (16.1%) 993 (15.0%) 0.028
≥3 1132 (11.9%) 675 (10.2%) 0.053
Admission fiscal year
2012–13 4379 (46.0%) 3260 (49.4%) 0.067 <0.001
2014–15 5141 (54.0%) 3345 (50.6%)

FFS, fee for service.

group: mean (95% CI), 29.7 (29.0–30.4) days in the general anesthe-
sia group and 28.0 (27.5–28.6) days in the regional anesthesia group
(P < 0.001). Furthermore, the reconverted perioperative LOS for the
general and regional anesthesia groups was 29.7 (29.1–30.4) and
28.0 (27.4–28.6) days, respectively. Therefore, the perioperative LOS
of the regional anesthesia group was significantly shorter by 1.7 days
than in the general anesthesia group (P < 0.001)
Discussion
In this study, we examined the impact of anesthetic techniques on
mortality and perioperative LOS in older patients following hip frac-
ture surgery in Fukuoka Prefecture, Japan. We found that the use of
regional anesthesia was not associated with 30- or 90-day mortality,
but it was associated with relatively short perioperative LOS.
To the best of our knowledge, this is the first study to compare
mortality and LOS between anesthetic techniques in Japan. The
healthcare system and resource utilization are different in Japan
from previously reported countries, so this study makes a notable
important contribution to the literature. Based on the evidence from
two meta-analyses, Japanese clinical practice guideline states that
either general or regional anesthesia is appropriate [11]. One meta-
analysis integrated the results from randomized or quasi-
randomized control trials. It reported that regional anesthesia was
associated with decreased mortality at 1 month after surgery; how-
ever, the results from six trials for 3-month mortality were not stat-
istically significant [23]. Another meta-analysis compared the
survival of patients who had undergone surgical repair of femoral
neck fracture with respect to anesthetic technique: only the incidence
of deep vein thrombosis was clearly greater in patients receiving gen-
eral anesthesia, but there were no significant differences for blood
loss or mortality [24]. Recent large observational studies for anes-
thetic techniques during hip fracture surgery or joint replacement
surgery for the lower extremities have produced conflicting results.
Some investigations reported that regional anesthesia was associated
with lower risk of postoperative complications or mortality [25–28];
others found no significant difference in mortality [29–34]. Basque
et al. reported that a general anesthesia group had shorter LOS [35].
However, our findings are similar to those reported in USA, UK
and Taiwan with respect to mortality among anesthetic techniques
[29, 31, 32, 34]. In particular, our assessment of the relative effect of
regional anesthesia on perioperative LOS is similar to that found in
previous studies, though we observed considerably longer LOS
[29, 32]. Given that LOS in Japan is much longer than in USA or
UK [5–7], reducing the perioperative LOS in Japan could have a major
economic impact. Therefore, if either type of anesthesia could be used
on a patient for hip fracture surgery, regional anesthesia would be
attractive in terms of effective healthcare resource utilization.
However, it is necessary to be cautious when interpreting results
that are not statistically significant but show a positive association
with 30- and 90-day mortalities. The mortality we found was lower
than that determined in previous studies. With inpatients aged 65
years or older after hip fracture surgery, Kondo et al. observed sig-
nificantly longer LOS and better survival in three Japanese hospitals
Anesthesia for hip surgery 5

Table 2 Subject characteristics after propensity score matching by anesthetic technique for hip fracture surgery

Anesthetic technique Absolute standardized difference P-value

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General Regional
(N = 4708) (N = 4708)

Age
Mean (SD) 86.6 (5.7) 86.5 (5.8) 0.019 0.369
Sex
Male 771 (16.4%) 806 (17.1%) 0.020 0.334
Female 3937 (83.6%) 3902 (82.9%)
Type of claim
FFS 1054 (22.4%) 1042 (22.1%) 0.006 0.766
DPC 3654 (77.6%) 3666 (77.9%)
Procedure
Osteosynthesis 3316 (70.4%) 3330 (70.7%) 0.007 0.756
Total hip arthroplasty 9 (0.2%) 12 (0.3%) 0.014
Bipolar hip arthroplasty 1383 (29.4%) 1366 (29.0%) 0.008
Timing of procedure
Admission day or day after 1711 (36.3%) 1726 (36.7%) 0.007 0.748
≥2 days after admission 2997 (63.7%) 2982 (63.3%)
Type of fracture
Subtrochanteric 91 (1.9%) 92 (2.0%) 0.002 0.997
Intertrochanteric 2662 (56.5%) 2660 (56.5%) 0.001
Femoral neck 1955 (41.5%) 1956 (41.5%) 0.000
Charlson comorbidity index
Mean (SD) 1.0 (1.2) 1.0 (1.2) 0.012 0.575
0 2057 (43.7%) 2003 (42.5%) 0.023 0.687
1 1447 (30.7%) 1463 (31.1%) 0.007
2 695 (14.8%) 724 (15.4%) 0.017
≥3 509 (10.8%) 518 (11.0%) 0.006
Admission fiscal year
2012–13 2313 (49.1%) 2262 (48.0%) 0.022 0.293
2014–15 2395 (50.9%) 2446 (52.0%)

FFS, fee for service.

Table 3 Comparison of study outcomes by matched and unmatched subjects

Unmatched P-value Matched P-value

Anesthetic technique Anesthetic technique

General Regional General Regional

(reference) (reference)

Unadjusted
Number of subjects 9,520 6,605 4,708 4,708
30-Day mortality, n (%) 98 (1.0%) 77 (1.2%) 0.411* 48 (1.0%) 58 (1.2%) 0.488*
Risk ratio (95% CI) 1.13 (0.84 to 1.52) 1.15 (0.78 to 1.68)
Risk difference (95% CI), % 0.1 (−0.2 to 0.5) 0.1 (−0.3 to 0.6)
90-Day mortality, n (%) 364 (3.8%) 265 (4.0%) 0.543* 178 (3.8%) 188 (4.0%) 0.594*
Risk ratio (95% CI) 1.05 (0.90 to 1.23) 1.06 (0.86 to 1.29)
Risk difference (95% CI), % 0.2 (−0.4 to 0.8) 0.2 (−0.6 to 1.0)
Perioperative LOS, mean (95% CI), days 30.4 (29.9 to 30.8) 28.3 (27.8 to 28.7) <0.001** 29.7 (29.0 to 30.4) 28.0 (27.5 to 28.6) <0.001**
Difference in days (95% CI) −2.1 (−2.8 to −1.5) −1.7 (−2.5 to −0.8)
Adjusted
30-Day mortality, estimate (95% CI), % 1.0 (0.8 to 1.2) 1.2 (0.9 to 1.4) 1.0 (0.7 to 1.3) 1.2 (0.9 to 1.5)
Odds ratio (95% CI) 1.14 (0.84 to 1.54) 0.408*** 1.13 (0.76 to 1.67) 0.540***
Marginal effect (95% CI) 0.1 (−0.2 to 0.5) 0.1 (−0.3 to 0.5)
90-Day mortality, estimate (95% CI), % 3.9 (3.5 to 4.2) 4.0 (3.5 to 4.4) 3.8 (3.3 to 4.3) 4.0 (3.4 to 4.5)
Odds ratio (95% CI) 1.03 (0.87 to 1.22) 0.713*** 1.04 (0.84 to 1.29) 0.689***
Marginal effect (95% CI) 0.1 (−0.5 to 0.7) 0.2 (−0.6 to 0.9)
Perioperative LOS, estimate (95% CI), days 29.9 (29.5 to 30.4) 28.9 (28.4 to 29.4) 29.7 (29.1 to 30.4) 28.0 (27.4 to 28.6)
Multiplicative effect (95% CI) 0.97 (0.94 to 0.99) 0.002*** 0.94 (0.91 to 0.97) <0.001***
Marginal effect (95% CI) −1.0 (−1.7 to −0.4) −1.8 (−2.6 to −0.9)

*Comparison made using Chi-square test.

**Comparison made using t-test.
***Adjusted by age, sex, type of claim, procedure, timing of procedure, type of fracture, comorbidity and admission fiscal year.
6 Nishi et al.
than in two US hospitals [36]. After adjusting for patient and
national characteristics, Kondo et al. also found that longer LOS fol-
lowing surgery was associated with lower risk of mortality after dis-
charge. Thus, the longer LOS in Japanese patients would appear to
suggest that they were in a more rigorous treatment setting.
Furthermore, somewhat similar results have been reported for inhos-
pital mortality among Japanese acute care hospitals that participated
in the DPC/PDPS [8]; such facilities treated more severe, complex
cases than general hospitals, whereas inhospital mortality is a prefer-
able indicator for hospitals with shorter LOS [37].
In addition to healthcare resource utilization and mortality, hip
fracture was the fourth most important cause of disability and third
in terms of needing long-term support and care in Japan in 2013
[38]. It has been estimated that social security expenditure in Japan
will rapidly increase from ~109.5 trillion yen in fiscal 2012 to
~148.9 trillion yen in fiscal 2025 [39]. Thus, it is necessary to inves-
tigate the effect of anesthetic techniques for hip fracture surgery on
long-term prognosis and resource use among patients with severe
comorbidities or disabilities by linking long-term care insurance
claims data. Further investigations about postoperative complica-
tions should also be implemented. Overall, for sustainable health
and long-term care with quality assurance, it is necessary to evaluate
the effects of healthcare technology on care resource utilization.
The present study has some limitations. First, we were unable to
obtain complete patient information, such as data about clinical
examinations and activities of daily living; thus, we could not evalu-
ate improvement in prognosis, including patient mobility, in detail.
Second, the study did not evaluate anesthetic agents, just anesthetic
techniques. Third, our study was limited to beneficiaries in Fukuoka
Prefecture, so it may be difficult to generalize our findings to other
regions in Japan or other countries. Fourth, this study was not a
randomized control trial; although we attempted to correct bias stat-
istically, unobserved confounding factors may have biased our
results. Conversely, the present study has several strengths. One is
that we were able to capture almost all older patients who under-
went hip fracture surgery in Fukuoka Prefecture. This was thus a
large-scale population-based study that included almost all older
subjects in that prefecture [40]. Another strength is that our propen-
sity score estimation models considered location bias using data on
the residential municipality of patients.
Conclusion
In conclusion, after adjusting for patient characteristics, we found
that the use of regional anesthesia was not associated with 30- or
90-day mortality among older patients who underwent hip fracture
surgery in Fukuoka Prefecture; however, regional anesthesia was
associated with a slightly shorter perioperative LOS by ~1.7 days.
Japan has much longer LOS than other countries, so our findings
have implications for more efficient healthcare resource utilization
and quality assurance in geriatric care.
Acknowledgments
The authors would like to express their thanks to Fukuoka Prefecture Wide-Area
Association of Latter-Stage Elderly Healthcare for the provision of valuable data.
Funding
This study was supported by JSPS KAKENHI (grant numbers 15H06921 and
17K15873).
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