Overall survival rate is most important measure

BMJ 1995;311:572 (26 August)

Letters

Overall survival rate is most important measure

EDITOR,--The audit of hip fracture in East Anglia concludesthat anticoagulant prophylaxis against thromboembolism reducesthe frequency of fatal pulmonary embolism.¹ The haemorrhagicside effects of such treatment may, however, be important ina group of patients known to have a high prevalence of coexistingcardiovascular and gastrointestinal disease.² The overall mortalityrather than the mortality related to pulmonary embolism shouldtherefore be recorded.

When hospital 6, which seemed to confer an idiosyncratic benefitto patients, is excluded the 90 day survival was marginallylower in the hospitals in which pharmaceutical thromboprophylaxiswas used routinely than in those in which it was not (table).The mortality from causes other than pulmonary embolism wassignificantly higher in the hospitals in which prophylaxis wasused routinely {chi} ²=5.5, P=0.02).

90 Day survival and mortality from pulmonary embolism
according to use of prophylaxis (figures are numbers
(percentages))
------------------------------------------------------------
                                         Death due to:
------------------------------------------------------------
             No of     90 Day        Pulmonary
Hospital   patients    survival       embolism   Other
------------------------------------------------------------
                  Prophylaxis given routinely
1            79         60 (76)           0       19 (24)
2            24         19 (79)           1 (4)     4 (17)
4            80         61 (76)           0       19 (24)

                 Prophylaxis given occasionally
3            79          63 (80)           2 (3)   14 (18)
5            80          68 (85)           3 (4)    9 (11)
7            79          65 (82)           2 (3)   12 (15)
8            78          63 (81)           5 (6)   10 (13)

In a Danish prospective clinical trial of 542 patients randomisedto receive either low molecular weight heparin or placebo aftertotal hip replacement the survival was lower in the group givenlow molecular weight heparin, regardless of the benefit againstthromboembolism (B S Andersen et al, proceedings of the 13thinternational congress on thrombosis, 1994).

We believe that the discrepancy between reduced overall survivaland reduced mortality from pulmonary embolism should be clarifiedbefore the conclusions of this study are accepted, since thedata suggest that anticoagulant treatment may have introduceddeaths due to other causes.

Lecturer in orthopaedic surgery University of Bristol, BristolRoyal Infirmary, Bristol BS2 8HW

Consultant orthopaedic surgeon Bone and Joint Research Unit,London E1 1AD

David Warwick, Michael Freeman

Todd CJ, Freeman CJ, Camilleri-Ferrante C, Palmer CR, Hyder A, Laxton CE, et al. Differences in mortality after fracture of hip: the East Anglian audit. BMJ 1995;310:904-8. (8 April.) [Abstract/Free Full Text]
Perez JV, Warwick DJ, Case CP, Bannister GC. Death after proximal femoral fracture--an autopsy study. Injury 1995;26:237-40. [Medline]

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Differences in mortality after fracture of hip: the East Anglian audit: C J Todd, C J Freeman, C Camilleri-Ferrante, C R Palmer, A Hyder, C E Laxton, M J Parker, B V Payne, and N Rushton
BMJ 1995 310: 904-908. [Abstract] [Full Text]