Do direct oral anticoagulants (DOACs) cause delayed surgery, longer length of hospital stay, and poorer outcome for hip fracture patients?

Leer-Salvesen, Sunniva; Dybvik, Eva; Ranhoff, Anette Hylen; Husebø, Bjørn Liljestrand; Dahl, Ola E.; Engesæter, Lars B.; Gjertsen, Jan‐Erik

doi:10.1007/s41999-020-00319-w

Cited by 29 publications

(48 citation statements)

References 38 publications

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“…Although more patients were taking VKA in 2016, a shift to DOACs was observed, such that more patients were taking DOACs in 2018. A 15% prevalence of anticoagulation with DOACs was recently described in a patient cohort from 2016 to 2017 among patients with proximal femur fractures [ 14 ].…”

Section: Discussionmentioning

confidence: 99%

“…The uncertainty in perioperative handling of these substances is increased by the lack of consensus on the appropriate drug-free interval until hip fracture surgery [ 2 ]. Overall, several authors advocate for early surgery even in DOAC users, as they did not find increased bleeding and transfusion rates in these patients compared to non-anticoagulated patients [ 14 , 20 ]…”

Section: Discussionmentioning

confidence: 99%

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Effect of Direct Oral Anticoagulants on Treatment of Geriatric Hip Fracture Patients: An Analysis of 15,099 Patients of the AltersTraumaRegister DGU®

et al. 2022

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Background and Objectives: The increased use of direct oral anticoagulants (DOACs) results in an increased prevalence of DOAC treatment in hip fractures patients. However, the impact of DOAC treatment on perioperative management of hip fracture patients is limited. In this study, we describe the prevalence of DOAC treatment in a population of hip fracture patients and compare these patients with patients taking vitamin K antagonists (VKA) and patients not taking anticoagulants. Materials and Methods: This study is a retrospective analysis from the Registry for Geriatric Trauma (ATR-DGU). The data were collected prospectively from patients with proximal femur fractures treated between January 2016 and December 2018. Among other factors, anticoagulation was surveyed. The primary outcome parameter was time-to-surgery. Further parameters were: type of anesthesia, surgical complications, soft tissue complications, length of stay and mortality. Results: In total, 11% (n = 1595) of patients took DOACs at the time of fracture, whereas 9.2% (n = 1325) were on VKA therapy. During the study period, there was a shift from VKA to DOACs. The time-to-surgery of patients on DOACs and of patients on VKA was longer compared to patients who did not take any anticoagulation. No significant differences with regard to complications, type of anesthesia and mortality were found between patients on DOACs compared to VKA treatment. Conclusion: An increased time-to-surgery in patients taking DOACs and taking VKA compared to non-anticoagulated patients was found. This underlines the need for standardized multi-disciplinary orthopedic, hematologic and ortho-geriatric algorithms for the management of hip fracture patients under DOAC treatment. In addition, no significant differences regarding complications and mortality were found between DOAC and VKA users. This demonstrates that even in the absence of widely available antidotes, the safe management of geriatric patients under DOACs with proximal femur fractures is possible.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Effect of Direct Oral Anticoagulants on Treatment of Geriatric Hip Fracture Patients: An Analysis of 15,099 Patients of the AltersTraumaRegister DGU®

et al. 2022

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“…In six (33.3%) studies in this review [26,[37][38][39][40][41], a matched comparison group was used or data were matched post hoc, but matching criteria were not consistent across studies, nor were consistent comparator groups used. Where matching was not used, only six (40.0%) studies specified and adjusted for potential covariates [42][43][44][45][46][47], indicating potential limitations of sample size to conduct regression analyses. In ten (47.6%) studies, there were less than 50 patients taking DOACs.…”

Section: Discussionmentioning

confidence: 99%

Synthesis of the evidence on the impact of pre-operative direct oral anticoagulants on patient health outcomes after hip fracture surgery: rapid systematic review

Mitchell

Jakobs

Halim

et al. 2022

Eur J Trauma Emerg Surg

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Purpose To synthesise the evidence on the impact of pre-operative direct oral anticoagulants (DOACs) on health outcomes for patients who sustain a hip fracture. Method A rapid systematic review of three databases (MEDLINE, Embase and Scopus) for English-language articles from January 2000 to August 2021 was conducted. Abstracts and full text were screened by two reviewers and articles were critically appraised. Data synthesis was undertaken to summarise health outcomes examined for DOAC users versus a no anticoagulant group. Key information was extracted for study type, country and time frame, population and sample size, type of DOACs, comparator population(s), key definitions, health outcome(s), and summary study findings. Results There were 21 articles identified. Of the 18 studies that examined time to surgery, 12 (57.1%) found DOAC users had a longer time to surgery than individuals not using anticoagulants. Five (83.3%) of six studies identified that DOAC users had a lower proportion of surgery conducted within 48 h Four (40.0%) of ten studies reporting hospital length of stay (LOS) identified a higher LOS for DOAC users. Where reported, DOAC users did not have increased mortality, blood loss, transfusion rates, complication rates of stroke, re-operation or readmissions compared to individuals not using anticoagulants. Conclusions The effect of DOAC use on hip fracture patient health was mixed, although patients on DOACs had a longer time to surgery. The review highlights the need for consistent measurement of health outcomes in patients with a hip fracture to determine the most appropriate management of patients with a hip fracture taking DOACs.

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“…This situation clearly translates into an accumulating body of evidence that subjects taking DOACs experience more frequent delays in HF surgery with a subsequent increase in mortality [57]. Notwithstanding this difficulty, many studies have highlighted that these patients do not present significant [58][59][60] increase in post-operative bleeding [58][59][60][61] or higher occurrence of major haemorrhage or death. A relevant factor to carefully consider in this respect is kidney function.…”

Section: Management Of Anticoagulant Therapymentioning

confidence: 99%

Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus

Vincentis

Behr²,

Bellelli

et al. 2021

Aging Clin Exp Res

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Background Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues. Aim To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF. Methods A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra-and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence. Results A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics). Conclusion These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.

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Do direct oral anticoagulants (DOACs) cause delayed surgery, longer length of hospital stay, and poorer outcome for hip fracture patients?

Cited by 29 publications

References 38 publications

Effect of Direct Oral Anticoagulants on Treatment of Geriatric Hip Fracture Patients: An Analysis of 15,099 Patients of the AltersTraumaRegister DGU®

Effect of Direct Oral Anticoagulants on Treatment of Geriatric Hip Fracture Patients: An Analysis of 15,099 Patients of the AltersTraumaRegister DGU®

Synthesis of the evidence on the impact of pre-operative direct oral anticoagulants on patient health outcomes after hip fracture surgery: rapid systematic review

Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus

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