New drug, new problem: do hip fracture patients taking NOACs experience delayed surgery, longer hospital stay, or poorer outcomes?

Abstract

Non-vitamin K antagonist oral anticoagulants (NOACs) may affect patient outcomes. We aimed to evaluate whether hip fracture patients admitted on warfarin or NOAC therapy were at risk of operative delay, prolonged length of stay, or increased mortality. Methods We collected data for 845 patients admitted to our centre between October 2014 and December 2016. Multivariable linear regression analysis was performed to test the association between warfarin and NOAC therapy on time to surgery and length of stay. Variables in the regression model were age, sex, admission AMTS, pre-fracture mobility, ASA score, fracture type, and operation type. Fisher's Exact Test was used to evaluate whether warfarin or NOAC therapy delayed surgery beyond 36 or 48 hours, or decreased 30-day, 6-month, or 12-month survival. Results Time to surgery was delayed in anticoagulated patients (p=0.028). NOAC therapy was independently associated with increased time to surgery beyond 36 hours (p=0.001), although not beyond 48 hours (p=0.355), whereas warfarin therapy was not associated with either. Anticoagulation did not increase length of stay (p=0.331). Warfarin therapy significantly reduced 30-day survival (p=0.007), but NOAC therapy did not (p=0.244). Neither warfarin nor NOAC therapy affected further survival. Conclusions NOAC therapy delays time to surgery beyond the NHS England 'Best Practice Tariff' in hip fracture patients. We aim to prospectively investigate long-term outcomes. Without a NOAC antidote, policy must change to ensure time-appropriate surgery for patients on NOACs. Preoperative involvement of the haematology team is essential.

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

“…Earlier hip fracture surgery has been associated with reduced LOS and reduced frequency of immobilization-related complications [ 25 – 28 ], and large resources have been applied to promote earlier surgical interventions [ 29 ]. Several studies have found increased surgical delay for DOAC-users [ 16 , 18 , 24 ], and the authors question whether the use of DOAC before the hip fracture results in unnecessary long surgical delay [ 14 , 24 , 30 – 32 ]. In contrast, our DOAC-using patients did not wait significantly longer for surgery than the non-users.…”

“…Most guidelines advocate that hip fracture surgery should be performed within 48 h after admission, preferably within 24 h, to reduce the rate of medical complications and mortality [ 11 – 13 ]. Earlier studies have indicated that patients exposed for DOAC before the hip fracture wait longer for surgery than recommended in treatment guidelines [ 14 – 16 ]. The consequences of DOAC on semi-urgent surgery such as for hip fracture patients has not been thoroughly investigated.…”

Proximal femur fractures in patients taking anticoagulants

“…A recent study has shown that DOAC treatment is related to a significant delay to surgery (beyond 36 hrs). 46 This problem is exacerbated by the confusion caused by the lack of consensus on the appropriate drug-free interval until hip fracture surgery. The British Society of Haematology recommends a 48-hour DOAC-free period prior to elective orthopaedic surgery in patients with normal renal function.…”

Are femoral fracture patients taking NOACs more complicated than those with warfarin or antiplatelet?

“…It has been consolidated for years that early treatment within 48 hours allows for earlier mobilization and rehabilitation 7 . Many elderly patients with hip fractures, however, have several comorbidities, among which the most frequent are cardiovascular disease that require treatment with anticoagulants and can lead to delayed surgery 8 . The clinical outcome is generally poor with a one-year mortality of around 36% 9 .…”