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

Abstract

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.

Assessing operative delay and complications in hip fracture patients on anticoagulants and antiplatelets

“…Mitchell et al in their systematic review of 21 articles noted 18.2% of DOAC users having increased blood transfusions, 40% of users had increased length of stay whilst there was no difference in overall blood loss, postoperative complication rates, stroke or mortality rates compared to the control group. 11 …”

“…Mitchell et al in their systematic review of 21 articles noted 18.2% of DOAC users having increased blood transfusions, 40% of users had increased length of stay whilst there was no difference in overall blood loss, postoperative complication rates, stroke or mortality rates compared to the control group. 11 Studies have been performed assessing DOAC patient's outcomes in the context of early surgery. Mullins et al in their retrospective study reported that 87.3% of the DOAC patients had an operation within 36 h and their results demonstrated no statistically significant increase in transfusions or mortality differences.…”

“… 10 It is unknown whether the timing of surgical intervention in patients prescribed DOACs for hip fractures has a deleterious effect on patient or healthcare utilisation outcomes. 11 Delay to surgery is balanced against potentially increased risk of patient complications, but this practice is currently variable.…”

Principles for management of hip fracture for older adults taking direct oral anticoagulants: an international consensus statement

“…For some older adults taking a DOAC, a delay in performing hip fracture surgery to allow medical optimisation may be necessary to reduce intra-and postoperative blood loss [26] and to deliver safe regional anaesthesia [27]. However, currently, there is an absence of consensus regarding the management of patients with a hip fracture taking DOACs [3,22,[28][29][30], with conflicting evidence as to whether delaying surgery provides a health benefit [31]. The hip fracture and DOAC working group, informed by systematic reviews [31,32], literature reviews [28,29] and related clinical practice guidelines [1,3,5,33], developed a core set of 10 themes and questions regarding the management of patients with a hip fracture taking DOACs (online Supporting Information Appendix S1, Table S1).…”

“…For some older adults taking a DOAC, a delay in performing hip fracture surgery to allow medical optimisation may be necessary to reduce intra‐ and postoperative blood loss [26] and to deliver safe regional anaesthesia [27]. However, currently, there is an absence of consensus regarding the management of patients with a hip fracture taking DOACs [3, 22, 28–30], with conflicting evidence as to whether delaying surgery provides a health benefit [31].…”