“Tiers of Delay”

Abstract

Anticoagulation reversal is a common cause of operative delay. We sought to establish for the first time the impact this has on best practice tariff (BPT) for patients with hip fracture admitted on warfarin. All patients with hip fracture treated operatively over a 32-month period were reviewed. Basic demographics, time to theater, length of stay, and mortality were recorded for all patients. Independent samples t-tests were used to identify statistically significant differences between patients on warfarin and those not taking the drug. A total of 83 patients were admitted anticoagulated with a mean international normalized ratio of 2.65 and a median time to theater of 49.7 hours. Of these patients, 79% breached BPT, incurring significant financial loss. In the control group, 908 patients took a median 24.5 hours, a 28% breach of BPT (P < .01). Length of stay, Nottingham Hip Fracture Score, and predicted 30-day mortality were similar for both the groups. As well as affecting clinical outcome following hip fracture, delay due to anticoagulation causes considerable loss of BPT. Potential loss of revenue due to delays over the study period was £80 000, inspiring the establishment of an ''early trigger'' anticoagulation protocol. Although it is accepted that there are limitations to this work, it should raise awareness of the real impact of warfarin on patients with hip fracture both in terms of outcome and for the first time, loss of potential revenue.

Do Patients Taking Warfarin Experience Delays to Theatre, Longer Hospital Stay, and Poorer Survival After Hip Fracture?

“…This delay has been reported in previous studies [7, 8, 16, 24], although our study is the first, to our knowledge, showing the same association after regression analysis using these prognostic factors. Ryan et al [21] conducted a study with more than two million patients sustaining a fractured neck of the femur and reported that a time to the operating room in excess of 48 hours resulted in higher mortality, with an OR of 1.13 for the delayed group after controlling for multiple prognostic factors including comorbidity.…”

“…Ranhoff et al [16], in a 2011 study of 1192 patients with hip fracture, found longer length of stay for warfarin users compared with nonusers. Conversely, Eardley et al [8], in a [2014 study of 1024 patients, showed no association between length of stay and the use of warfarin at the time of admission for hip fracture. Our study differs from both of these in that we have controlled for age, sex, ASA score, AMTS, WAI, fracture type, and operation type in our analysis.…”

“…Between 7.8% and 10.3% of all patients admitted with these fractures are receiving long-term warfarin therapy, which produces a coagulopathic state as expressed by increased International Normalized Ratio (INR) [8, 9, 25]. This coagulopathy must be reduced or eliminated before surgery can safely be performed.…”

“…The time taken to achieve a safe INR together with the presence of multiple comorbidities has the potential to delay surgical treatment, which conflicts with policy initiatives (such as the 2010 ‘Best Practice Tariff’ in the UK) that aim to improve patient outcomes by reducing delays in hip fracture surgery to less than 48 or 36 hours [5, 19]. Few studies have investigated the degree to which warfarin therapy is associated with delays to surgery [2, 7, 8, 16], and the degree to which such warfarin-associated care delays are associated with length of stay and mortality has not been reported, to our knowledge.…”

Anticoagulation therapy and proximal femoral fracture treatment

“…Eardley et al 11 studied the time to surgery of the warfarinised patients affected with hip fractures and the economic impact on the best tariff practice (BTP) over the study period of 32 months.…”