Use of Warfarin is Associated with Delay in Surgery for Hip Fracture in Older Patients

Ranhoff, Anette Hylen; Martinsen, Mette Irene; Holvik, Kristin; Solheim, Ludvig Fjeld

doi:10.3810/hp.2011.02.372

Cited by 30 publications

(38 citation statements)

References 16 publications

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“…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.…”

Section: Discussionsupporting

confidence: 90%

“…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.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

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

Lawrence

Fountain

Cundall-Curry

et al. 2017

Clinical Orthopaedics &Amp; Related Research

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BackgroundPatients sustaining a fractured neck of the femur are typically of advanced age with multiple comorbidities. As a consequence, the proportion of these patients receiving warfarin therapy is approximately 10%. There are currently few studies investigating outcomes in this subset of patients.Questions/purposesThe purpose of this study was to assess the association between warfarin therapy and time to surgery, length of hospital stay, and survival in patients sustaining a fractured neck of the femur.MethodsData for 2036 patients admitted to our center between July 2009 and July 2014 with a fractured neck of the femur were extracted from the National Hip Fracture Database. Fifty-seven patients received no surgical treatment and were excluded from analysis. Multivariable ordinary least squares regression was performed to test the association between warfarin treatment on time to surgery and length of stay, and Cox proportional hazards to test followup survival. Variables included in the regression model were age, sex, American Society of Anesthesiologists (ASA) score, admission Abbreviated Mental Test Score (AMTS), fracture type, operation type, and premorbid Work Ability Index (WAI). One hundred fifty-two of 1979 surgically treated patients (8%) were receiving warfarin therapy at the time of admission.ResultsAfter controlling for age, sex, ASA score, AMTS, fracture type, operation type, and WAI, we found that patients taking warfarin were less likely to go to surgery by 36 hours (odds ratio [OR], 0.20; 95% CI, 0.14–0.30), and less likely to go to surgery by 48 hours (OR, 0.17; 95% CI, 0.11–0.24). Patients taking warfarin had a longer length of stay (median, 15 days; interquartile range [IQR], 12–22 days) compared with patients not taking warfarin (median, 13 days; IQR, 9–20 days; p < 0.001). Survival analysis to June 2015 showed a higher mortality for patients taking warfarin (12-month survival, 66% vs 76%; hazard ratio, 1.57; 95% CI, 1.21–2.04; p < 0.001).ConclusionsAfter controlling for multiple prognostic factors such as age, ASA score, AMTS, and WAI, warfarin therapy at the time of injury is associated with increased time to surgery, length of stay, and decreased survival. This study highlights the need to view warfarin therapy as a ‘red flag’ in patients presenting with a fractured neck of the femur. Preoperatively, prompt warfarin reversal together with adequate investigation and optimization of the patient should ensure timely, safe surgery. Early involvement of the anesthesia team should ensure an appropriate level of postoperative care for these patients.Level of EvidenceLevel III, therapeutic studyElectronic supplementary materialThe online version of this article (doi:10.1007/s11999-016-5056-0) contains supplementary material, which is available to authorized users.

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Section: Discussionsupporting

confidence: 90%

Section: Introductionmentioning

confidence: 99%

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

Lawrence

Fountain

Cundall-Curry

et al. 2017

Clinical Orthopaedics &Amp; Related Research

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“…Surgery is often postponed to stabilize patients' clinical condition and optimize their hemodynamic status, since most patients admitted after a PFF are clinically unstable, dehydrated, anemic, and malnourished 36 . In addition, patients on antithrombotic medication prior to the fracture (highly common in the elderly for preventing thrombosis and atrial fibrillation) normally have their surgery delayed to prevent excessive intraoperative bleeding 37,38 . However, according to our findings a simple analysis of the use of antithrombotic medication does not appear to result in differences in time to surgery, since men on antithrombotic medication prior to surgery waited an average of 0.5 days longer than women.…”

Section: Discussionmentioning

confidence: 99%

Time to death in a prospective cohort of 252 patients treated for fracture of the proximal femur in a major hospital in Portugal

et al. 2015

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Time to death in a prospective cohort of 252 patients treated for fracture of the proximal femur in a major hospital in PortugalTempo até a morte após fratura do fêmur proximal: uma coorte prospectiva de 252 doentes tratados no segundo maior hospital em Portugal Tiempo transcurrido hasta la muerte después de una fractura de cadera: una cohorte prospectiva de 252 pacientes del segundo mayor hospital de Portugal

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“…There is firm evidence both for the requirement of protocols in hip fracture care, the morbidity associated with delays to theater in patients with hip fracture on warfarin, and the benefits of IVK administration. 11,12,14,15,[28][29][30][31] In particular, Leonidou et al found that IVK administration resulted in not only a decreased delay to theater but also the lowest rate of complications. 30 It is appropriate that any broad protocol-driven path of care should be met with a degree of concern, but for the early administration of IVK in the warfarinized population with hip fracture, the wealth of evidence supports its safe and beneficial use.…”

Section: Discussionmentioning

confidence: 99%

“…Admission to hospital with a hip fracture while on warfarin with a significantly (>2.0) raised international normalized ratio (INR) has been associated with delay to theater and a trend toward greater mortality. 11 Pharmaceutical intervention leads to improved outcomes 12,13 and while a range of reversal agents are available, including oral vitamin K, the administration of low-dose intravenous vitamin K (IVK) has been shown in particular to expedite time to theater.…”

Section: Introductionmentioning

confidence: 99%

“Tiers of Delay”

Eardley

MacLeod

Freeman

et al. 2014

Geriatr Orthop Surg Rehabil

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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.

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Use of Warfarin is Associated with Delay in Surgery for Hip Fracture in Older Patients

Abstract: Hip fracture patients who are using warfarin experience a longer waiting time for surgery, most likely due to more comorbidities. A more active approach to better management of comorbidities may reduce waiting time for surgery in warfarin users.

Cited by 30 publications

References 16 publications

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

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

Time to death in a prospective cohort of 252 patients treated for fracture of the proximal femur in a major hospital in Portugal

“Tiers of Delay”

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