Use of Direct-Acting Anticoagulants (DOAC) Among Hip Fracture Patients Is Not an Indication to Delay Surgical Intervention.

Abstract

OBJECTIVES: To compare outcomes in patients on direct oral anticoagulants (DOAC) treated within 48 hours of last preoperative dose to those with surgical delays >48 hours. DESIGN: Retrospective cohort study. Setting: Three academic Level 1 trauma centers. Patient Selection Criteria: Patients aged 65+ year old on DOACs prior to hip fracture treated between 2010-2018. Patients were excluded if: last DOAC dose was >24 hours prior to admission, patient suffered from polytrauma, and/or delay to surgery was not attributed to DOAC. Outcome Measures and Comparisons: Primary outcome measures were the post-operative complication rate as determined by diagnosis of deep venous thrombosis (DVT) or pulmonary embolus (PE), wound breakdown, drainage, or infection. Secondary outcomes included transfusion requirement, perioperative bleeding, length of stay, reoperation rates, readmission rates, and mortality. RESULTS: 205 patients were included in the study, with a mean cohort age of 81.9 years (65-100 years), 64% (132/205) female, and a mean CCI of 6.4 (2-20). No significant difference was observed among age, gender, CCI, or fracture pattern between cohorts (p > 0.05 for all comparisons). 71 patients had surgery <48 hours following final preoperative DOAC dose; 134 patients had surgery >48 hours after. No significant difference in complication rate between the two cohorts was observed (p = 0.30). Patients with delayed surgical management were more likely to require transfusion (OR 2.39, 95% CI [1.05, 5.44]; p=0.04). Patients with early surgical management had significantly shorter lengths of stay (5.9 days vs 7.6 days, p<0.005). There was no difference in estimated blood loss, anemia, reoperations, readmissions, 90-day mortality, or 1-year mortality (p > 0.05 for all comparisons). CONCLUSION: Geriatric hip fracture patients who underwent surgical management within 48 hours of their last preoperative DOAC dose required less transfusions and had decreased length of stay, with comparable mortality and complication rates compared to patients with surgery delayed beyond 48 hours. Providers should consider early intervention in this population rather than adherence to elective procedure guidelines.