Association of Reversal of Anticoagulation Preoperatively on 30-Day Mortality and Outcomes for Hip Fracture Surgery

Abstract

Background: Hip fracture is common in the elderly, many of whom are on anticoagulation. However, data are limited on outcomes with anticoagulation reversal in patients undergoing hip fracture surgery.

Methods: Adults ≥60 years old on oral anticoagulation who underwent hip fracture surgery at 21 hospitals in Northern California from 2006 to 2016 were identified through electronic databases. Outcomes were compared among patients treated and untreated with anticoagulation reversal preoperatively.

Results: Of 1984 patients on oral anticoagulation who underwent hip fracture surgery, 1943 (97.9%) were on warfarin and 41 (2.1%) were on direct oral anticoagulants. Reversal agents were administered to 1635 (82.4%). Compared to a watch-and-wait strategy, patients receiving reversal agents were more likely to be white, male, comorbid, and with higher admission and preoperative international normalized ratios (P <0.001 for all comparisons). No difference for 30-day mortality was detected between reversal vs non-reversal (7.8% vs 6.0%, respectively; hazard ratio [HR], 1.30 [95% confidence interval (CI), 0.82-2.07]). For secondary outcomes, reversal was associated with higher risk of delirium (8.6% vs 4.9%, risk ratio [RR], 1.77 [95% CI, 1.08-2.89]) and increased mean length of stay (6.4 vs 5.8 days, P <0.05). After adjustment, associations were no longer significant for delirium (RR 1.60, 95% CI, 0.97-2.65) or length of stay (mean difference 0.08, 95% CI, -0.55-0.71). No associations were detected between reversal and other secondary outcomes.

Conclusion: No significant associations were found between reversal agents and 30-day mortality or other outcomes in patients on oral anticoagulation who underwent hip fracture surgery. Further investigation is needed.

Keywords: Anticoagulation; Hip fracture; Outcomes; Perioperative medicine; Reversal agents.