New drug, new problem: do hip fracture patients taking NOACs experience delayed surgery, longer hospital stay, or poorer outcomes?

Introduction: Neck of femur fractures are common in the comorbid, often anticoagulated, elderly. Non-vitamin K antagonist oral anticoagulants (NOACs) may affect patient outcomes. We aimed to evaluate whether hip fracture patients admitted on warfarin or NOAC therapy were at risk of operative delay, prolonged length of stay, or increased mortality.

Methods: We collected data for 845 patients admitted to our centre between October 2014 and December 2016. Multivariable linear regression analysis was performed to test the association between warfarin and NOAC therapy on time to surgery and length of stay. Variables in the regression model were age, sex, admission AMTS, pre-fracture mobility, ASA score, fracture type, and operation type. Fisher's exact test was used to evaluate whether warfarin or NOAC therapy delayed surgery beyond 36 or 48 hours, or decreased 30-day, 6-month, or 12-month survival.

Results: Time to surgery was delayed in anticoagulated patients ( 0.028). NOAC therapy was independently associated with increased time to surgery beyond 36 hours ( 0.001), although not beyond 48 hours ( 0.355), whereas warfarin therapy was not associated with either. Anticoagulation did not increase length of stay ( 0.331). Warfarin therapy significantly reduced 30-day survival ( 0.007), but NOAC therapy did not ( 0.244). Neither warfarin nor NOAC therapy affected further survival.

Conclusions: NOAC therapy delays time to surgery beyond the NHS England 'Best Practice Tariff' in hip fracture patients. We aim to prospectively investigate long-term outcomes. Without a NOAC antidote, policy must change to ensure time-appropriate surgery for patients on NOACs. Preoperative involvement of the haematology team is essential.