Anticoagulation management in individuals with hip fracture

Objectives: To determine the interventions taken to lower international normalized ratio (INR) in individuals with hip fracture using warfarin before admission for hip fracture surgery in a geriatric fracture center (GFC) and compare outcomes with those of individuals not taking warfarin.

Design: Cohort study using retrospective chart review.

Setting: University-affiliated community teaching hospital.

Participants: Individuals aged 60 and older admitted to a GFC for surgical repair of a nonpathological, nonperiprosthetic hip fracture between April 2006 and April 2012.

Measurements: Descriptive data collected from a quality improvement registry with additional information for individuals taking warfarin obtained from chart review.

Results: Of the 1,080 individuals included in the analysis, 84 (7.8%) were taking warfarin on admission. Participants using warfarin had a higher average Charlson Comorbidity Index (3.8 vs 3.1, P < .001). Atrial fibrillation was the most common indication for anticoagulation (83.3%). Average INR before surgery was 1.7 (range 1.2-3.6). Vitamin K, fresh frozen plasma, or both were given to 100% of those taking warfarin with an admission INR of 2.0 or greater. There was a trend toward longer time to surgery in those taking warfarin than in those not taking warfarin (28.9 vs 21.7 hours, P = .05). Length of stay was longer for those taking warfarin than those not taking warfarin (4.8 vs 4.2 days, P = .04). Neither time to surgery nor length of stay were significantly different after adjustment for baseline comorbidity. Participants taking warfarin were not found to have any significant differences in thromboembolic event rates, bleeding complications rates, mortality, or 30-day readmission after surgery than those not taking warfarin on admission.

Conclusion: Active management in a GFC model to reverse anticoagulation before surgery may facilitate earlier surgery without increasing observed complications.