Background and Importance Hip fractures are excruciating for the elderly. Reducing hospital stays can improve health results, and entail important savings for healthcare centres.
Aim and Objectives To estimate the hypothetical cost of anticoagulation reversal and the potential hospital stay reduction by early surgery.
Material and Methods Retrospective, observational study among orthogeriatric patients candidates for hip fracture surgery between January 1/2020-December 31/2021. Variables: number of patients, admission/surgery timespan, anticoagulant, reversal drugs and costs, pretreatment INR, potential days and admission costs saved. Calculation of reversal strategy:
Vitamin K antagonists: prothrombin complex concentrate, 4-factor, unactivated (4F-PCC):
Pretreatment INR<1,4: no reversal; 1,4 to <4: 25IU/kg, maximum: 2,500IU; 4–6: 35IU/kg, maximum: 3,500IU; >6: 50IU/kg, maximum: 5,000IU. All patients would require simultaneous vitamin K administration (1 injectable solution/patient, intravenous dose =1–10mg, based on INR).
Factor Xa inhibitors direct oral anticoagulants: 4F-PCC:
Intravenous fixed-dose: 2000IU.
5g (two separate 2.5g doses).
Reversal strategy costs in Spain: 4F-PCC Laboratory Sale Price (LSP) 500 UI/20mL: 214,9€, vitamin K LSP 10mg/1mL: 1,1 €, Idarucizumab LSP 2.5g/50 mL: 1500€. Cost calculated by rounding to the number of vials (for example, 4F-PCC 1600IU=4 vials). Currently, daily hospital stay cost in a surgical unit =258,8€/day.
Results 691 patients included,148(21,0%) anticoagulated. 25(4,0%) excluded because of no surgery, so the final analysis included 666 patients,141 anticoagulated. 63(44,7%) were anticoagulated with acenocoumarol, 40(28,4%) apixaban, 29(20,6%) rivaroxaban, 12(8,5%) dabigatran, 8(5,7%) edoxaban and 1(0,7%) with warfarin. Early surgical goal in orthogeriatric patients in Spain (proximal femur fracture in patients >65 years) is intervention in <48 hours since admission. It was only achieved in 12,8% of anticoagulated patients in 2020 and 2021(18). Meantime between admission and surgery =4 ± 6 days. Days between admission and surgery =574 for all anticoagulated patients in total. Estimated total cost of anticoagulant reversal =134.683,5€ (955,2€/patient). Assuming this strategy is used and surgery is performed in the first 24 hours, hypothetical hospitalisation cost could decrease, saving 574 admission days and 148.537,3€.
Conclusion and Relevance Early hip fracture surgery within 48 hours from admission reduces complications in elderly patients. Anticoagulation reversal strategies in anticoagulated patients have a significant economic impact but would allow to reduce hospital stay with potential savings in healthcare costs.
Conflict of Interest No conflict of interest
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