Impact of Early (<24 Hours) vs. Delayed (≥24 Hours) Surgery on Hemoglobin Decrease in Patients With Hip Fracture on Direct Oral Anticoagulants: A Multicenter Retrospective Cohort Study.

Background: Surgery in patients with hip fracture on direct oral anticoagulants (DOACs) is frequently delayed because of concerns about bleeding risk. However, evidence supporting such delays remains limited, and institutional practices vary widely. This study aims to determine whether early surgery within 24 hours is associated with a greater perioperative hemoglobin decrease compared with delayed surgery after 24 hours or more in patients with hip fracture on DOACs. Methods: This multicenter retrospective cohort study included patients with hip fracture aged ≥70 years on DOACs at admission across 5 hospitals from 2018 to 2023. Patients were stratified by time to surgery: <24 hours (early surgery) versus ≥24 hours (delayed surgery). The primary outcome was hemoglobin decrease in mmol/L. Secondary outcomes included a hemoglobin decrease of more than 2 mmol/L, preoperative and postoperative blood transfusion, packed red blood cells administered, postoperative anemia, hospital length of stay, and in-hospital and 30-day mortality. Multiple linear regression and multiple imputation were applied. Results: Among the 875 patients included, 504 underwent early surgery and 371 underwent delayed surgery. Early surgery was associated with a lower median decrease in hemoglobin levels (0.6 vs. 0.9 mmol/L, p < 0.001); with an adjusted mean difference of -0.25 mmol/L (95% CI, -0.37 to -0.13, p < 0.001). No significant differences were observed in a hemoglobin decrease of more than 2 mmol/L, blood transfusion rates, postoperative anemia, or in-hospital and 30-day mortality. Early surgery was associated with a shorter hospital length of stay median 2 days (95% CI, 2-3; p < 0.001). Conclusions: Early surgery within 24 hours was associated with a modestly smaller hemoglobin decrease and a shorter hospital length of stay, without an increased blood transfusion rate or mortality rates compared with delayed surgery. These findings suggest that early surgery in patients with hip fracture on DOACs may be safe and potentially beneficial in reducing hospital length of stay. Level of Evidence: Level III. See Instructions for Authors for a complete description of levels of evidence.