(1) Background: Hip fracture patients with very limited life expectancy can opt for non-operative management (NOM) within a palliative care context. The implementation of NOM in the palliative context may affect the mortality of the operatively treated population. This retrospective cohort study aimed to determine whether the operatively treated geriatric hip fracture population would have a lower in-hospital mortality rate and fewer postoperative complications after the introduction of NOM within a palliative care context for patients with very limited life expectancy. (2) Methods: Data from 1 February 2019 to 1 February 2022 of patients aged 70 years or older were analyzed to give a comparison between patients before and after implementation of NOM within a palliative care context. (3) Results: Comparison between 550 patients before and 485 patients after implementation showed no significant difference in in-hospital or 1-year mortality rates (2.9% vs. 1.4%, p = 0.139; 22.4% vs. 20.2%, p = 0.404, respectively). Notably, post-implementation, fewer patients had prior dementia diagnoses (15% vs. 21%, p = 0.010), and intensive care unit admissions decreased (3.5% vs. 1.2%, p = 0.025). (4) Conclusions: The implementation of NOM within a palliative care context did not significantly reduce mortality or complications. However, NOM within palliative care is deemed a more patient-centered approach for geriatric hip fracture patients with very limited life expectancy.

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.

Background: early surgical intervention is associated with improved outcomes in hip fracture care, yet in patients using Direct Oral Anticoagulants (DOACs), surgery is frequently delayed due to concerns about increased intraoperative bleeding. Despite the increasing prevalence of hip fracture patients on DOACs, no consensus exists on optimal surgical timing. This has led to substantial practice variation between hospitals, with some operating within 24 hours of last DOAC intake and others delaying surgery beyond 24 hours. This study hypothesizes that early surgery (24 hours) in hip fracture patients on DOACs. This protocol describes the design and methodological rationale of a natural experiment. Methods and analysis: a multicenter cohort study designed as a natural experiment will be conducted across seven Dutch level 2 trauma centers, using predefined and standardized prospectively collected variables from electronic health records. Centers adhere to distinct local surgical timing protocols, forming two cohorts: early surgery within 24 hours after last DOAC intake and delayed surgery after more than 24 hours. Patients presenting with an isolated hip fracture who are using a DOAC and have taken their last dose within 24 hours before admission will be included. The primary endpoint is postoperative blood transfusion. Secondary endpoints include additional bleeding-related outcomes, thrombotic and postoperative complications, and hospital length of stay. The primary analysis will be conducted on a per-protocol basis, with an intention-to-treat analysis performed as a supplementary assessment. Non-inferiority will be established if the upper bound of the one-sided 95% confidence interval for the risk difference does not exceed the predefined margin of 5%. Ethics and dissemination: ethical approval was obtained from the Medical Ethics Committee United, Utrecht, the Netherlands. As this is a cohort study without altering clinical care, individual informed consent is not required. All data will be pseudonymised, and findings will be disseminated through peer-reviewed journals and scientific conferences. Registration details: Medical Ethics Committee United, Utrecht, the Netherlands, registration number W25.034.

Background: Early surgical intervention is associated with improved outcomes in hip fracture care, yet in patients using Direct Oral Anticoagulants (DOACs), surgery is frequently delayed due to concerns about increased intraoperative bleeding. Despite the increasing prevalence of hip fracture patients on DOACs, no consensus exists on optimal surgical timing. This has led to substantial practice variation between hospitals, with some operating within 24 h of last DOAC intake and others delaying surgery beyond 24 h. This study hypothesizes that early surgery within 24 h results in a non-inferior blood transfusion risk compared to delayed surgery 24 h or more after last DOAC intake in hip fracture patients on DOACs. This protocol describes the design and methodological rationale of a natural experiment. Methods and analysis: A multicenter cohort study designed as a natural experiment will be conducted across seven Dutch level 2 trauma centers, using predefined and standardized prospectively collected variables from electronic health records. Centers will adhere to distinct local surgical timing protocols, forming two cohorts: early surgery within 24 h and delayed surgery 24 h or more after last DOAC intake. Patients presenting with an isolated hip fracture who are using a DOAC and have taken their last dose within 24 h before admission will be included. The primary endpoint is postoperative blood transfusion. Secondary endpoints include additional bleeding-related outcomes, thrombotic and postoperative complications, and hospital length of stay. The primary analysis will be conducted on a per-protocol basis, with an intention-to-treat analysis performed as a supplementary assessment. Non-inferiority will be established if the upper bound of the one-sided 95% confidence interval for the risk difference does not exceed the predefined margin of 5%. Ethics and dissemination: Ethical approval was obtained from the Medical Ethics Committee United, Utrecht, The Netherlands. As this is a cohort study without altering clinical care, individual informed consent is not required. All data will be pseudonymized, and findings will be disseminated through peer-reviewed journals and scientific conferences. Registration details: Medical Ethics Committee United, Utrecht, The Netherlands, registration number W25.034.