Suboptimal Use of DOACs Post-Discharge for Geriatric Hip Fractures with Isolated Calf Deep Vein Thrombosis: Do Clinician Prescribing Preferences and Patient Compliance Alters Clinical Outcomes?

Figures & data

Figure 1 Flow chart for the selection of study participants.

Figure 2 Results of the survey of DOACs prescription orders at the time of discharge.

Figure 3 Results of the survey on compliance according to the type, dosing, and duration of direct oral anticoagulants among patients. (A1 and A2) Patients’ compliance with Rivaroxaban and Apixaban. (B1 and B2) Patients’ compliance with QD regimen and Bid regimen, (C1 and C2) Patients’ compliance with 14 days regimen and 28 days regimen.

Table 1 ICDVT Clinical Outcomes and Different DOACs Compliance Safety and Efficacy

	Group A (N=375)	Group B (N=270)	Group C (N=57)	P value
30 days post-discharge
ICDVT clinical outcomes (n, %)				<0.001
Completely dissolved	290(73.33%)	132(48.89%)	14(24.56%)
Partially dissolved	67(17.87%)	99(36.67%)	22(38.60%)
No change	9(2.40%)	20(7.41%)	7(12.28%)
Localised propagation	6(1.60%)	12(4.44%)	7(12.28%)
Proximal propagation	3(0.80%)	7(2.59%)	7(12.28%)
Out-hospital bleeding events (n,%)	0	0	0	–
Symptomatic venous thrombosis (n, %)	4 (1.07%)	9(3.33%)	6(10.53%)	<0.001
Petechiae or ecchymosis (n,%)	7(1.87%)	5(1.85%)	3(5.26%)	0.235
90 days post-discharge
ICDVT clinical outcomes (n,%)				0.007
Completely dissolved	361(96.27%)	251(94.96%)	47(82.46%)
Partially dissolved	6(1.60%)	12(4.44%)	6(10.53%)
No change	4(1.07%)	4(1.48%)	1(1.75%)
Localised propagation	2(0.53%)	2(0.74%)	2(3.51%)
Proximal propagation	2(0.53%)	1(0.37%)	1(1.75%)
Out-hospital bleeding events (n,%)	0	0	0	–
Symptomatic venous thrombosis (n,%)	2(0.53%)	2(0.74%)	1(1.75%)	0.592
Petechiae or ecchymosis (n,%)	1(0.27%)	1(0.37%)	0	0.888

Notes: Patients whose ICDVT had not dissipated at the 30-day post-discharge outpatient review were not investigated for any re-administration of oral DOACs and therefore more caution should be exercised when interpreting the clinical outcome of ICDVT at 90 days post-discharge. Statistically significant p values are in bolded text.

Abbreviation: ICDVT, isolated calf deep vein thrombosis.

Table 2 Results of Multivariate Logistic Regression Analysis of Surgeons DOACs QD Regimen

Risk Factor	β	S.E	Wald	OR (95% CI)	P
Pensions (no)	0.386	0.160	5.831	1.471(1.075–2.013)	0.016
Movement disorders (no)	−0.334	0.168	3.969	0.716(0.515–0.995)	0.046
Recent surgical history (no)	0.679	0.313	4.689	1.971(1.067–3.643)	0.030
Long-term caregiver(spouse)	−0.427	0.273	2.446	0.653(0.382–1.114)	0.118
Long-term caregiver (children)	−0.146	0.271	0.290	0.864(0.508–1.471)	0.590
Discharge destination (home)	−0.872	0.341	6.545	0.418(0.214–0.816)	0.011
Discharge destination (community care centers)	−0.929	0.298	5.440	0.395(0.181–0.862)	0.020
Postoperative weight-bearing activities (yes)	−0.892	0.160	30.862	0.410(0.299–0.562)	<0.001

Note: Statistically significant p values are in bolded text.

Table 3 Results of Multivariate Logistic Regression Analysis of Surgeons DOACs 14 Days Regimen

Risk Factor	β	S.E	Wald	OR (95% CI)	P
Mechanism of injury (low energy)	−0.622	0.263	6.371	0.561(0.308–0.864)	0.012
ASA classification (I–II)	0.483	0.168	6.781	1.549(1.114–2.154)	0.009
Surgical technique (THA)	−0.495	0.229	4.702	0.609(0.389–0.954)	0.030
Timing of ICDVT formation (admission)	−0.671	0.256	6.888	0.511(0.310–0.844)	0.009

Note: Statistically significant p values are in bolded text.

Abbreviations: ASA, American Society of Anesthesiologists; THA, total hip arthroplasty; ICDVT, isolated calf deep vein thrombosis.

Table 4 Results of Ordinal Logistic Regression Analysis of Patient Compliance with DOACs

Risk Factor	β	S.E	Wald	OR (95% CI)	P
Rural region of habitation	0.821	0.230	12.773	2.273(1.449–3.565)	<0.001
Timing of ICDVT formation (admission)	0.867	0.326	7.095	2.380(1.257–4.506)	0.008
Timing of ICDVT formation (pre-operation)	0.610	0.294	4.308	1.841(1.035–3.247)	0.038

Note: Statistically significant p values are in bolded text.

Abbreviation: ICDVT, isolated calf deep vein thrombosis.

Table 5 Continuous Variable Comparison Between Completely Dissolved (CD) and Non-Completely Dissolved (Non-CD) Groups

Variable	CD Group (n=436)	Non-CD Group (n=266)	P
Age (years)	75.49±7.96	75.76±7.86	0.662
BMI (kg/m^2)	26.27±4.72	25.64±7.30	0.210
Hospitalization duration (d)^a	9.91±2.00	8.96±1.78	<0.001
Operative duration (min)	101.20±45.34	103.09±48.67	0.602
Intraoperative blood loss(mL)	234.43±163.43	250.47±172.36	0.217
Thrombus length (mm)	4.25±2.92	4.68±1.70	0.027
Thrombus diameter (mm)	2.49±1.04	2.61±1.08	0.143
HGB (g/L)	102.91±7.83	104.46±8.86	0.016
HCT (%)	30.79±3.18	30.49±3.38	0.232
RBC (10^9/L)	3.13±0.85	3.06±0.56	0.189
WBC (10^9/L)	8.58±2.84	8.91±3.13	0.161
PLT (10^9/L)	231.27±97.18	237.43±112.04	0.458
PT (s)	14.76±3.87	14.07±5.11	0.074
APTT (s)	29.53±5.53	30.15±5.01	0.158
FIB (g/L)	3.92±0.89	4.06±1.16	0.089
D-dimer (mg/L)	2.41±1.35	2.85±1.46	<0.001

Note: Statistically significant p values are in bolded text.

Abbreviations: CD, completely dissolved; Non-CD, non-completely dissolved; BMI, body mass index; HGB hemoglobin; RBC, red blood cell; WBC, white blood cell; PLT, platelet; TP total protein; PT, prothrombin time; APTT, activated partial thromboplastin time; FIB, fibrinogen.

Table 6 Categorical Variable Comparison Between Completely Dissolved (CD) and Non-Completely Dissolved (Non-CD) Groups

Variable	CD Group (n=436)	Non-CD Group (n=266)	P
Gender (male/female)	151/285	85/181	0.466
Habitation region (rural/urban)	185/251	146/120	0.001
Marital disruption (yes/no)	94/342	73/193	0.076
Pensions (yes/no)	198/238	112/154	0.392
Smoking (yes/no)	34/402	29/237	0.163
Alcoholism (yes/no)	19/417	17/249	0.236
Major chronic diseases
No chronic disease	181	101	0.649
1–2 chronic diseases	202	131
>2 chronic diseases	53	34
Neurological and psychiatric diseases (yes/no)	34/402	21/245	0.963
Movement disorders (yes/no)	153/283	96/170	0.789
Recent surgical history (yes/no)	38/398	20/246	0.576
Perioperative ABT (yes/no)	190/246	130/136	0.172
Perioperative major bleeding (yes/no)	26/410	17/249	0.819
Postoperative weight-bearing activities (yes/no)	191/245	109/157	0.462
Surgical technique
Hemiarthroplasty	78	39	0.038
Total hip arthroplasty	162	81
Internal fixation	196	146
ASA classification
I–II	281	187	0.111
III–IV	155	79
Mechanism of injury
Low-energy injury	396	232	0.131
High-energy injury	40	34
Timing of ICDVT formation
Admission	50	35	<0.001
Pre-operation	67	95
Post-operation	319	136
Symptomatic ICDVT
Yes	32	21	0.787
No	401	245
Long-term caregiver
Spouse	205	99
Children	191	130	0.019
Carer	40	37
Discharge destination
Home	343	208
Community care centers	58	44	0.195
Rehabilitation unit	36	14
DOACs compliance
Full	291	83
Fair	133	137	<0.001
Poor	12	45

Note: Statistically significant p values are in bolded text.

Abbreviations: CD, completely dissolved; Non-CD, non-completely dissolved; ABT, allogeneic blood transfusion; ASA, American Society of Anesthesiologists.

Table 7 Multivariate Analysis of Factors Associated with Non-Completely Dissolved ICDVT

Risk Factor	β	S.E	Wald	OR (95% CI)	P
Habitation region (rural)	0.458	0.177	6.695	1.518(1.117–2.236)	0.010
Long-term caregiver(spouse)	−0.526	0.296	3.164	0.591(0.331–1.055)	0.075
Long-term caregiver (children)	−0.407	0.292	1.945	0.666(0.376–1.179)	0.163
Timing of ICDVT formation (admission)	0.250	0.271	0.852	1.284(0.755–2.184)	0.356
Timing of ICDVT formation (pre-operation)	1.035	0.211	24.071	2.816(1.862–4.259)	<0.001^a
DOACs compliance (full)	−2.445	0.369	44.253	0.087(0.042–0.178)	<0.001
DOACs compliance (fair)	−1.261	0.365	11.967	0.283(0.139–0.579)	0.001
Surgical technique (hemiarthroplasty)	−0.181	0.252	0.515	0.835(0.510–1.367)	0.473
Surgical technique (THA)	−0.331	0.200	2.753	0.718(0.486–1.062)	0.097
HGB (g/L)	−0.130	0.211	1.174	1.030(1.009–1.052)	0.305
D-dimer (mg/L)	−0.280	0.163	8.171	1.197(1.058–1.355)	0.164
Thrombus length (mm)	0.417	0.093	19.962	1.157(1.263–1.821)	<0.001
Hospitalization duration (days)	−0.232	0.068	11.509	0.793(0.694–0.907)	0.001

Notes: The current analysis was performed with clinical outcomes at 30 days post-discharge and without include outcomes at 90 days for further analysis, considering that outpatients will be treated further if their ICDVT non-completely dissolved. Statistically significant p values are in bolded text.

Data Sharing Statement

Data is available on reasonable request via contacting the corresponding authors (Kun Zhang or Teng Ma).