Direct oral anticoagulants do not worsen traumatic brain injury after low-level falls in the elderly.

BACKGROUND: Falls are now the leading cause of trauma and represent the most common type of trauma in the elderly. The use of anticoagulants is increasing in older patients, but there are little data on outcomes after traumatic brain injury while anticoagulated with direct oral anticoagulants compared with warfarin. We hypothesized that anticoagulated patients would have a greater mortality and complications than nonanticoagulated patients, and patients on direct oral anticoagulants would have more fatal outcomes after low-level falls because of lack of reversal agents. METHODS: Patients 65 years or older admitted to level 1-3 trauma centers with 24-hour neurosurgical care were identified through the administrative database of 19 Trinity Health hospitals. Patients with International Classification of Diseases, Ninth Revision, codes consistent with low-level fall and traumatic brain injury from May 2013 through October 2015 were included. Preadmission warfarin or direct oral anticoagulant use was extracted from admission reconciliation of medications in the database. RESULTS: A total of 700 patients met inclusion criteria with 177 on anticoagulants before admission. Anticoagulated patients had more cardiac (P < .001), pulmonary (P < .001), and clotting (P < .02) comorbidities. Warfarin patients had the greatest neurosurgical intervention rate at 18% compared with direct oral anticoagulants (2.8%, P < .02) or nonanticoagulation (11%, P < .02). No difference was identified in overall mortality and mortality after neurosurgical intervention between the nonanticoagulated, warfarin, or direct oral anticoagulant groups. Warfarin patients received more plasma (P < .001) and red cell transfusions (P = .035) with greater intensive care unit stays (P < .001) compared with direct oral anticoagulant or nonanticoagulated patients. With logistic regression, only advancing age (P < .05) and a lesser Glasgow Coma Scale score (P < .01) were associated with greater mortality. CONCLUSION: Older direct oral anticoagulant patients with traumatic brain injury after low-level fall did not have increased morbidity or mortality compared with those treated with warfarin or who were not treated with anticoagulants. Concerns over the use of direct oral anticoagulant agents in this population may be overstated and deserve more scrutiny.

Evaluation of the B-SAFE campaign to reduce clinically significant warfarin-drug interactions among fee-for-service Medicare beneficiaries.

The objective of this study was to evaluate the effectiveness of a health communication campaign designed to reduce the rate of serious warfarin-related drug interactions. The B-SAFE campaign was conducted in 2009 to educate patients located in a Michigan hospital's service area about the risk of serious adverse drug events associated with warfarin. The rate of warfarin-related drug interactions among Medicare fee-for-service (FFS) patients admitted to the exposed hospital with hemorrhagic complications was compared with the rate of warfarin-related drug interactions among a similar cohort admitted to a control hospital before and after the campaign. The χ(2) test and logistic regression were used to analyze differences. The authors observed a marginally significant decline in the rate of warfarin-related drug interactions (odds ratio [OR] = 0.66; 95% confidence interval [CI] = 0.33-1.29) among FFS Medicare patients admitted for bleeding complications to the hospital targeted by the B-SAFE campaign. The same association was not observed in the control hospital (OR = 1.15; CI = 0.42-3.14). These findings suggest that patient exposure to the B-SAFE campaign may have resulted in a decrease in the rate of clinically significant warfarin-related drug interactions.