Outpatient Management of Emergency Department Patients With Acute Pulmonary Embolism: Variation, Patient Characteristics, and Outcomes

Vinson, David R.; Ballard, Dustin; Huang, Jie; Reed, Mary; Lin, James S.; Kene, Mamata V.; Sax, Dana R.; Rauchwerger, Adina S.; Wang, David H.; McLachlan, D. Ian; Pleshakov, Tamara S.; Silver, Matthew; Clague, Victoria A; Klonecke, Andrew; Mark, Dustin G.

doi:10.1016/j.annemergmed.2017.10.022

Cited by 42 publications

(73 citation statements)

References 49 publications

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“…8 Despite these recommendations and the increasing evidence that home treatment is safe and efficacious, many patients, even those with low risk of complications, are admitted for hospital management. 9,10 In this report, we provide a comprehensive and systematic review of the literature and elect to incorporate prospective observational studies in addition to RCTs to determine whether any evidence to avoid home management of DVT or PE exists, particularly among those with "low-risk PE. "…”

Section: Introductionmentioning

confidence: 99%

“…An analysis of 652 000 and 394 000 emergency room visits in the US for DVT and PE between 2006 and 2010 indicate that 52% of DVT patients and 90% of PE patients were managed in the hospital 10. Similarly, a more recent analysis of 2387 patients diagnosed with PE across 21 emergency departments between 2013 to 2015 reports that only 7.5% of patients were managed at home 9. Although these observational studies do not stratify by risk of complications, the large number of hospital admission suggests that many patients at low risk of complications are being admitted, despite the evidence favoring outpatient management.…”

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confidence: 99%

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Home vs hospital treatment of low-risk venous thromboembolism: a systematic review and meta-analysis

Khatib,

Ross,

Kennedy

et al. 2020

Blood Advances

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Increasing evidence supports the safety and effectiveness of managing low-risk deep vein thrombosis (DVT) or pulmonary embolism (PE) in outpatient settings. We performed a systematic review to assess safety and effectiveness of managing patients with DVT or PE at home compared with the hospital. Medline, Embase, and Cochrane databases were searched up to July 2019 for relevant randomized clinical trials (RCTs), and prospective cohort studies. Two investigators independently screened titles and abstracts of identified citations and extracted data from relevant full-text papers. Risk ratios (RRs) were calculated, and certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Seven RCTs (1922 patients) were included in metaanalyses on managing patients with DVT. Pooled estimates indicated decreased risk of PE (RR 5 0.64; 95% confidence interval [CI], 0.44-0.93) and recurrent DVT (RR 5 0.61; 95% CI, 0.42-0.90) for home management, both with moderate certainty of the evidence. Reductions in mortality and major bleeding were not significant, both with low certainty of the evidence. Two RCTs (445 patients) were included in meta-analyses on home management of low-risk patients with PE. Pooled estimates indicated no significant difference in all-cause mortality, recurrent PE, and major bleeding, all with low certainty of the evidence. Results of pooled estimates from 3 prospective cohort studies (234 patients) on home management of PE showed similar results. Our findings indicate that low-risk DVT patients had similar or lower risk of patient-important outcomes with home treatment compared with hospital treatment. In patients with low-risk PE, there was important uncertainty about a difference between home and hospital treatment.

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Section: Introductionmentioning

confidence: 99%

mentioning

confidence: 99%

Home vs hospital treatment of low-risk venous thromboembolism: a systematic review and meta-analysis

Khatib,

Ross,

Kennedy

et al. 2020

Blood Advances

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“…However, the change in the proportion of PE patients discharged was more modest than we originally expected, partly because the proportion of patients with PE discharged before protocol implementation was larger (12%) than we originally estimated. Nonetheless, the proportion of PE patients discharged after protocol implementation was approximately two to three times the national average and we saw no evidence of an increase in mortality, major bleeding, or returns to the ED with this change.…”

Section: Discussionmentioning

confidence: 61%

Multicenter Implementation of a Novel Management Protocol Increases the Outpatient Treatment of Pulmonary Embolism and Deep Vein Thrombosis

Kabrhel

Rosovsky

Baugh

et al. 2018

Academic Emergency Medicine

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Objective: The objective was to determine whether a protocol combining risk stratification, treatment with the direct-acting oral anticoagulant rivaroxaban, and defined follow-up is associated with a greater proportion of patients with venous thromboembolism (VTE) treated as outpatients, without hospital admission. Methods:We performed a multicenter study of patients diagnosed with VTE (pulmonary embolism [PE] or deep vein thrombosis [DVT]) in two urban EDs, 18 months before and 18 months after implementation of an outpatient VTE treatment protocol. Patients with radiographically confirmed acute VTE were eligible. Our primary outcome was the proportion of VTE patients discharged from the ED or observation unit (i.e., without hospital admission). We performed subgroup analyses according to hospital, DVT and PE, and low-risk PE. We also assessed 7-and 30-day mortality, major bleeding, and returns to the ED. We compared proportions using chi-square and Fisher's exact tests.Results: We enrolled 2,212 patients, 1,081 (49%) before protocol and 1,131 (51%) after protocol. Mean age (59 years vs. 60 years), female sex (49% vs. 49%), other demographics, comorbid illness, and PE risk stratification were similar before and after. After protocol, more VTE (35% from 26%, p < 0.001), PE (18% from 12%, p = 0.002), low-risk PE (28% from 18%, p < 0.001), and DVT (60% from 49%, p = 0.002) patients were treated as outpatients. Mortality, bleeding, and returns to ED were rare and did not increase after protocol. Conclusions:A treatment protocol combining risk-stratification, rivaroxaban treatment and defined follow-up is associated with an increase in PE and DVT patients treated as outpatients, with no increase in adverse outcomes.

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“…1. Vinson et al 1 performed this retrospective cohort study examining the outpatient management of patients with acute pulmonary embolism at 21 community emergency departments (EDs) in Northern California between January 2013 and April 2015. The study found that 7.5% of patients were discharged.…”

Section: Discussion Pointsmentioning

confidence: 99%

“…The authors believe these low-risk patients were hospitalized because of "entrenched practice patterns," in which the automatic response to a pulmonary embolism diagnosis is admission. 1 This is also complicated by the fact that there was no definitive pathway in place for discharge of patients with a pulmonary embolism diagnosis. Vinson et al 1 cite a number of previous studies that showed that outpatient pulmonary embolism management is low, 1% to 8%, at centers without defined clinical pathways or realtime clinical decision support.…”

Section: Discussion Pointsmentioning

confidence: 99%

Outpatient Pulmonary Embolism Management: If You Walk Into the Emergency Department With a Pulmonary Embolism, Maybe You Should Also Walk Out

Barrett

Freeman

2018

Annals of Emergency Medicine

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Outpatient Management of Emergency Department Patients With Acute Pulmonary Embolism: Variation, Patient Characteristics, and Outcomes

Cited by 42 publications

References 49 publications

Home vs hospital treatment of low-risk venous thromboembolism: a systematic review and meta-analysis

Home vs hospital treatment of low-risk venous thromboembolism: a systematic review and meta-analysis

Multicenter Implementation of a Novel Management Protocol Increases the Outpatient Treatment of Pulmonary Embolism and Deep Vein Thrombosis

Outpatient Pulmonary Embolism Management: If You Walk Into the Emergency Department With a Pulmonary Embolism, Maybe You Should Also Walk Out

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