Admission rates for emergency department patients with venous thromboembolism and estimation of the proportion of low risk pulmonary embolism patients: a US perspective

Singer, Adam J.; Thode, Henry C.; Peacock, W. Frank

doi:10.15441/ceem.15.096

Cited by 49 publications

(54 citation statements)

References 23 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%

“…However, observational studies continue to report in hospital management of DVT and PE. 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.…”

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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%

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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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“…Of the approximately 900,000 annual venous thromboembolism (VTE) events occurring in the United States, it is estimated that more than 250,000 are diagnosed with pulmonary embolus in the emergency department (ED) . In a U.S. National Hospital Ambulatory Medical Care Survey analysis, during 2006 to 2010, >90% of ED patients diagnosed with pulmonary embolism (PE) were hospitalized . Since the average PE hospitalization costs approximately $14,000, this represents >$2 billion in annual expenditures.…”

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confidence: 99%

Emergency Department Discharge of Pulmonary Embolus Patients

Peacock

Coleman

Diercks

et al. 2018

Academic Emergency Medicine

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BackgroundHospitalization for low‐risk pulmonary embolism (PE) is common, expensive, and of questionable benefit.ObjectiveThe objective was to determine if low‐risk PE patients discharged from the emergency department (ED) on rivaroxaban require fewer hospital days compared to standard of care (SOC).MethodsMulticenter, open‐label randomized trial in low‐risk PE defined by Hestia criteria. Adult subjects were randomized to early ED discharge on rivaroxaban or SOC. Primary outcome was total number of initial hospital hours, plus hours of hospitalization for bleeding or venous thromboembolism (VTE), 30 days after randomization. A 90‐day composite safety endpoint was defined as major bleeding, clinically relevant nonmajor bleeding, and mortality.ResultsOf 114 randomized subjects, 51 were early discharge and 63 were SOC. Of 112 (98.2%) receiving at least one dose of study drug, 99 (86.8%) completed the study. Initial hospital LOS was 4.8 hours versus 33.6 hours, with a mean difference of –28.8 hours (95% confidence interval [CI] = –42.55 to –15.12 hours) for early discharge versus SOC, respectively. At 90 days, mean total hospital days (for any reason) were less for early discharge than SOC, 19.2 hours versus 43.2 hours, with a mean difference of 26.4 hours (95% CI = –46.97 to –3.34 hours). At 90 days, there were no bleeding events, recurrent VTE, or deaths. The composite safety endpoint was similar in both groups, with a difference in proportions of 0.005 (95% CI = –0.18 to 0.19). Total costs were $1,496 for early discharge and $4,234 for SOC, with a median difference of $2,496 (95% CI = –$2,999 to –$2,151).ConclusionsLow‐risk ED PE patients receiving early discharge on rivaroxaban have similar outcomes to SOC, but fewer total hospital days and lower costs over 30 days.

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“…More than 50% of these are in the emergency department (ED) . Historically, greater than 90% of patients with PE and most patients with DVT have been admitted to a hospital to initiate anticoagulation and to monitor for clinical deterioration . Recently, two clinical trials demonstrated the safety of outpatient treatment of patients with low‐risk PE .…”

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confidence: 99%

“…The safety and availability of direct‐acting oral anticoagulants (DOACs) may facilitate this approach . However, despite evidence supporting the outpatient treatment of DVT and PE dating back more than 20 years, the adoption of outpatient PE treatment in the United States is still limited . Clinician concerns that may limit outpatient treatment include a lack of follow‐up, unfamiliarity with the process of outpatient management, and concerns about risk stratification and associated medicolegal liability …”

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confidence: 99%

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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Admission rates for emergency department patients with venous thromboembolism and estimation of the proportion of low risk pulmonary embolism patients: a US perspective

Cited by 49 publications

References 23 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

Emergency Department Discharge of Pulmonary Embolus Patients

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

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