Emergency Department Discharge of Pulmonary Embolus Patients

Abstract

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.

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

“…Home vs hospital treatment of low-risk PE. We included 2 RCTs (453 patients) 22,23 and 3 prospective observational studies (234 patients) [24][25][26] (Table 2). Studies were conducted in United States, Italy, Spain, and Switzerland.…”

“…Studies were conducted in United States, Italy, Spain, and Switzerland. [23][24][25][26] One study was conducted in multiple countries including Switzerland, France, Belgium, and the United States. 22 Assessment of low risk of death to determine eligibility for home treatment varied by study.…”

“…PESI was used in 1 RCT 22 and Hestia criteria were used in the other RCT. 23 One of the prospective cohort studies used an unvalidated risk score 24 and the remaining 2 studies did not report their methods. 25,26 One of the studies included patients treated with DOACs, 23 the remaining studies included LMWH and UFH with transition to vitamin K antagonist (VKA) therapy.…”

“…23 One of the prospective cohort studies used an unvalidated risk score 24 and the remaining 2 studies did not report their methods. 25,26 One of the studies included patients treated with DOACs, 23 the remaining studies included LMWH and UFH with transition to vitamin K antagonist (VKA) therapy. 22,[24][25][26] Little information was reported on defining the intervention (home treatment).…”

“…Among the 2 included RCTs, overall risk of bias was low as both studies adequately concealed allocation, blinded outcome adjudicators, and missing data were minimal. 22,23 A summary of risk of bias for each RCT and associated forest plots are presented in Figure 2. Among the 3 prospective cohort studies, risk of bias was high due to lack of adjustment for possible confounders, subjective assessment of outcomes, and lack of information on loss to followup (supplemental Material 3).…”