Net clinical benefit of hospitalization versus outpatient management of patients with acute pulmonary embolism

Outpatient management of cancer-associated pulmonary embolism: A post-hoc analysis from the HOME-PE trial

INTRODUCTION

Cancer-related pulmonary embolism (PE) is associated with poor prognosis. Some decision rules identifying patients eligible for home treatment categorize cancer patients at high risk of complications, precluding home treatment. We sought to assess the effectiveness and the safety of outpatient management of patients with low-risk cancer-associated PE.

METHODS

In the HOME-PE trial, hemodynamically stable patients with symptomatic PE were randomized to either triaging with Hestia criteria or sPESI score. We analyzed 3 groups of low-risk PE patients: 47 with active cancer treated at home (group 1), 691 without active cancer treated at home (group 2), and 33 with active cancer as the only sPESI criterion qualifying them for hospitalization (group 3). The main outcome was the composite of recurrent venous thromboembolism, major bleeding, and all-cause death within 30 days after randomization.

RESULTS

Patients treated at home had composite outcome rates of 4.3 % (2/47) for those with cancer vs. 1.0 % (7/691) for those without (odds ratio (OR) 4.98, 95%CI 1.15-21.49). Patients with cancer had rates of complications of 4.3 % when treated at home vs. 3.0 % (1/33) when hospitalized (OR 1.19, 95%CI 0.15-9.47). In multivariable analysis, active cancer was associated with an increased risk of complications for patients treated at home (OR 7.95; 95%CI 1.48-42.82). For patients with active cancer, home treatment was not associated with the primary outcome (OR 1.19, 95%CI 0.15-9.74).

CONCLUSIONS

Among patients treated at home, active cancer was a risk factor for complications, but among patients with active cancer, home treatment was not associated with adverse outcomes.

Early discharge and home treatment of patients with acute pulmonary embolism in the tertiary care setting

Acute pulmonary embolism (PE) is a potentially life-threatening disease. Current guidelines suggest risk-adapted management. Hospitalization is required for intermediate- and high-risk patients. Early discharge and home treatment are considered safe in the majority of low-risk patients. In this study, we describe characteristics, discharge, and outcome of outpatients diagnosed with acute PE at a tertiary care center. All outpatients undergoing computed tomography pulmonary angiography or ventilation/perfusion lung scan between 01.01.2016 and 31.12.2019 at the University Hospital Vienna, Austria, were screened for a PE diagnosis. Electronic patient charts were used to extract characteristics, clinical course, and outcomes. Within the 4-year period, 709 outpatients (median age: 62 years, 50% women) were diagnosed with PE. Thirty-three (5%) patients were classified as high-risk, 159 (22%) as intermediate-high, 332 (47%) as intermediate-low, and 185 (26%) as low-risk PE according to the European Society of Cardiology risk stratification. In total, 156 (22%) patients (47% with low-risk and 20% with intermediate-low-risk PE) were discharged as outpatients and received home treatment. Rates for home treatment increased 2.4-fold during the study period. Thirty-day mortality in the entire population was 4.9%. All low-risk patients and all but one patient with home treatment survived the first 30 days. Home treatment significantly increased over time and seems to be safe in routine clinical practice. Notably, one in five intermediate-low-risk patients was discharged immediately, suggesting that a subpopulation of intermediate-low-risk patients may also be eligible for home treatment.

Application of the RIETE score to identify low-risk patients with pulmonary embolism: From the COMMAND VTE Registry

BACKGROUND

The RIETE score could be specifically useful for identification of low-risk pulmonary embolism (PE) patients for home treatment. However, the external validation of the RIETE score has been limited.

METHODS

The COMMAND VTE Registry is a multicenter registry enrolling consecutive patients with acute symptomatic venous thromboembolism (VTE). The current study population consisted of 1479 patients with acute PE, who were divided into 2 groups; RIETE scores of 0 (N = 260) and ≥ 1 (N = 1219).

RESULTS

The cumulative 10-day and 30-day incidences of a composite endpoint of all-cause death, recurrent PE, or major bleeding were lower in patients with the RIETE score of 0 than in those with the RIETE score of ≥1 (10-day: 0.4 % vs. 6.7 %, P < 0.001, and 30-day: 0.4 % vs. 10.0 %, P < 0.001). The area under the receiver-operating characteristic curve (AUC) in the RIETE score for the 10-day composite endpoint showed numerically better predictive ability than that in the sPESI score (0.77 vs. 0.73, P = 0.07), and the AUC in the RIETE score for the 30-day composite endpoint showed significantly better predictive ability than that in the sPESI score (0.77 vs. 0.71, P = 0.003).

CONCLUSIONS

The RIETE score was well validated in the current large real-world registry. The RIETE score of 0 could identify patients with reasonably low risks of the 10-day and 30-day composite endpoint of all-cause death, recurrent PE, or major bleeding.

[Home treatment of low-risk pulmonary embolism patients : Efficacy and safety of an outpatient program including the general practitioner]

AIM

Outpatient treatment (OT) of patients with low-risk pulmonary embolisms (PE) is recommended. A multidisciplinary OT program including the general practitioner (GP) has been implemented at Versailles hospital in 2019. The objectives of the study were to assess the feasibility, safety and acceptability of the program.

MATERIAL AND METHODS

The feasibility of, and the inclusion criteria for OT were defined from a retrospective cohort study of PE patients carried out in 2018. In the prospective study, consecutive patients consulting in the emergency department between 2019 and 2021 with confirmed PE were eligible for OT if they had sPESI and HESTIA scores equal to 0, normal troponin and NT-pro-BNP levels, and no right ventricular dilation on imaging. PEs associated with COVID were excluded. The OT program included 4 appointments within 3 months, including 2 with the GP. Events (death, recurrence of PE or venous thromboembolism, bleeding, rehospitalisation) were collected at 3-month follow-up.

RESULTS

In the retrospective study, 19% of the 138 PE patients seen in the emergency department were eligible for OT. No complication occurred at Day 90. In the prospective study, 313 consecutive patients with confirmed PE in the emergency department were included, 66 (21%) were eligible for OT. Overall, 43 patients (14%) received OT (39 eligible) and 27 patients eligible for OT were hospitalised (92% because of pulmonary infarction). At 3-month follow-up, there were no death, no recurrence of thromboembolism, and one patient has been early hospitalised for COVID; 3 female patients treated with rivaroxaban had minor bleeding (heavy menstrual bleeding). The satisfaction rate of general practitioner was 95%.

CONCLUSIONS

This study confirms the feasibility and safety of our OT program for low-risk EP patients, centered on the general practitioner. It reduces the time spent in the emergency department, reduces hospitalisations and strengthens the city-hospital link for care.

Sustainability of a Clinical Decision Support Intervention for Outpatient Care for Emergency Department Patients With Acute Pulmonary Embolism

IMPORTANCE

Physicians commonly hospitalize patients presenting to the emergency department (ED) with acute pulmonary embolism (PE), despite eligibility for safe outpatient management. Risk stratification using electronic health record-embedded clinical decision support systems can aid physician site-of-care decision-making and increase safe outpatient management. The long-term sustainability of early improvements after the cessation of trial-based, champion-led promotion is uncertain.

OBJECTIVE

To evaluate the sustainability of recommended site-of-care decision-making support 4 years after initial physician champion-led interventions to increase outpatient management for patients with acute PE.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted in 21 US community hospitals in an integrated health system. Participants included adult patients presenting to the ED with acute PE. Study sites had participated in an original decision-support intervention trial 4 years prior to the current study period: 10 sites were intervention sites, 11 sites were controls. In that trial, decision support with champion promotion resulted in significantly higher outpatient management at intervention sites compared with controls. After trial completion, all study sites were given continued access to a modified decision-support tool without further champion-led outreach. Data were analyzed from January 2019 to February 2020.

EXPOSURES

ED treatment with a modified clinical decision support tool.

MAIN OUTCOMES AND MEASURES

The main outcome was frequency of outpatient management, defined as discharge home directly from the ED, stratified by the PE Severity Index. The safety measure of outpatient care was 7-day PE-related hospitalization.

RESULTS

This study included 1039 patients, including 533 (51.3%) women, with a median (IQR) age of 65 (52-74) years. Nearly half (474 patients [45.6%]) were rated lower risk on the PE Severity Index. Overall, 278 patients (26.8%) were treated as outpatients, with only four 7-day PE-related hospitalizations (1.4%; 95% CI, 0.4%-3.6%). The practice gap in outpatient management created by the earlier trial persisted in the outpatient management for patients with lower risk: 109 of 236 patients (46.2%) at former intervention sites vs 81 of 238 patients (34.0%) at former control sites (difference, 12.2; [95% CI, 3.4-20.9] percentage points; P = .007), with wide interfacility variation (range, 7.1%-47.1%).

CONCLUSIONS AND RELEVANCE

In this cohort study, a champion-led, decision-support intervention to increase outpatient management for patients presenting to the ED with acute pulmonary embolism was associated with sustained higher rates of outpatient management 4 years later. The application of our findings to improving sustainability of practice change for other clinical conditions warrants further study.

Evaluating the Appropriateness of Pulmonary Embolism Admissions in a Community Hospital Emergency Department

Pulmonary embolism (PE) is a diagnosis on the broader spectrum of venous thromboembolic (VTE) disease. The diagnostic key for clinicians is detecting which patients have a "high risk" of complications or mortality and who are in the "low-risk" population. The Pulmonary Embolism Severity Index (PESI) and HESTIA scores are validated risk stratification tools to determine if patients diagnosed with PE can be successfully managed in the outpatient versus inpatient setting. We aimed to investigate the appropriateness of PE admissions to our institution based on the risk stratification recommendations from PESI and HESTIA scores. We retrospectively identified 175 patients admitted with a diagnosis of PE over one year at our hospital. Baseline demographics, length of admission, and admitting diagnoses were collected for all patients included in this study. PESI and HESTIA scores were then calculated for all included patients. The average PESI score was 91.65 (95% confidence interval: 86.33, 96.97). There were 87 patients (49.7%) that had a low or very low PESI score of fewer than 85 points. Fifty-seven patients (33.7%) presented with a HESTIA score of 0. The risk stratification score indicates these patients as low risk, and appropriate for outpatient management. However, they were instead admitted to the hospital which contributes to increased costs, risk of adverse events, etc. There were 0 mortalities reported for patients in the "low or very low risk" groups, with four reported mortalities in the "very high risk" groups.  In our cohort, 33.7%-49.7% of admissions for PE were risk-stratified as "low risk" and qualified for outpatient management based on HESTIA and PESI risk stratification scores, respectively. The underutilization of validated risk scores upon initial diagnosis of PE may lead to worse outcomes and increased healthcare expenditure.

Inpatient Versus Outpatient Acute Venous Thromboembolism Management: Trends and Postacute Healthcare Utilization From 2011 to 2018

Background Acute outpatient management of venous thromboembolism (VTE), which includes pulmonary embolism (PE) and deep vein thrombosis (DVT), is perceived to be as safe as inpatient management in some settings. How widely this strategy is used is not well documented. Methods and Results Using MarketScan administrative claims databases for years 2011 through 2018, we identified patients with International Classification of Diseases (ICD) codes indicating incident VTE and trends in the use of acute outpatient management. We also evaluated healthcare utilization and hospitalized bleeding events in the 6 months following the incident VTE event. A total of 200 346 patients with VTE were included, of whom 50% had evidence of PE. Acute outpatient management was used for 18% of those with PE and 57% of those with DVT only, and for both DVT and PE its use increased from 2011 to 2018. Outpatient management was less prevalent among patients with cancer, higher Charlson comorbidity index scores, and whose primary treatment was warfarin as compared with a direct oral anticoagulant. Healthcare utilization in the 6 months following the incident VTE event was generally lower among patients managed acutely as outpatients, regardless of initial presentation. Acute outpatient management was associated with lower hazard ratios of incident bleeding risk for both patients who initially presented with PE (0.71 [95% CI, 0.61, 0.82]) and DVT only (0.59 [95% CI, 0.54, 0.64]). Conclusions Outpatient management of VTE is increasing. In the present analysis, it was associated with lower subsequent healthcare utilization and fewer bleeding events. However, this may be because healthier patients were managed on an outpatient basis.

Triaging acute pulmonary embolism for home treatment by Hestia or simplified PESI criteria: the HOME-PE randomized trial

AIMS

The aim of this study is to compare the Hestia rule vs. the simplified Pulmonary Embolism Severity Index (sPESI) for triaging patients with acute pulmonary embolism (PE) for home treatment.

METHODS AND RESULTS

Normotensive patients with PE of 26 hospitals from France, Belgium, the Netherlands, and Switzerland were randomized to either triaging with Hestia or sPESI. They were designated for home treatment if the triaging tool was negative and if the physician-in-charge, taking into account the patient's opinion, did not consider that hospitalization was required. The main outcomes were the 30-day composite of recurrent venous thrombo-embolism, major bleeding or all-cause death (non-inferiority analysis with 2.5% absolute risk difference as margin), and the rate of patients discharged home within 24 h after randomization (NCT02811237). From January 2017 through July 2019, 1975 patients were included. In the per-protocol population, the primary outcome occurred in 3.82% (34/891) in the Hestia arm and 3.57% (32/896) in the sPESI arm (P = 0.004 for non-inferiority). In the intention-to-treat population, 38.4% of the Hestia patients (378/984) were treated at home vs. 36.6% (361/986) of the sPESI patients (P = 0.41 for superiority), with a 30-day composite outcome rate of 1.33% (5/375) and 1.11% (4/359), respectively. No recurrent or fatal PE occurred in either home treatment arm.

CONCLUSIONS

For triaging PE patients, the strategy based on the Hestia rule and the strategy based on sPESI had similar safety and effectiveness. With either tool complemented by the overruling of the physician-in-charge, more than a third of patients were treated at home with a low incidence of complications.

Venous thromboembolism

Venous thromboembolism, comprising both deep vein thrombosis and pulmonary embolism, is a chronic illness that affects nearly 10 million people every year worldwide. Strong provoking risk factors for venous thromboembolism include major surgery and active cancer, but most events are unprovoked. Diagnosis requires a sequential work-up that combines assessment of clinical pretest probability for venous thromboembolism using a clinical score (eg, Wells score), D-dimer testing, and imaging. Venous thromboembolism can be considered excluded in patients with both a non-high clinical pretest probability and normal D-dimer concentrations. When required, ultrasonography should be done for a suspected deep vein thrombosis and CT or ventilation-perfusion scintigraphy for a suspected pulmonary embolism. Direct oral anticoagulants (DOACs) are the first-line treatment for almost all patients with venous thromboembolism (including those with cancer). After completing 3-6 months of initial treatment, anticoagulation can be discontinued in patients with venous thromboembolism provoked by a major transient risk factor. Patients whose long-term risk of recurrent venous thromboembolism outweighs the long-term risk of major bleeding, such as those with active cancer or men with unprovoked venous thromboembolism, should receive indefinite anticoagulant treatment. Pharmacological venous thromboembolism prophylaxis is generally warranted in patients undergoing major orthopaedic or cancer surgery. Ongoing research is focused on improving diagnostic strategies for suspected deep vein thrombosis, comparing different DOACs, developing safer anticoagulants, and further individualising approaches for the prevention and management of venous thromboembolism.

Contemporary management of acute pulmonary embolism

This review examines the recent progress in the initial management of pulmonary embolism (PE). Diagnostic strategies allowing the safe decrease of imaging testing have been proposed. New modalities of catheter-based interventions have emerged for hemodynamically unstable PE patients. For normotensive PE patients, direct oral anticoagulant treatment has become the new norm and a large proportion of patients are eligible for home treatment.

Monotherapy Anticoagulation to Expedite Home Treatment of Patients Diagnosed With Venous Thromboembolism in the Emergency Department: A Pragmatic Effectiveness Trial

BACKGROUND

The objective was to test if low-risk emergency department patients with vitamin K antagonist (venous thromboembolism [VTE]; including venous thrombosis and pulmonary embolism [PE]) can be safely and effectively treated at home with direct acting oral (monotherapy) anticoagulation in a large-scale, real-world pragmatic effectiveness trial.

METHODS

This was a single-arm trial, conducted from 2016 to 2019 in accordance with the Standards for Reporting Implementation Studies guideline in 33 emergency departments in the United States. Participants had newly diagnosed VTE with low risk of death based upon either the modified Hestia criteria, or physician judgment plus the simplified PE severity index score of zero, together with nonhigh bleeding risk were eligible. Patients had to be discharged within 24 hours of triage and treated with either apixaban or rivaroxaban. Effectiveness was defined by the primary efficacy and safety outcomes, image-proven recurrent VTE and bleeding requiring hospitalization >24 hours, respectively, with an upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0% for both outcomes.

RESULTS

We enrolled 1421 patients with complete outcomes data, including 903 with venous thrombosis and 518 with PE. The recurrent VTE requiring hospitalization occurred in 14/1421 (1.0% [95% CI, 0.5%-1.7%]), and bleeding requiring hospitalization occurred in 12/1421 (0.8% [0.4%-1.5%). The rate of severe bleeding using International Society for Thrombosis and Haemostasis criteria was 2/1421 (0.1% [0%-0.5%]). No patient died, and serious adverse events occurred in 2.5% of venous thrombosis patients and 2.3% of patients with PE. Medication nonadherence was reported by patients in 8.0% (6.6%-9.5%) and was associated with a risk ratio of 6.0 (2.3-15.2) for VTE recurrence. Among all patients diagnosed with VTE in the emergency department during the period of study, 18% of venous thrombosis patients and 10% of patients with PE were enrolled.

CONCLUSIONS

Monotherapy treatment of low-risk patients with venous thrombosis or PE in the emergency department setting produced a low rate of bleeding and VTE recurrence, but may be underused. Patients with venous thrombosis and PE should undergo risk-stratification before home treatment. Improved patient adherence may reduce rate of recurrent VTE. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03404635.

Outpatient treatment of emergency department patients diagnosed with venous thromboembolism

Venous thromboembolism (VTE) includes the diagnosis of either deep venous thrombosis (DVT) and/or pulmonary embolism (PE). This review discusses an evidence-based approach to the outpatient treatment of VTE in the emergency care setting. Main findings: The majority of patients diagnosed with VTE in the acute care setting are at low risk for an adverse event. Outpatient treatment for patients deemed low-risk by validated clinical decision tools leads to safe, efficacious, patient-centered, and cost-effective care. From a patient perspective, outpatient treatment of VTE can been simplified by the use of direct oral anticoagulant (DOACs) medications, and is supported by clinical trial evidence, and clinical practice guidelines from international societies. Outpatient treatment of patients with DVT has been more widely accepted as a best practice, while adoption of outpatient treatment of low-risk patients with acute PE has lagged. Many acute care clinicians remain wary of discharging patients with PE, concerned about drug access, adherence, and follow-up. Patients with VTE should be risk stratified identically as emerging evidence has demonstrated efficacy and safety in the interdependence of acute care protocols for the outpatient treatment of low-risk DVT and PE. Clinicians who practice in the acute care setting should be comfortable with risk stratification, anticoagulation, and discharge of low-risk VTE.

Apixaban anti-Xa level monitoring in treatment of acute upper extremity deep vein thrombosis for patient on chronic hemodialysis: a case report

Background

Patients on dialysis are at higher risk of major bleeding and recurrent thrombosis creating acute venous thromboembolism (VTE) treatment challenges. DOACs represent an interesting option but there are concerns of bioaccumulation and increased bleeding risk. Anti-Xa trough levels may be used to monitor for bioaccumulation but there is little data.

Case presentation

We describe a case, a 51 yo female, 36 kg on hemodialysis with a provoked acute upper extremity deep vein thrombosis in whom body habitus and calciphylaxis contraindicated the use of standard therapy. She received apixaban 2.5 mg twice daily for 6 weeks. The apixaban anti-Xa trough levels were measured weekly 12 h after the morning dose and ranged from 58 to 84 ng/mL, similar to expected levels with normal renal function. There were no adverse events in the 3 months follow-up.

Conclusions

We saw no evidence of bioaccumulation indicating a potential role for low dose apixaban for acute VTE in dialysis patients.

Study protocol for a multicentre implementation trial of monotherapy anticoagulation to expedite home treatment of patients diagnosed with venous thromboembolism in the emergency department

INTRODUCTION

In the USA, many emergency departments (EDs) have established protocols to treat patients with newly diagnosed deep vein thrombosis (DVT) as outpatients. Similar treatment of patients with pulmonary embolism (PE) has been proposed, but no large-scale study has been published to evaluate a comprehensive, integrated protocol that employs monotherapy anticoagulation to treat patients diagnosed with DVT and PE in the ED.

METHODS AND ANALYSIS

This protocol describes the implementation of the Monotherapy Anticoagulation To expedite Home treatment of Venous ThromboEmbolism (MATH-VTE) study at 33 hospitals in the USA. The study was designed and executed to meet the requirements for the Standards for Reporting Implementation Studies guideline. The study was funded by investigator-initiated awards from industry, with Indiana University as the sponsor. The study principal investigator and study associates travelled to each site to provide on-site training. The protocol identically screens patients with both DVT or PE to determine low risk of death using either the modified Hestia criteria or physician judgement plus a negative result from the simplified PE severity index. Patients must be discharged from the ED within 24 hours of triage and treated with either apixaban or rivaroxaban. Overall effectiveness is based upon the primary efficacy and safety outcomes of recurrent VTE and bleeding requiring hospitalisation respectively. Target enrolment of 1300 patients was estimated with efficacy success defined as the upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0%. Thirty-three hospitals in 17 states were initiated in 2016-2017.

ETHICS AND DISSEMINATION

All sites had Institutional Review Board approval. We anticipate completion of enrolment in June 2020; study data will be available after peer-reviewed publication. MATH-VTE will provide information from a large multicentre sample of US patients about the efficacy and safety of home treatment of VTE with monotherapy anticoagulation.

Systems-based hematology: highlighting successes and next steps

Systems-based hematology is dedicated to improving care delivery for patients with blood disorders. First defined by the American Society of Hematology in 2015, the idea of a systems-based hematologist arose from evolving pressures in the health care system and increasing recognition of opportunities to optimize the quality and cost effectiveness of hematologic care. In this review, we begin with a proposed framework to formalize the discussion of the range of initiatives within systems-based hematology. Classification by 2 criteria, project scope and method of intervention, facilitates comparison between initiatives and supports dialogue for future efforts. Next, we present published examples of successful systems-based initiatives in the field of hematology, including efforts to improve stewardship in the diagnosis and management of complex hematologic disorders (eg, heparin-induced thrombocytopenia and thrombophilias), the development of programs to promote appropriate use of hematologic therapies (eg, blood products, inferior vena cava filters, and anticoagulation), changes in care delivery infrastructure to improve access to hematologic expertise (eg, electronic consultation and disorder-specific care pathways), and others. The range of projects illustrates the broad potential for interventions and highlights different metrics used to quantify improvements in care delivery. We conclude with a discussion about future directions for the field of systems-based hematology, including extension to malignant disorders and the need to define, expand, and support career pathways.

CT Pulmonary Angiography for Risk Stratification of Patients with Nonmassive Acute Pulmonary Embolism

Purpose

To investigate the prognostic value of an integrative approach combining clinical variables and the Qanadli CT obstruction index (CTOI) in patients with nonmassive acute pulmonary embolism (PE).

Materials and Methods

This retrospective study included 705 consecutive patients (mean age, 63 years; range, 18-95 years) with proven PE. Clot burden was quantified using the CTOI, which reflects the ratio of fully or partially obstructed pulmonary arteries to normal arteries. Patients were subdivided into two groups according to the presence (group A) or absence (group B) of preexisting cardiopulmonary disease. Thirty-day and 3-month mortality was evaluated. CTOI thresholds of 20% and 40% were used to stratify patients regarding outcome (low, intermediate, and high risk). The predictive value of CTOI was assessed through logistic regression analysis.

Results

Analysis included 690 patients (mean age, 63.3 years ± 18 [standard deviation]) with complete follow-up data: 247 (36%) in group A and 443 (64%) in group B. The mean CTOI was 23% ± 19, 30-day mortality was 9.7%, and 3-month mortality was 11.6%. Three-month mortality was higher in group A than in group B (17.8% and 8.1%, respectively; P = .001). Within group B, CTOI predicted outcome and allowed stratification: significantly higher mortality with CTOI greater than 40% (P < .001) and lower mortality with CTOI less than 20% (P = .05). CTOI did not predict outcome in group A. Age was an independent mortality risk factor (P ≤ .04).

Conclusion

CTOI predicted outcome in this cohort of patients with PE and no cardiopulmonary disease, and it may provide a simple single-examination-based approach for risk stratification in this subset of patients.© RSNA, 2020See also the commentary by Kay and Abbara in this issue.

Hospitalization Is Less Common in Ambulatory Patients With Acute Pulmonary Embolism Diagnosed Before Emergency Department Referral Than After Arrival

BACKGROUND

Emergency department (ED) patients with acute pulmonary embolism (PE) may undergo diagnostic pulmonary imaging as an outpatient before referral to the ED for definitive management. This population has not been well characterized.

METHODS

This retrospective cohort study included ambulatory adults with acute objectively confirmed PE across 21 EDs in an integrated health care system from January 1, 2013, through April 30, 2015. We excluded patients arriving by ambulance. We compared outpatients with diagnostic pulmonary imaging in the 12 hours prior to ED arrival (the clinic-based cohort) with those receiving imaging for PE only after ED arrival. We reported adjusted odds ratio (aOR) with 95% confidence intervals (CIs) for hospitalization, adjusted for race, presyncope or syncope, proximal clot location, and PE Severity Index class.

RESULTS

Among 2,352 eligible ED patients with acute PE, 344 (14.6%) had a clinic-based diagnosis. This cohort had lower PE Severity Index classification and were less likely to be hospitalized than their counterparts with an ED-based diagnosis: 80.8% vs. 92.0% (p < 0.0001). The inverse association with hospitalization persisted after adjusting for the above patient characteristics with aOR of 0.36 (95% CI = 0.26 to 0.50).

CONCLUSION

In the study setting, ambulatory outpatients with acute PE are commonly diagnosed before ED arrival. A clinic-based diagnosis of PE identifies ED patients less likely to be hospitalized. Research is needed to identify which patients with a clinic-based PE diagnosis may not require transfer to the ED before home discharge.

Home treatment of venous thromboembolism disease

Despite the potential benefits of outpatient care, most patients with pulmonary embolisms are treated in hospitals for fear of possible adverse events. However, there is a wealth of scientific evidence from studies covering more than 4000 outpatients, which has led the current clinical practice guidelines to recommend early discharge or outpatient treatment when a low risk of death or complications has been confirmed, when there are no comorbidities or aggravating processes present to warrant hospitalisation and when appropriate monitoring and treatment are observed. This approach minimises the complications that can arise in hospitals and represents considerable cost savings. When selecting these patients, the use of prognostic tools such as the Pulmonary Embolism Severity Index (PESI), its simplified version (sPESI) and the Hestia Criteria are of paramount importance. Using these tools, the short-term outcomes (30-90days) show low mortality (in general <3%) and a low incidence of other complications (rate of recurrence and major bleeding <2%). Based on the available evidence, outpatient treatment can be considered the most appropriate strategy at this time for most hemodynamically stable patients with pulmonary embolisms.

Concise Review of the Clinical Approach to the Exclusion and Diagnosis of Pulmonary Embolism in 2020

Pulmonary embolism has extremely varied clinical presentations and can be difficult to diagnose. Clinical decision rules can help determine the probability of pulmonary embolism by assessment of the clinical presentation. After the diagnosis, several prognostic rules can be used to risk-stratify and facilitate outpatient treatment of pulmonary embolism. This review addresses the utility of clinical decision rules, biomarkers in the diagnosis of pulmonary emoblism, high-risk patient phenotypes, the use of this data to make disposition decisions for patients with a diagnosis of PE, and recent shifts in the management of pulmonary embolism in the clinical setting.

Comprehensive Outpatient Management of Low-Risk Pulmonary Embolism: Can Primary Care Do This? A Narrative Review

INTRODUCTION

The evidence for outpatient management of hemodynamically stable, low-risk patients with acute symptomatic pulmonary embolism (PE) is mounting. Guidance in identifying patients who are eligible for outpatient (ambulatory) care is available in the literature and society guidelines. Less is known about who can identify patients eligible for outpatient management and in what clinical practice settings.

OBJECTIVE

To answer the question, "Can primary care do this?" (provide comprehensive outpatient management of low-risk PE).

METHODS

We undertook a narrative review of the literature on the outpatient management of acute PE focusing on site of care. We searched the English-language literature in PubMed and Embase from January 1, 1950, through July 15, 2019.

RESULTS

We identified 26 eligible studies. We found no studies that evaluated comprehensive PE management in a primary care clinic or general practice setting. In 19 studies, the site-of-care decision making occurred in the Emergency Department (or after a short period of supplemental observation) and in 7 studies the decision occurred in a specialty clinic. We discuss the components of care involved in the diagnosis, outpatient eligibility assessment, treatment, and follow-up of ambulatory patients with acute PE.

DISCUSSION

We see no formal reason why a trained primary care physician could not provide comprehensive care for select patients with low-risk PE. Leading obstacles include lack of ready access to advanced pulmonary imaging and the time constraints of a busy outpatient clinic.

CONCLUSION

Until studies establish safe parameters of such a practice, the question "Can primary care do this?" must remain open.

Home treatment of patients with cancer-associated venous thromboembolism - An evaluation of daily practice

BACKGROUND

Home treatment of cancer-associated venous thromboembolism (VTE) is challenging due to the high risk of adverse events. While home treatment is quite agreeable to cancer patients, studies evaluating the safety of VTE home treatment in this setting are largely unavailable.

METHODS

This was an observational study in patients with cancer-associated VTE. The main outcomes were the proportion of patients treated at home (hospital discharge <24 h after diagnosis) and the 3-month incidence of VTE-related adverse events (major bleeding, recurrent VTE and/or suspected VTE-related mortality) in patients managed in hospital versus at home.

RESULTS

A total of 183 outpatients were diagnosed with cancer-associated VTE: 69 had deep vein thrombosis (DVT) and 114 had pulmonary embolism (PE ± DVT). Of those, 120 (66%) were treated at home; this was 83% for patients with DVT and 55% for patients with PE (±DVT). The 3-month incidence of any VTE-related adverse event was 13% in those treated at home versus 19% in the hospitalized patients (HR 0.48; 95%CI 0.22-1.1), independent of initial presentation as PE or DVT. All-cause 3-month mortality occurred in 33 patients treated as inpatient (54%) compared to 29 patients treated at home (24%; crude HR 3.1 95%CI 1.9-5.0).

CONCLUSIONS

Two-third of patients with cancer-associated VTE - including PE - were selected to start anticoagulant treatment at home. Cancer-associated VTE is associated with high rates of VTE-related adverse events independent of initial in hospital or home treatment. However, home treatment may be a good option for selected patients with cancer-associated DVT or PE.

Definitions, adjudication, and reporting of pulmonary embolism-related death in clinical studies: A systematic review

BACKGROUND

Pulmonary embolism (PE)-related death is a component of the primary outcome in many venous thromboembolism (VTE) studies. The absence of a standardized definition for PE-related death hampers study outcome evaluation and between-study comparisons.

OBJECTIVES

To summarize definitions for PE-related death used in recent VTE studies and to assess the PE-related death rate.

PATIENTS/METHODS

A systematic literature search was conducted on 26 April 2018 from 1 January 2014 up to the search date in MEDLINE, Embase, and CENTRAL. Cohort studies and randomized trials in which PE-related death was included in the primary outcome were eligible. Screening of titles, abstracts, and full-text articles, and data extraction were independently performed in duplicate by two authors. Study outcomes included the definition for PE-related death, VTE case-fatality rate, and death due to PE rate. Descriptive statistics were used to analyze the data.

RESULTS

Of the 6807 identified citations, 83 studies were included of which 27% were randomized trials, 31% were prospective, and 42% retrospective cohort studies. Thirty-five studies (42%) had a central adjudication committee. Thirty-eight (46%) reported a definition for PE-related death of which the most frequently used components were "autopsy-confirmed PE" (50%), "objectively confirmed PE before death" (55%), and "unexplained death" (58%). Median VTE case-fatality rate was 1.8% (interquartile range, 0.0-13).

CONCLUSIONS

Only half of the included studies reported definitions for PE-related death, which were very heterogeneous. Case-fatality rate of VTE events varied widely across studies. Standardization of the definition and guidance on adjudication and reporting of PE-related death is needed.

Reducing the hospital burden associated with the treatment of pulmonary embolism

Pulmonary embolism (PE) is the most feared clinical presentation of venous thromboembolism (VTE). Patients with PE have traditionally been treated in hospital; however, many are at low risk of adverse outcomes and current guidelines suggest outpatient treatment as an option. Outpatient treatment of PE offers several advantages, including reduced risk of hospital-acquired conditions and potential cost savings. Despite this, patients with low-risk PE are still frequently hospitalized for treatment. This narrative review summarizes current guideline recommendations for the identification of patients with low-risk PE who are potentially suitable for outpatient treatment, using prognostic assessment tools (e.g. the Pulmonary Embolism Severity Index [PESI] and simplified PESI) and clinical exclusion criteria (e.g. Hestia criteria) alone or in combination with additional cardiac assessments. Treatment options are discussed along with recommendations for the follow-up of patients managed in the non-hospital environment. The available data on outpatient treatment of PE are summarized, including details on patient selection, anticoagulant choice, and short-term outcomes in each study. Accumulating evidence suggests that outcomes in patients with low-risk PE treated as outpatients are at least as good as, if not better than, those of patients treated in the hospital. With mounting pressures on health care systems worldwide, increasing the proportion of patients with PE treated as outpatients has the potential to reduce health care burdens associated with VTE.

A New Model for Risk Stratification of Patients With Acute Pulmonary Embolism

Pulmonary embolism (PE) is associated with mortality. There are many clinical prediction tools to predict early mortality in acute PE but little consensus on which is best. Our study aims to validate existing prediction tools and derive a predictive model that can be applied to all patients with acute PE in both inpatient and outpatient settings. This is a retrospective cohort study of patients with acute PE. For each patient, the Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI), European Society of Cardiology (ESC), and Angriman scores were calculated. Scores were assessed by the area under the receive-operating curve (AUC) for 30-day, all-cause mortality. To develop a new prognostic model, elastic logistic regression was used on the derivation cohort to estimate β-coefficients of 8 different variables; these were normalized to weigh them. A total of 321 patients (mean age 60±17 years) were included. Overall 30-day mortality was 10.3%. None of the scores performed well; the AUCs for the PESI, sPESI, ESC, and Angriman scores were 0.67 (95% confidence interval [CI], 0.57-0.77), 0.58 (0.48-0.69), 0.65 (0.55-0.75), and 0.67 (0.57-0.76), respectively. Our new prediction model outperformed PESI, with an AUC of 0.82 (95% CI, 0.76-0.88). At a cutoff score of 100, 195 (60.1%) patients were classified as low risk. Thirty-day mortality was 2.1% (95% CI, 0.8%-5.2%) and 23.0% (16.5%-31.1%) for low- and high-risk groups, respectively (P < .001). In conclusion, we have developed a new model that outperforms existing prediction tools in all comers with PE. However, further validation on external cohorts is required before application.

Early decision-making in acute pulmonary embolism: a retrospective clinical audit

BACKGROUND

There is increasing evidence supporting early discharge of patients with acute pulmonary embolism (aPE) deemed 'low prognostic risk' as a safe and viable alternative to admission if identified correctly by guideline algorithms.

AIM

To determine if risk stratification guidelines were followed accurately in an Australian tertiary hospital.

METHODS

Patients admitted to the emergency department with a diagnosis of PE were included from December 2012 to December 2017. The 272 patients were retrospectively assessed for prognostic risk prior to and after release of the 2014 European Society of Cardiology (ESC) guidelines. This included the simplified Pulmonary Embolism Severity Index (sPESI), and evidence of right heart dysfunction. Thereafter, patients were dichotomised into low (i.e. sPESI = 0) and non-low (i.e. sPESI ≥1 with or without the evidence of right heart dysfunction) prognostic risk groups.

RESULTS

Prior to ESC guideline release, 52 (65%) of the 80 patients diagnosed with PE were non-low risk and 12 (23%) of these were discharged home; 11 (91.7%) of the 12 discharges had unrecognised sPESI medical history components. After ESC guideline release, 122 (63.5%) of the 192 patients were non-low risk and 20 (16.4%) of these were discharged home; 18 (90%) of the 20 discharges had unrecognised sPESI medical history components.

CONCLUSION

We found that the sPESI score is not adequately applied in determining prognostic risk for acute PE. In cases of non-low-risk discharge, both prior to and after ESC guideline release, the medical history components of the sPESI score are under-recognised as a marker of increased prognostic risk.

Pulmonary embolism severity assessment and prognostication

For patients who have acute symptomatic pulmonary embolism (PE), risk of short-term death and adverse outcomes should drive the initial treatment decisions. Practice guidelines recommend that patients who have a high-risk of PE-related death and adverse outcomes, determined by the presence of haemodynamic instability (i.e., shock or hypotension), should receive systemically administered thrombolytic therapy. Intermediate-high risk patients might benefit from close observation, and some should undergo escalation of therapy beyond standard anticoagulation, particularly if haemodynamic deterioration occurs. Low-risk for adverse outcomes should lead to early hospital discharge or full treatment at home. Validated prognostic tools (i.e., clinical prognostic scoring systems, imaging studies, and cardiac laboratory biomarkers) assist with risk classification of patients who have acute symptomatic PE.