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Parmar CD, Felsenreich DM, Salminen P, Di Lorenzo N, Prager G. Guidelines for Management of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Occurring After Metabolic Bariatric Surgery (MBS). Obes Surg 2024; 34:1964-1968. [PMID: 38530553 DOI: 10.1007/s11695-024-07187-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 03/28/2024]
Affiliation(s)
- Chetan D Parmar
- Whittington Hospital, London, N19 5NF, UK.
- University College London, London, UK.
- Apollo Hospitals, Chennai, India.
| | | | | | - Nicola Di Lorenzo
- Department of Surgical Sciences, University of Tor Vergata, Policlinico Tor Vergata, Rome, Italy
| | - Gerhard Prager
- Department of Surgery, Vienna Medical University, Vienna, Austria
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Nopp S, Bohnert J, Mayr T, Steiner D, Prosch H, Lang I, Behringer W, Janata-Schwatczek K, Ay C. Early discharge and home treatment of patients with acute pulmonary embolism in the tertiary care setting. Intern Emerg Med 2024; 19:191-199. [PMID: 37670173 PMCID: PMC10827840 DOI: 10.1007/s11739-023-03415-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/26/2023] [Indexed: 09/07/2023]
Abstract
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.
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Affiliation(s)
- Stephan Nopp
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Julia Bohnert
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas Mayr
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Daniel Steiner
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Helmut Prosch
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Irene Lang
- Clinical Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Wilhelm Behringer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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3
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Lanham S, Maiter A, Swift AJ, Dwivedi K, Alabed S, Evans O, Sharkey MJ, Matthews S, Johns CS. The reproducibility of manual RV/LV ratio measurement on CT pulmonary angiography. BJR Open 2022; 4:20220041. [PMID: 38495814 PMCID: PMC10941330 DOI: 10.1259/bjro.20220041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 09/18/2022] [Indexed: 11/29/2022] Open
Abstract
Objectives Right ventricular (RV) dysfunction carries elevated risk in acute pulmonary embolism (PE). An increased ratio between the size of the right and left ventricles (RV/LV ratio) is a biomarker of RV dysfunction. This study evaluated the reproducibility of RV/LV ratio measurement on CT pulmonary angiography (CTPA). Methods 20 inpatient CTPA scans performed to assess for acute PE were retrospectively identified from a tertiary UK centre. Each scan was evaluated by 14 radiologists who provided a qualitative overall opinion on the presence of RV dysfunction and measured the RV/LV ratio. Using a threshold of 1.0, the RV/LV ratio measurements were classified as positive (≥1.0) or negative (<1.0) for RV dysfunction. Interobserver agreement was quantified using the Fleiss κ and intraclass correlation coefficient (ICC). Results Qualitative opinion of RV dysfunction showed weak agreement (κ = 0.42, 95% CI 0.37-0.46). The mean RV/LV ratio measurement for all cases was 1.28 ± 0.68 with significant variation between reporters (p < 0.001). Although agreement for RV/LV measurement was good (ICC = 0.83, 95% CI 0.73-0.91), categorisation of RV dysfunction according to RV/LV ratio measurements showed weak agreement (κ = 0.46, 95% CI 0.41-0.50). Conclusion Both qualitative opinion and quantitative manual RV/LV ratio measurement show poor agreement for identifying RV dysfunction on CTPA. Advances in knowledge Caution should be exerted if using manual RV/LV ratio measurements to inform clinical risk stratification and management decisions.
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Affiliation(s)
- Sarah Lanham
- Department of Clinical Radiology, Sheffield Teaching Hospitals
NHS Foundation Trust, Sheffield, United Kingdom
| | - Ahmed Maiter
- Department of Clinical Radiology, Sheffield Teaching Hospitals
NHS Foundation Trust, Sheffield, United Kingdom
- Department of Infection, Immunity and Cardiovascular Disease,
University of Sheffield, Sheffield, United Kingdom
| | - Andrew J Swift
- Department of Clinical Radiology, Sheffield Teaching Hospitals
NHS Foundation Trust, Sheffield, United Kingdom
- Department of Infection, Immunity and Cardiovascular Disease,
University of Sheffield, Sheffield, United Kingdom
- INSIGNEO Institute for In Silico Medicine, University of
Sheffield, Sheffield, United Kingdom
| | - Krit Dwivedi
- Department of Clinical Radiology, Sheffield Teaching Hospitals
NHS Foundation Trust, Sheffield, United Kingdom
- Department of Infection, Immunity and Cardiovascular Disease,
University of Sheffield, Sheffield, United Kingdom
- INSIGNEO Institute for In Silico Medicine, University of
Sheffield, Sheffield, United Kingdom
| | - Samer Alabed
- Department of Clinical Radiology, Sheffield Teaching Hospitals
NHS Foundation Trust, Sheffield, United Kingdom
- Department of Infection, Immunity and Cardiovascular Disease,
University of Sheffield, Sheffield, United Kingdom
- INSIGNEO Institute for In Silico Medicine, University of
Sheffield, Sheffield, United Kingdom
| | - Oscar Evans
- Department of Clinical Radiology, Sheffield Teaching Hospitals
NHS Foundation Trust, Sheffield, United Kingdom
| | - Michael J Sharkey
- Department of Infection, Immunity and Cardiovascular Disease,
University of Sheffield, Sheffield, United Kingdom
- INSIGNEO Institute for In Silico Medicine, University of
Sheffield, Sheffield, United Kingdom
| | - Suzanne Matthews
- Department of Clinical Radiology, Sheffield Teaching Hospitals
NHS Foundation Trust, Sheffield, United Kingdom
| | - Christopher S Johns
- Department of Clinical Radiology, Sheffield Teaching Hospitals
NHS Foundation Trust, Sheffield, United Kingdom
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Vinson DR, Hofmann ER, Johnson EJ, Rangarajan S, Huang J, Isaacs DJ, Shan J, Wallace KL, Rauchwerger AS, Reed ME, Mark DG. Management and Outcomes of Adults Diagnosed with Acute Pulmonary Embolism in Primary Care: Community-Based Retrospective Cohort Study. J Gen Intern Med 2022; 37:3620-3629. [PMID: 35020167 PMCID: PMC9585133 DOI: 10.1007/s11606-021-07289-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The management and outcomes of patients diagnosed with acute pulmonary embolism in primary care have not been characterized. OBJECTIVE To describe 30-day outcomes stratified by initial site-of-care decisions DESIGN: Multicenter retrospective cohort study PARTICIPANTS: Adults diagnosed with acute pulmonary embolism in primary care in a large, diverse community-based US health system (2013-2019) MAIN MEASURES: The primary outcome was a composite of 30-day serious adverse events (recurrent venous thromboembolism, major bleeding, and all-cause mortality). The secondary outcome was 7-day pulmonary embolism-related hospitalization, either initial or delayed. KEY RESULTS Among 652 patient encounters (from 646 patients), median age was 64 years; 51.5% were male and 70.7% identified as non-Hispanic white. Overall, 134 cases (20.6%) were sent home from primary care and 518 cases (79.4%) were initially referred to the emergency department (ED) or hospital. Among the referred, 196 (37.8%) were discharged home from the ED without events. Eight patients (1.2%; 95% CI 0.5-2.4%) experienced a 30-day serious adverse event: 4 venous thromboemboli (0.6%), 1 major bleed (0.2%), and 3 deaths (0.5%). Seven of these patients were initially hospitalized, and 1 had been sent home from primary care. All 3 deaths occurred in patients with known metastatic cancer initially referred to the ED, hospitalized, then enrolled in hospice following discharge. Overall, 328 patients (50.3%) were hospitalized within 7 days: 322 at the time of the index diagnosis and 6 following initial outpatient management (4 clinic-only and 2 clinic-plus-ED patients). CONCLUSIONS Patients diagnosed with acute pulmonary embolism in this primary care setting uncommonly experienced 30-day adverse events, regardless of initial site-of-care decisions. Over 20% were managed comprehensively by primary care. Delayed 7-day pulmonary embolism-related hospitalization was rare among the 51% treated as outpatients. Primary care management of acute pulmonary embolism appears to be safe and could have implications for cost-effectiveness and patient care experience.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, CA, USA.
- Kaiser Permanente Division of Research, Oakland, CA, USA.
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, 1600 Eureka Road, Roseville, CA, 95661, USA.
| | - Erik R Hofmann
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | | | - Suresh Rangarajan
- The Permanente Medical Group, Oakland, CA, USA
- Department of Adult and Family Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Jie Huang
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Dayna J Isaacs
- School of Medicine, University of California, Davis, Sacramento, CA, USA
- Internal Medicine Residency Program, University of California Los Angeles, Los Angeles, CA, USA
| | - Judy Shan
- Kaiser Permanente Division of Research, Oakland, CA, USA
- University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Karen L Wallace
- The Permanente Medical Group, Oakland, CA, USA
- Department of Radiology, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | | | - Mary E Reed
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Dustin G Mark
- The Permanente Medical Group, Oakland, CA, USA
- Kaiser Permanente Division of Research, Oakland, CA, USA
- Departments of Emergency and Critical Care Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
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Right heart strain assessment on CTPA following acute pulmonary embolism: Interobserver variability between expert radiologists and physicians. Respir Med 2022; 200:106928. [PMID: 35853266 DOI: 10.1016/j.rmed.2022.106928] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/19/2022] [Accepted: 07/04/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Accuracy of right heart strain (RHS) measured on computed tomography pulmonary angiogram (CTPA) scans by non-radiologists is unknown. We assessed inter-observer variability of four RHS features and determined the accuracy of measurements by respiratory physicians. METHOD 1560 consecutive patients with acute PE were identified, and those who had a CTPA and an echocardiogram within 24-h included. CTPAs were independently scored prospectively by two radiologists, two thoracic physicians and a specialist registrar. Inter-observer variability was assessed, and diagnostic accuracy compared to echocardiography. RESULTS 182 patients (median age 62.8 years, IQR 49.8-71.5) with acute PE (7.7% high-risk, 40.7% intermediate high-risk, 31.3% intermediate low-risk and 20.3% low-risk) were included. Right ventricle to left ventricle diameter ratio (RV:LV) measurement had low inter-observer variability among the radiologists and non-radiologists with interclass correlation coefficient (ICC) of 0.95 (95%CI 0.92-0.97) and 0.96 (95%CI 0.94-0.97) respectively. RV:LV ratio had high diagnostic accuracy compared to RV dilatation on echocardiography (AUC 0.89, 95%CI 0.84-0.94 for radiologists and AUC 0.84, 95%CI 0.77-0.90 for non-radiologists). Main pulmonary artery to ascending aorta diameter ratio (MPA:Ao) measurement also had excellent agreement amongst the radiologists and non-radiologists (ICC 0.93 (95%CI 0.88-0.96) and 0.92 (95%CI 0.81-0.96) respectively). Significant variability was seen in the assessment of subjective features of RHS (leftward bowing of interventricular septum and contrast reflux into inferior vena cava) amongst the non-radiologists. CONCLUSION RV:LV and MPA:Ao diameter ratios on CTPA measured by non-radiologists have low inter-observer variability and good agreement with radiologists, and can be reliably used where an expert report is unavailable.
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Muñoz-Guglielmetti D, Cooksley T, Ahn S, Beato C, Aramberri M, Escalante C, Font C. Risk stratification for clinical severity of pulmonary embolism in patients with cancer: a narrative review and MASCC clinical guidance for daily care. Support Care Cancer 2022; 30:8527-8538. [PMID: 35579753 DOI: 10.1007/s00520-022-07131-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 05/09/2022] [Indexed: 11/26/2022]
Abstract
Pulmonary embolism (PE) is a leading cause of morbidity and mortality in patients with cancer. The clinical presentation and outcomes of PE range from an acute life-threatening condition requiring intensive care to a mild symptomatic condition associated with favorable outcomes and potentially candidate for early hospital discharge. The wide clinical spectrum of PE has led to the development of risk stratification models aimed at the triage of patients in emergency care departments and optimizing the utilization of health care resources. Incidental or unsuspected PE (UPE), detected during routine staging computed tomography scans, make up a significant proportion of this cohort among the oncology population. The present narrative review is aimed at examining the currently available PE risk assessment models developed for the general population and for patients with cancer including UPE. We include general recommendations for the daily care of patients with cancer-related PE and hypothesize on the factors that would potentially favor hospitalization with early discharge or ambulatory management in this setting.
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Affiliation(s)
| | - Tim Cooksley
- The Christie Hospital, University of Manchester, Wythenshawe Hospital, Manchester, UK
| | - Shin Ahn
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Carmen Beato
- Medical Oncology Department, Hospital Universitario Macarena, Seville, Spain
| | - Mario Aramberri
- Internal Medicine Department, Hospital Galdakao-Usansolo, Vizcaya, Spain
| | - Carmen Escalante
- Internal Medicine Department, MD Anderson Cancer Center, University of Texas, Houston, USA
| | - Carme Font
- Medical Oncology Department, Hospital Clinic Barcelona, Barcelona, Spain.
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Maraziti G, Cimini LA, Becattini C. Risk stratification to optimize the management of acute pulmonary embolism. Expert Rev Cardiovasc Ther 2022; 20:377-387. [PMID: 35544707 DOI: 10.1080/14779072.2022.2077194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pulmonary embolism (PE) is a life-threatening disease. Risk stratification in patients with acute PE can guide clinical decisions. Clinical assessment, including hemodynamics, respiratory parameters, patient history, and right ventricle evaluation, has a pivotal role in this scope. AREAS COVERED This review aims to describe: i) the role of individual tools for prognostic stratification, from simple clinical parameters to the models suggested by international guidelines; ii) the implications of risk stratification in terms of patient disposition and treatment. The bleeding risk assessment in acute PE was also reviewed. The literature search was performed in PubMed and Embase to address these issues. EXPERT OPINION Prognostic assessment is essential to proceed with life-saving treatments in hemodynamically unstable patients and consider home treatment or short hospital stay in patients at low risk for death. In hemodynamically stable patients, risk stratification allows the implementation of personalized treatment pathways to reduce the risk of death, early PE recurrence, and bleeding. With the aim of optimizing healthcare resources, risk stratification may suggest appropriate patient disposition.
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Affiliation(s)
- Giorgio Maraziti
- Internal and Cardiovascular Medicine - Stroke Unit, Ospedale Santa Maria della Misericordia -University of Perugia, Perugia, Italy
| | - Ludovica Anna Cimini
- Internal and Cardiovascular Medicine - Stroke Unit, Ospedale Santa Maria della Misericordia -University of Perugia, Perugia, Italy
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine - Stroke Unit, Ospedale Santa Maria della Misericordia -University of Perugia, Perugia, Italy
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Yoo HH, Nunes-Nogueira VS, Fortes Villas Boas PJ, Broderick C. Outpatient versus inpatient treatment for acute pulmonary embolism. Cochrane Database Syst Rev 2022; 5:CD010019. [PMID: 35511086 PMCID: PMC9070407 DOI: 10.1002/14651858.cd010019.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) is a common life-threatening cardiovascular condition, with an incidence of 23 to 69 new cases per 100,000 people each year. For selected low-risk patients with acute PE, outpatient treatment might provide several advantages over traditional inpatient treatment, such as reduction of hospitalisations, substantial cost savings, and improvements in health-related quality of life. This is an update of an earlier Cochrane Review. OBJECTIVES To assess the effects of outpatient versus inpatient treatment in low-risk patients with acute PE. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 31 May 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) of outpatient versus inpatient treatment of adults (aged 18 years and over) diagnosed with low-risk acute PE. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were short- and long-term all-cause mortality. Secondary outcomes were bleeding, adverse effects, recurrence of PE, and patient satisfaction. We used GRADE to assess certainty of evidence for each outcome. MAIN RESULTS We did not identify any new studies for this update. We included a total of two RCTs involving 453 participants. Both trials discharged participants randomised to the outpatient group within 36 hours of initial triage, and both followed participants for 90 days. One study compared the same treatment regimens in both outpatient and inpatient groups, and the other study used different treatment regimens. There was no clear difference in treatment effect for the outcomes of mortality at 30 days (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.01 to 7.98; 2 studies, 453 participants; low-certainty evidence), mortality at 90 days (RR 0.98, 95% CI 0.06 to 15.58; 2 studies, 451 participants; low-certainty evidence), major bleeding at 14 days (RR 4.91, 95% CI 0.24 to 101.57; 2 studies, 445 participants; low-certainty evidence) and at 90 days (RR 6.88, 95% CI 0.36 to 132.14; 2 studies, 445 participants; low-certainty evidence), minor bleeding (RR 1.08, 95% CI 0.07 to 16.79; 1 study, 106 participants; low-certainty evidence), recurrent PE within 90 days (RR 2.95, 95% CI 0.12 to 71.85; 2 studies, 445 participants; low-certainty evidence), and patient satisfaction (RR 0.97, 95% CI 0.90 to 1.04; 2 studies, 444 participants; moderate-certainty evidence). We downgraded the certainty of the evidence because the CIs were wide and included treatment effects in both directions, the sample sizes and numbers of events were small, and it was not possible to determine the effect of missing data or the presence of publication bias. The included studies did not assess PE-related mortality or adverse effects, such as haemodynamic instability, or adherence to treatment. AUTHORS' CONCLUSIONS Currently, only low-certainty evidence is available from two published randomised controlled trials on outpatient versus inpatient treatment in low-risk patients with acute PE. The studies did not provide evidence of any clear difference between the interventions in overall mortality, bleeding, or recurrence of PE.
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Affiliation(s)
- Hugo Hb Yoo
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University-UNESP, Botucatu, Brazil
| | - Vania Santos Nunes-Nogueira
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University-UNESP, Botucatu, Brazil
| | - Paulo J Fortes Villas Boas
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University-UNESP, Botucatu, Brazil
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Vinson DR, Casey SD, Vuong PL, Huang J, Ballard DW, Reed ME. Sustainability of a Clinical Decision Support Intervention for Outpatient Care for Emergency Department Patients With Acute Pulmonary Embolism. JAMA Netw Open 2022; 5:e2212340. [PMID: 35576004 PMCID: PMC9112064 DOI: 10.1001/jamanetworkopen.2022.12340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- David R. Vinson
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Division of Research, Oakland, California
- The Kaiser Permanente CREST Network
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California
| | - Scott D. Casey
- The Kaiser Permanente CREST Network
- Department of Emergency Medicine, UC Davis Health, University of California, Davis, Sacramento
| | - Peter L. Vuong
- Department of Emergency Medicine, Kaiser Permanente Modesto Medical Center, Modesto, California
| | - Jie Huang
- Kaiser Permanente Division of Research, Oakland, California
- The Kaiser Permanente CREST Network
| | - Dustin W. Ballard
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Division of Research, Oakland, California
- The Kaiser Permanente CREST Network
- Department of Emergency Medicine, Kaiser Permanente San Rafael Medical Center, San Rafael, California
| | - Mary E. Reed
- Kaiser Permanente Division of Research, Oakland, California
- The Kaiser Permanente CREST Network
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10
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Zhou Q, Xiong XY, Liang ZA. Developing a Nomogram-Based Scoring Tool to Estimate the Risk of Pulmonary Embolism. Int J Gen Med 2022; 15:3687-3697. [PMID: 35411176 PMCID: PMC8994654 DOI: 10.2147/ijgm.s359291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/28/2022] [Indexed: 11/23/2022] Open
Abstract
Background Pulmonary embolisms (PEs) are clinically challenging because of their high morbidity and mortality. This study aimed to develop a scoring tool for predicting PEs to improve their clinical management. Methods Clinical, laboratory, and imaging parameters were retrospectively collected from suspected PE patients who had cough or chest pain and were hospitalized in West China Hospital of Sichuan University from May 2015 to April 2020. The final diagnosis of PE was defined based on findings from computed tomographic pulmonary angiography (CTPA). In this study, patients were randomly divided 2:1 into derivation and validation cohorts, which were used to create and validate, respectively, a nomogram. Model performance was estimated with the area under the receiver operating characteristic curve and a calibration curve. Results Our study incorporated data on more than 100 features from 1480 patients (811 non-PE, 669 PE). The nomogram was constructed using important predictive features including D-dimer, APTT, FDP, platelet count, sodium, albumin and cholesterol and achieved AUC values of 0.692 with the derivation cohort (95% CI 0.688–0.696, P < 0.01) and 0.688 with the validation cohort (95% CI 0.653–0.723, P < 0.01). The calibration curve showed good agreement between the probability predicted by the nomogram and the actual probability. Conclusion In this study, we successfully developed a nomogram that can predict the risk of PE, which can not only improve the clinical management of PE patients but also decrease unnecessary CTPA scans and their adverse effects.
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Affiliation(s)
- Qiao Zhou
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, People’s Republic of China
| | - Xing-Yu Xiong
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, People’s Republic of China
| | - Zong-An Liang
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, People’s Republic of China
- Correspondence: Zong-An Liang, Email
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Atkin C, Riley B, Sapey E. How do we identify acute medical admissions that are suitable for same day emergency care? Clin Med (Lond) 2022; 22:131-139. [PMID: 38589174 PMCID: PMC8966832 DOI: 10.7861/clinmed.2021-0614] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Medical emergencies causing unplanned hospital admission place considerable demands on acute healthcare services. Some patients can be assessed and treated through ambulatory pathways without inpatient admission, via same day emergency care (SDEC), potentially benefiting patients and reducing demands on inpatient services. There is currently considerable variation within acute medicine in aspects of SDEC delivery ranging from overall service design to patient selection methods. Scoring systems identifying patients likely to be successfully managed through SDEC services have been suggested, but evidence of utility in diverse populations is lacking. Specific scoring systems exist for some common medical problems, including cardiac chest pain and pulmonary embolism, but further research is needed to demonstrate how these are most effectively incorporated into SDEC services. This review defines SDEC and describes the variation in services nationally. It reviews the evidence for their clinical impact, tools to screen patients for SDEC and current gaps in our knowledge regarding service deployment.
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Affiliation(s)
| | - Bridget Riley
- South Warwickshire NHS Foundation Trust, Warwick, UK
| | - Elizabeth Sapey
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK, and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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12
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Sanders A, El-Bouri WK, Lip GYH. The Birmingham and Black Country cohort of Venous Thromboembolism (BBC-VTE) registry: Rationale, design and preliminary results. Eur J Intern Med 2022; 97:50-55. [PMID: 35078696 DOI: 10.1016/j.ejim.2022.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 12/15/2021] [Accepted: 01/10/2022] [Indexed: 11/16/2022]
Abstract
The Birmingham Black Country Venous Thromboembolism registry (BBC-VTE) is a multi-ethnic cohort of patients who suffered a first episode of venous thromboembolism (VTE) and were admitted to various hospital sites across the West Midlands and Black Country regions in the United Kingdom. The BBC-VTE registry is a retrospective, observational cohort study which aims to collect data on outcomes including mortality, bleeding and VTE recurrence in this patient cohort. In addition, the comprehensive, structured data collected will allow us to conduct machine learning analyses for risk prediction in such patients and also to compare to previously derived mortality scores such as the PESI and the simplified PESI (sPESI). Our registry included 2183 patients admitted to hospital between the years 2012-14 and 2016-18 with a first episode of VTE and the mean follow up was 36 months. The cohort was ethnically diverse with 72.5% white Caucasian, 8.2% Asian (including South Asian), 6.7% black, and 11.7% of unknown/other ethnicity. Of those admitted during the collection period 56% had PE, 40% had DVT, with the rest presenting with both PE and DVT. Around 7% of patients went on to develop a bleeding episode and 36% died (all-cause mortality). Of the deaths, 10% of patients died within 30-days of admission (30-day mortality), with 16% dying within 90 days. In summary, this study investigates real-world outcomes of patients after the first index VTE event and attempts to bridge the gap in evidence for contemporary data in this population which will allow to construct more accurate risk prediction tools and management decisions.
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Affiliation(s)
- Alexander Sanders
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.
| | - Wahbi K El-Bouri
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
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13
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Le Mao R, Orione C, de Moreuil C, Tromeur C, Hoffmann C, Fauché A, Robin P, Didier R, Guegan M, Jiménez D, Le Moigne E, Leroyer C, Lacut K, Couturaud F. Risk stratification for predicting recurrent venous thromboembolism after discontinuation of anticoagulation: a post-hoc analysis of a French prospective multicenter study. Eur Respir J 2022; 60:13993003.03002-2021. [PMID: 35210315 DOI: 10.1183/13993003.03002-2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 01/30/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND We aimed to validate and to refine current recurrent venous thromboembolism (VTE) risk classification. METHODS We performed a post-hoc analysis of a multicentre cohort, including 1,881 patients with a first symptomatic VTE prospectively followed after anticoagulation discontinuation. The primary objective was to validate the International Society of Thrombosis and Haemostasis (ISTH) risk classification in predicting recurrence risk. Secondary objective was to evaluate a refined ISTH classification based on recurrence risk estimate for each individual risk factors. RESULTS During a 4.8-year median follow-up after anticoagulation discontinuation, symptomatic recurrent VTE occurred in 230 patients (12.2%). Based on ISTH classification, patients with unprovoked VTE or VTE with minor or major persistent risk factor had a 2-fold increased recurrence risk as compared to those with VTE and major transient risk factor. Recurrence risk was not increased in patients with minor transient factor (Hazard Ratio[HR] 1.31;95%CI0.84-2.06). Individual risk factors analysis identified hormone-related VTE (pregnancy: HR 0.26; 95%CI0.08-0.82; estrogens: HR 0.25; 95%CI0.14-0.47) and amyotrophic lateral sclerosis (HR 5.84; 95%CI1.82-18.70). After reclassification of these factors as major transient for the former and major persistent for the latter, refined ISTH classification allowed to accurately discriminate between patients at low-risk (i.e., with major transient risk factor) and those at high-risk of recurrence (i.e., without major transient risk factors). CONCLUSIONS Among patients who stopped anticoagulation after a first VTE, a refined ISTH classification based on recurrence risk intensity of individual factors allowed to discriminate between patients at low-recurrence risk, including hormonal exposure in women, and patients at high-recurrence risk.
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Affiliation(s)
- Raphael Le Mao
- Département de médecine interne et pneumologie, EA3878, CHU de Brest, Univ_Brest, Brest, France .,Centre d'Investigation Clinique INSERM 1412, Brest, France
| | - Charles Orione
- Département de médecine interne et pneumologie, EA3878, CHU de Brest, Univ_Brest, Brest, France.,Centre d'Investigation Clinique INSERM 1412, Brest, France
| | - Claire de Moreuil
- Département de médecine interne et pneumologie, EA3878, CHU de Brest, Univ_Brest, Brest, France.,Centre d'Investigation Clinique INSERM 1412, Brest, France
| | - Cécile Tromeur
- Département de médecine interne et pneumologie, EA3878, CHU de Brest, Univ_Brest, Brest, France.,Centre d'Investigation Clinique INSERM 1412, Brest, France.,FCRIN INNOVTE network, Brest, France
| | - Clément Hoffmann
- Département de médecine interne et pneumologie, EA3878, CHU de Brest, Univ_Brest, Brest, France.,Centre d'Investigation Clinique INSERM 1412, Brest, France
| | - Alexandre Fauché
- Département de médecine interne et pneumologie, EA3878, CHU de Brest, Univ_Brest, Brest, France.,Centre d'Investigation Clinique INSERM 1412, Brest, France
| | - Philippe Robin
- Centre d'Investigation Clinique INSERM 1412, Brest, France.,FCRIN INNOVTE network, Brest, France.,Service de médecine nucléaire, EA3878, CHU de Brest, Univ_Brest, Brest, France
| | - Romain Didier
- Centre d'Investigation Clinique INSERM 1412, Brest, France.,Service de cardiologie, EA3878, CHU de Brest, Univ_Brest, Brest, France
| | - Marie Guegan
- Département de médecine interne et pneumologie, EA3878, CHU de Brest, Univ_Brest, Brest, France.,Centre d'Investigation Clinique INSERM 1412, Brest, France.,FCRIN INNOVTE network, Brest, France
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain.,Medicine Department, Universidad de Alcalá, (IRYCIS), Madrid, Spain.,CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Emmanuelle Le Moigne
- Département de médecine interne et pneumologie, EA3878, CHU de Brest, Univ_Brest, Brest, France.,Centre d'Investigation Clinique INSERM 1412, Brest, France.,FCRIN INNOVTE network, Brest, France
| | - Christophe Leroyer
- Département de médecine interne et pneumologie, EA3878, CHU de Brest, Univ_Brest, Brest, France.,Centre d'Investigation Clinique INSERM 1412, Brest, France.,FCRIN INNOVTE network, Brest, France
| | - Karine Lacut
- Département de médecine interne et pneumologie, EA3878, CHU de Brest, Univ_Brest, Brest, France.,Centre d'Investigation Clinique INSERM 1412, Brest, France.,FCRIN INNOVTE network, Brest, France.,In memory of Karine Lacut
| | - Francis Couturaud
- Département de médecine interne et pneumologie, EA3878, CHU de Brest, Univ_Brest, Brest, France.,Centre d'Investigation Clinique INSERM 1412, Brest, France.,FCRIN INNOVTE network, Brest, France
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14
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Ibero-American Society of Interventionism (SIDI) and the Spanish Society of Vascular and Interventional Radiology (SERVEI) Standard of Practice (SOP) for the Management of Inferior Vena Cava Filters in the Treatment of Acute Venous Thromboembolism. J Clin Med 2021; 11:jcm11010077. [PMID: 35011826 PMCID: PMC8745208 DOI: 10.3390/jcm11010077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/06/2021] [Accepted: 12/10/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives: to present an interventional radiology standard of practice on the use of inferior vena cava filters (IVCFs) in patients with or at risk to develop venous thromboembolism (VTE) from the Iberoamerican Interventional Society (SIDI) and Spanish Vascular and Interventional Radiology Society (SERVEI). Methods: a group of twenty-two interventional radiologist experts, from the SIDI and SERVEI societies, attended online meetings to develop a current clinical practice guideline on the proper indication for the placement and retrieval of IVCFs. A broad review was undertaken to determine the participation of interventional radiologists in the current guidelines and a consensus on inferior vena cava filters. Twenty-two experts from both societies worked on a common draft and received a questionnaire where they had to assess, for IVCF placement, the absolute, relative, and prophylactic indications. The experts voted on the different indications and reasoned their decision. Results: a total of two-hundred-thirty-three articles were reviewed. Interventional radiologists participated in the development of just two of the eight guidelines. The threshold for inclusion was 100% agreement. Three absolute and four relative indications for the IVCF placement were identified. No indications for the prophylactic filter placement reached the threshold. Conclusion: interventional radiologists are highly involved in the management of IVCFs but have limited participation in the development of multidisciplinary clinical practice guidelines.
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15
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Ramjug S, Phillips G. Update in the diagnosis and management of acute pulmonary embolism for the non-respiratory physician. Clin Med (Lond) 2021; 21:e591-e597. [PMID: 34862218 DOI: 10.7861/clinmed.2021-0666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
An increasingly common scenario on the acute medical take is that of 'possible pulmonary embolism'. The aim of this article is to update the reader about the available clinical decision tools that can help to avoid the over investigation of such patients, as well as other tools that can support an outpatient management strategy in appropriate patient groups. The importance of risk stratification methodologies in acute pulmonary embolism management is emphasised. We address the evidence on the long-term risk of venous thromboembolism recurrence and show how this can be used to make decisions about duration of anticoagulation. Finally, we discuss a number of special scenarios, including the implications of incidentally discovered isolated subsegmental pulmonary embolus and the management of pulmonary embolus in malignancy and pregnancy.
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Affiliation(s)
| | - Gerrard Phillips
- Federation of Royal Colleges of Physicians, London, UK and Dorset County Hospital, Dorchester, UK
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16
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Abstract
Ventilation/Perfusion scanning for suspected pulmonary embolism is undergoing a renaissance due to the advent of single-photon emission computed tomography (SPECT). The scan protocol demands the inhalation of a radioactive gas or vapour for the ventilation scan. The purpose of this article is to report the radioactive environmental contamination that can occur when Tc Technegas vapours are administered to patients for the ventilation SPECT scan. This contamination can concentrate within gamma camera heads to degrade images and is also a radiation hazard to staff. A method for sequestrating this airborne contamination was investigated using an ultra-low particulate air filter. The prevalence of radioactive contamination and the levels of contamination captured were quantified and only 36% of patients were found to have undergone the ventilation procedure without producing significant airborne contamination. Advice is given on best practice that will minimize airborne contamination and minimize the risks to staff working in the Nuclear Medicine department. The use of an extraction/filtration device may be seen as an effective additional control measure against airborne radioactive contamination for health professionals.
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17
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"Whole life changed" - Experiences of how symptoms derived from acute pulmonary embolism affects life. A qualitative interview study. Thromb Res 2021; 205:56-62. [PMID: 34247098 DOI: 10.1016/j.thromres.2021.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/01/2021] [Accepted: 07/02/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Acute pulmonary embolism (PE) presents itself with a wide range of hemodynamic consequences. Respiratory symptoms as dyspnea and respiratory pain are common. The aim of this study was to explore patients' experiences of how symptoms affected their physical and social activities following the PE. MATERIALS AND METHODS Qualitative interviews were conducted with 14 patients, with median time of 7 months (range 3-34 months) since the PE and analysed with qualitative content analysis according to Graneheim and Lundman. RESULTS The findings indicated that respiratory symptoms affected many aspects of life, illustrated by an overall theme: "Whole life changed". Two major categories, on changes of psychological/social nature, and changes of perception towards physical activity, described how the participants experienced changes in themselves and their relations, and that the psychological affection resulted in an existential crisis. All participants experienced changes in their physical activity and that remaining respiratory symptoms hindered them from being active. Fear inhibited physical activity and created a feeling of low self-efficacy concerning activity in general. CONCLUSIONS To the best of our knowledge, this is the first study to present results on experiences of how the symptoms deriving from PE affected the physical and social activities of the participants during recovery phase. The results indicate that patients with PE need support from the health care system to manage both psychological and physical symptoms in the aftermath of their illness. Further research is needed to find out how optimal rehabilitation for these patients should be designed.
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18
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Chang J, Isaacs DJ, Leung J, Vinson DR. Comprehensive management of acute pulmonary embolism in primary care using telemedicine in the COVID-era. BMJ Case Rep 2021; 14:e243083. [PMID: 34112636 PMCID: PMC8193694 DOI: 10.1136/bcr-2021-243083] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 12/23/2022] Open
Abstract
A healthy, active woman in her 70s reported intermittent exertional dyspnoea for 2 months, notable during frequent open-water swimming. Symptoms were similar to an episode of travel-provoked pulmonary embolism 3 years prior. She denied chest pain, cough, fever, extremity complaints and symptoms at rest. Due to the COVID-19 pandemic, her healthcare system was using secure telemedicine to evaluate non-critical complaints. During the initial video visit, she appeared well, conversing normally without laboured breathing. An elevated serum D-dimer prompted CT pulmonary angiography, which identified acute lobar pulmonary embolism. After haematology consultation and telephone conversation with the patient, her physician prescribed rivaroxaban. Her symptoms rapidly improved. She had an uneventful course and is continuing anticoagulation indefinitely. The pandemic has increased the application of telemedicine for acute care complaints. This case illustrates its safe and effective use for comprehensive management of acute pulmonary embolism in the primary care setting.
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Affiliation(s)
- Joshua Chang
- Internal Medicine Residency Program, Kaiser Foundation Health Plan Inc, Oakland, California, USA
| | - Dayna J Isaacs
- University of California Davis School of Medicine, Sacramento, California, USA
- Internal Medicine Residency Program, University of California Los Angeles Health, Los Angeles, California, USA
| | - Joseph Leung
- Adult and Family Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - David R Vinson
- Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California, USA
- Kaiser Permanente Division of Research and the CREST Network, Oakland, California, USA
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19
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Stubblefield WB, Kline JA. Outpatient treatment of emergency department patients diagnosed with venous thromboembolism. Postgrad Med 2021; 133:11-19. [PMID: 33840338 DOI: 10.1080/00325481.2021.1916299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center Nashville United States
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, USA
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20
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Li X, Hu Y, Lin P, Zhang J, Tang Y, Yi Q, Liang Z, Zhou H, Wang M. Comparison of Different Clinical Prognostic Scores in Patients with Pulmonary Embolism and Active Cancer. Thromb Haemost 2021; 121:834-844. [PMID: 33450779 DOI: 10.1055/a-1355-3549] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE This article aimed to validate and compare the prognostic performance of generic scores (Pulmonary Embolism Severity Index [PESI] and Hestia) and cancer-specific pulmonary embolism (PE)/venous thromboembolism (VTE) scales (Registro Informatizado de la Enfermedad TromboEmbólica [RIETE], POMPE-C, and modified Ottawa) in PE patients with active cancer. METHODS A retrospective study was conducted among 460 patients with PE and active cancer. The primary outcome was 30-day overall mortality. Secondary outcomes were 30-day PE-related death and overall adverse outcomes. The prognostic accuracy of clinical scores was determined using receiver operating characteristic (ROC) curve analysis. RESULTS Within 30 days, 18.0% of patients died, 2.0% suffered major bleeding, and 0.2% presented recurrence of VTE. All scales showed a high area under the ROC curve (AUC) for predicting 30-day overall mortality except modified Ottawa (0.74 [0.70-0.78] for PESI, Hestia, and RIETE; 0.78 (0.74-0.81) for POMPE-C; 0.64 (0.59-0.68) for modified Ottawa]. PESI divided the least patients (9.1%) into low risk, followed by modified Ottawa (17.0%). Hestia stratified the most patients (65.4%) as low risk. But overall mortality of low-risk patients based on these three scales is high (>5%). RIETE and POMPE-C both classified 30.9% of patients as low risk, and low-risk patients stratified by these two scales presented a low overall mortality (1.4 and 3.5%). Similar predictive performance was found for 30-day PE-related death and overall adverse outcomes in these scores. CONCLUSION Cancer-specific PE prognostic scores (RIETE and POMPE-C) performed better than generic scales (PESI and Hestia) and a cancer-specific VTE prognostic scale (modified Ottawa) in identifying low-risk PE patients with active cancer who may be suitable for outpatient treatment.
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Affiliation(s)
- Xiaoqian Li
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Yuehong Hu
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Ping Lin
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Jiarui Zhang
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Yongjiang Tang
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Qun Yi
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Zong'an Liang
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Haixia Zhou
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Maoyun Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
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21
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Jackson K, Aujayeb A. Pleural Effusions in Pulmonary Emboli: A Single Centre Experience. Cureus 2020; 12:e11942. [PMID: 33425521 PMCID: PMC7785488 DOI: 10.7759/cureus.11942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Pleural effusions commonly occur in conjunction with acute pulmonary emboli (PE). There are no guidelines on the investigation and management of these effusions. We aimed to review local management to inform future practice Material and Methods: This was a retrospective, observational single centre study, looking at all computed tomography pulmonary angiograms done in a large hospital in the North East of England in 2019. Electronic notes, imaging and discharge letters of patients with PE were reviewed. Statistical analysis was performed to describe patient-specific variables, clinical characteristics, pathological findings and subsequent management decisions. Results: 1630 computed tomography pulmonary angiographies (CTPAs) were requested to investigate for PE. Three hundred sixteen (19.4%) were positive for PE. Of those, 89 (28.1%) were identified as having associated pleural effusions. Five (5.8%) patients had a contemporaneous pleural aspiration. All pleural effusions were exudative. Four were consistent with known malignant diagnoses. The other patient had concurrent pneumonia and pancreatitis. Nineteen (21%) had no risk factors for effusion development. The presence of pulmonary infarction/consolidation was associated with the development of a pleural effusion. CONCLUSIONS This project is a single centre review with the largest number of patients looking at pleural effusions associated with pulmonary emboli. Although pleural effusions commonly occur with PE and lung infarction, pleural aspiration is rarely performed. Management is not altered by the presence of an effusion.
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Affiliation(s)
- Karl Jackson
- Respiratory Medicine, Northumbria HealthCare NHS Foundation Trust, Newcastle, GBR
| | - Avinash Aujayeb
- Respiratory Medicine, Northumbria HealthCare NHS Foundation Trust, Newcastle, GBR
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22
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Marchetti AA, Davila BO, Oddi FM, Ippoliti A. Pulmonary embolism: Successful treatment of floating thrombus in SFJ after vena cava filter insertion and surgical thrombectomy. JRSM Cardiovasc Dis 2020; 9:2048004020976256. [PMID: 33294173 PMCID: PMC7708661 DOI: 10.1177/2048004020976256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 11/16/2022] Open
Abstract
The floating venous thrombus in the common femoral vein has a high potential risk for pulmonary embolization. Clinical treatments, using anticoagulants or fibrinolytic, open thrombectomies, or thrombectomies by endovascular devices have all been used. Our case describe an obese patient affected by floating thrombus coming from GSV and diving in common femoral vein successful treated by combined both temporary vena cava insertion and open surgical thrombectomy.
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Affiliation(s)
- Andrea Ascoli Marchetti
- Vascular Surgery Unit, Biomedicine and Prevention Department, University of Rome, Rome, Italy
| | | | - Fabio Massimo Oddi
- Vascular Surgery Unit, Biomedicine and Prevention Department, University of Rome, Rome, Italy
| | - Arnaldo Ippoliti
- Vascular Surgery Unit, Biomedicine and Prevention Department, University of Rome, Rome, Italy
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23
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Prognostic significance of computed tomography-assessed right ventricular enlargement in low-risk patients with pulmonary embolism: Systematic review and meta-analysis. Thromb Res 2020; 197:48-55. [PMID: 33181471 DOI: 10.1016/j.thromres.2020.10.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/08/2020] [Accepted: 10/29/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND For patients with acute low-risk pulmonary embolism (PE), determined by a validated clinical prognostic score, the additive prognostic significance of computed tomography (CT)-assessed right ventricular (RV) enlargement is uncertain. METHODS We performed a systematic review and meta-analysis of studies that enrolled patients with acute low-risk PE to assess the prognostic value of concomitant CT-assessed RV enlargement for 30-day all-cause mortality and PE-related death. We conducted unrestricted searches of PubMed and Embase through December 2019. We used a random-effects model to pool study results; Begg rank correlation method to evaluate for publication bias; and I2 testing to assess for heterogeneity. RESULTS Of the 7 cohorts with 2197 participants who had low-risk PE and provided results on the primary outcome, 743 (34%; 95% confidence interval [CI], 32-36%) patients had concomitant RV enlargement. Six of 743 (0.8%; 95% CI, 0.3-1.8%) patients with concomitant RV enlargement died 30-days after the diagnosis of PE compared with 3 of 1454 (0.2%, 95% CI, 0-0.6%) without RV enlargement. CT-assessed RV enlargement did not have a significant association with 30-day all-cause mortality (odds ratio [OR], 2.6; 95% CI, 0.7-9.4; I2 = 0%; P = 0.15) or PE-related mortality (OR, 2.8; 95% CI, 0.7-12.1; I2 = 0%; P = 0.16). CONCLUSIONS CT-assessed RV enlargement occurs in a third of PE patients identified as low-risk by clinical scores. Mortality rate in these patients is low, and CT-assessed RV enlargement was not associated with a significantly increased risk of death within 30 days of PE diagnosis.
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24
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Koomson D, Smith N, McPherson S, Srivastava V. Know the score: management of patients with a new diagnosis of acute pulmonary embolism. Br J Hosp Med (Lond) 2020; 81:1-4. [PMID: 33263484 DOI: 10.12968/hmed.2020.0345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The National Confidential Enquiry into Patient Outcome and Death review into the quality of care provided to UK patients with a new diagnosis of acute pulmonary embolism highlights both clinical and organisational changes that should be made to improve patient care and outcomes.
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Affiliation(s)
- D'Marieanne Koomson
- National Confidential Enquiry into Patient Outcome and Death (NCEPOD), London, UK
| | - Neil Smith
- National Confidential Enquiry into Patient Outcome and Death (NCEPOD), London, UK
| | - Simon McPherson
- National Confidential Enquiry into Patient Outcome and Death (NCEPOD), London, UK
| | - Vivek Srivastava
- National Confidential Enquiry into Patient Outcome and Death (NCEPOD), London, UK
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Ekezie W, Murray RL, Agrawal S, Bogdanovica I, Britton J, Leonardi-Bee J. Quality of smoking cessation advice in guidelines of tobacco-related diseases: An updated systematic review. Clin Med (Lond) 2020; 20:551-559. [PMID: 33199319 PMCID: PMC7687319 DOI: 10.7861/clinmed.2020-0359] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Tobacco smoking is a major risk factor for a wide range of diseases, and smoking cessation significantly reduces these risks. Clinical guidelines for diseases associated with smoking should therefore include guidance on smoking cessation. This review updated evidence on the proportion of clinical guidelines that do so. We conducted a systematic review investigating clinical guidelines and recommendations developed by UK national or European transnational medical specialty associations and societies between January 2014 and October 2019 on 16 diseases to be at least twice as common among smokers than non-smokers. Outcomes of interest were the reporting of smoking as a risk factor, and the inclusion either of smoking cessation advice or referral to other cessation guidance. We compared our findings with an earlier review of guidelines published between 2000 and 2013. We identified 159 clinical guidelines/recommendations. Over half (51%) made no mention of smoking, while 43% reported smoking as a risk factor for the development of the disease, 31% recommended smoking cessation and 19% provided detailed information on how to deliver smoking cessation support. These proportions were similar to those in our earlier review. Smoking cessation continues to be neglected in clinical management guidance for diseases caused by smoking.
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Ramjug S, Weatherald J, Sahay S, Khoury J, Foris V, Chandran N, Bokan A, Godinas L, Delcroix M. ERS International Congress, Madrid, 2019: highlights from the Pulmonary Vascular Diseases Assembly. ERJ Open Res 2020; 6:00304-2020. [PMID: 33083438 PMCID: PMC7553109 DOI: 10.1183/23120541.00304-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/28/2020] [Indexed: 12/17/2022] Open
Abstract
The 2019 European Respiratory Society (ERS) International Congress, held in Madrid, Spain, had exciting sessions regarding the field of pulmonary vascular disease. The symposia related to the new ERS/European Society of Cardiology (ESC) Guidelines for the diagnosis and management of acute pulmonary embolism were well received, as were sessions on pulmonary hypertension related to lung disease, demonstrating the concept of pulmonary hypertension not being the rarity that it was previously thought to be. The use of risk stratification in relation to pulmonary arterial hypertension (PAH) was heavily featured and the scientific sessions informing the respiratory community of potential biomarkers and targets for future therapies were thought-provoking. This article discusses highlights of the 2019 pulmonary vascular disease sessions as a summary of current knowledge and practice. We have summarised the key points from the sessions pertaining to the new ERS/ESC Guidelines for the management of acute pulmonary embolism. We have also focused on prognostic factors and potential therapies in pulmonary hypertension related to interstitial lung disease. Relating to PAH, we have reviewed the symposia on risk stratification, along with the use of noninvasive measures and the sessions relating to biomarkers in PAH.
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Affiliation(s)
- Sheila Ramjug
- Dept of Respiratory Medicine, Manchester University NHS Foundation Trust, Wythenshawe, UK
| | - Jason Weatherald
- Dept of Medicine, Division of Respirology, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Sandeep Sahay
- Houston Methodist Lung Center, Division of Pulmonary Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Johad Khoury
- Pulmonary Division, Lady Davis-Carmel Medical Center, Haifa, Israel
| | - Vasile Foris
- Medical University of Graz, Dept of Internal Medicine, Division of Pulmonology, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Nagaraj Chandran
- Medical University of Graz, Dept of Internal Medicine, Division of Pulmonology, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Aleksandar Bokan
- Dept for Emergency Pulmonology, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine Novi Sad, Novi Sad, Serbia
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Condliffe R, Albert P, Alikhan R, Gee E, Horner D, Hunter L, Jacobs P, Limbrey R, Newnham M, Preston W, Patel S, Smith LJ, Suntharalingam J. British Thoracic Society Quality Standards for outpatient management of pulmonary embolism. BMJ Open Respir Res 2020; 7:7/1/e000636. [PMID: 32816797 PMCID: PMC7437715 DOI: 10.1136/bmjresp-2020-000636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The purpose of the quality standards document is to provide healthcare professionals, commissioners, service providers and patients with a guide to standards of care that should be met for outpatient management of pulmonary embolism in the UK, together with measurable markers of good practice. Quality statements are based on the British Thoracic Society (BTS) Guideline for the Initial Outpatient Management of Pulmonary Embolism. METHODS Development of BTS Quality Standards follows the BTS process of quality standard production based on the National Institute for Health and Care Excellence process manual for the development of quality standards. RESULTS Six quality statements have been developed, each describing a standard of care for the outpatient management of pulmonary embolism in the UK, together with measurable markers of good practice. DISCUSSION BTS Quality Standards for Outpatient Management of Pulmonary Embolism form a key part of the range of supporting materials that the society produces to assist in the dissemination and implementation of a guideline's recommendations.
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Affiliation(s)
- Robin Condliffe
- Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Paul Albert
- Respiratory Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Raza Alikhan
- Haematology, University Hospital of Wales, Cardiff, UK
| | - Emma Gee
- Thrombosis and Coagulation, King's College Hospital, London, UK
| | - Daniel Horner
- Emergency Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - Laura Hunter
- Emergency Medicine, St Thomas' Hospital, London, UK
| | | | - Rachel Limbrey
- Respiratory Medicine, Southampton General Hospital, Southampton, UK
| | - Michael Newnham
- Respiratory Medicine, Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Wendy Preston
- Respiratory Medicine, George Eliot Hospital NHS Trust, Nuneaton, Warwickshire, UK
| | - Sheena Patel
- Anticoagulation and Medication Safety/Clinical Governance, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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Stevenson A, Davis S, Murch N. Pulmonary embolism in acute medicine: a case-based review incorporating latest guidelines in the COVID-19 era. Br J Hosp Med (Lond) 2020; 81:1-12. [PMID: 32589531 DOI: 10.12968/hmed.2020.0300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pulmonary embolism remains an important cause of morbidity and mortality in the UK, particularly following the outbreak of the novel coronavirus 2019 (COVID-19), where those infected have an increased prevalence of venous thromboembolic events. The pathophysiology in COVID-19 patients is thought to relate to a thromboinflammatory state within the pulmonary vasculature, triggered by the infection, but other risk factors such as reduced mobility, prolonged immobilisation and dehydration are likely to contribute. Several societies have released comprehensive guidelines emphasising the importance of risk stratification in patients with acute pulmonary embolism. They advocate the use of clinically validated risk scores in conjunction with biochemical and imaging results. Patients with mild disease can now be managed in the outpatient setting and with newly developed therapies, such as catheter-directed thrombolysis, becoming available in more centres, treatment options for those with more severe disease are also expanding. This article presents four theoretical but realistic cases, each diagnosed with acute pulmonary embolism, but differing in levels of severity. These demonstrate how the guidelines can be applied in a clinical setting, with particular focus on risk stratification and management.
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Affiliation(s)
| | - Sarah Davis
- Acute Medicine Department, Royal Free Hospital, London, UK
| | - Nick Murch
- Acute Medicine Department, Royal Free Hospital, London, UK
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Montes Santiago J, Argibay Filgueira AB. Home treatment of venous thromboembolism disease. Rev Clin Esp 2020; 220:S0014-2565(20)30130-2. [PMID: 32560918 DOI: 10.1016/j.rce.2020.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/08/2020] [Accepted: 03/24/2020] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- J Montes Santiago
- Departamento de Medicina Interna, Complejo Hospital Universitario, Vigo, Pontevedra, España.
| | - A B Argibay Filgueira
- Departamento de Medicina Interna, Complejo Hospital Universitario, Vigo, Pontevedra, España
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McCormack T, Harrisingh MC, Horner D, Bewley S. Venous thromboembolism in adults: summary of updated NICE guidance on diagnosis, management, and thrombophilia testing. BMJ 2020; 369:m1565. [PMID: 32430311 DOI: 10.1136/bmj.m1565] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Terry McCormack
- Institute of Clinical and Applied Health Research, Hull York Medical School, Hull, UK
| | | | - Daniel Horner
- Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Susan Bewley
- Division of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
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Chen C, Millar FR, Jones A. Outpatient management of pulmonary emboli: when to ambulate. Br J Hosp Med (Lond) 2020; 81:1-10. [PMID: 32239990 DOI: 10.12968/hmed.2019.0370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pulmonary embolism is a potentially fatal consequence of venous thromboembolism and constitutes a significant proportion of the acute medical take. Standard management has previously required admission of all patients presenting with acute pulmonary embolism for initiation of anticoagulation and initial investigations. However, clinical trial data have demonstrated the feasibility and safety of managing a subset of patients with low-risk pulmonary embolism in the outpatient setting and this has since been reflected in national guidelines. This article provides a practical overview for general physicians with regards to identifying patients with low-risk pulmonary embolism, and when and how to manage these patients on an outpatient basis.
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Affiliation(s)
- Cheng Chen
- Department of Respiratory Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Fraser R Millar
- CRUK Edinburgh Centre, University of Edinburgh, Edinburgh, UK
| | - Anne Jones
- Department of Respiratory Medicine, Western General Hospital, Edinburgh, Edinburgh, UK
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Vinson DR, Aujesky D, Geersing GJ, Roy PM. Comprehensive Outpatient Management of Low-Risk Pulmonary Embolism: Can Primary Care Do This? A Narrative Review. Perm J 2020; 24:19.163. [PMID: 32240089 DOI: 10.7812/tpp/19.163] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, CA.,Kaiser Permanente Division of Research, Oakland, CA.,Department of Emergency Medicine, Kaiser Permanente Sacramento Medical Center, CA
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire, UMR (CNRS 6015 - INSERM 1083) Institut Mitovasc, Université d'Angers, France
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Calais C, Mercier G, Meusy A, Le Collen L, Kahn SR, Quéré I, Galanaud JP. Pulmonary embolism home treatment: What GP want? Thromb Res 2020; 187:180-185. [DOI: 10.1016/j.thromres.2020.01.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 12/23/2019] [Accepted: 01/14/2020] [Indexed: 11/27/2022]
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Abstract
Hypoxaemia is a common presentation in critically ill patients, with the potential for severe harm if not addressed appropriately. This review provides a framework to guide the management of any hypoxaemic patient, regardless of the clinical setting. Key steps in managing such patients include ascertaining the severity of hypoxaemia, the underlying diagnosis and implementing the most appropriate treatment. Oxygen therapy can be delivered by variable or fixed rate devices, and non-invasive ventilation; if patients deteriorate they may require tracheal intubation and mechanical ventilation. Early critical care team involvement is a key part of this pathway. Specialist treatments for severe hypoxaemia can only be undertaken on an intensive care unit and this field is developing rapidly as trial results become available. It is important that each new scenario is approached in a structured manner with an open diagnostic mind and a clear escalation plan.
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Affiliation(s)
- Luke Flower
- Anaesthetics Department, University College Hospital, London, UK
| | - Daniel Martin
- Intensive Care Unit, Royal Free Hospital, London, UK
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35
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Cooksley T, Marshall W, Ahn S, Lasserson DS, Marshall E, Rice TW, Klotz A. Ambulatory emergency oncology: A key tenet of future emergency oncology care. Int J Clin Pract 2020; 74:e13436. [PMID: 31633264 DOI: 10.1111/ijcp.13436] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/16/2019] [Accepted: 10/13/2019] [Indexed: 12/19/2022] Open
Abstract
Ambulatory emergency oncology The challenges of emergency oncology alongside its increasing financial burden have led to an interest in developing optimal care models for meeting patients' needs. Ambulatory care is recognised as a key tenet in ensuring the safety and sustainability of acute care services. Increased access to ambulatory care has successfully reduced ED utilisation and improved clinical outcomes in high-risk non-oncological populations. Individualised management of acute cancer presentations is a key challenge for emergency oncology services so that it can mirror routine cancer care. There are an increasing number of acute cancer presentations, such as low-risk febrile neutropenia and incidental pulmonary embolism, that can be risk assessed for care in an emergency ambulatory setting. Modelling of ambulatory emergency oncology services will be dependent on local service deliveries and pathways, but are key for providing high quality, personalised and sustainable emergency oncology care. These services will also be at the forefront of much needed emergency oncology to define the optimal management of ambulatory-sensitive presentations.
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Affiliation(s)
- Tim Cooksley
- Department of Acute Medicine and Critical Care, The Christie, Manchester, UK
| | - Will Marshall
- Department of Acute Medicine, Manchester University Foundation Trust, Manchester, UK
| | - Shin Ahn
- Department of Emergency Medicine, Cancer Emergency Room, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Daniel S Lasserson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Ernie Marshall
- Department of Medical Oncology, Clatterbridge Cancer Centre, Wirral, UK
| | - Terry W Rice
- Division of Internal Medicine, Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adam Klotz
- Department of Emergency Medicine, Memorial Sloan Kettering, New York, NY, USA
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36
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Bernardo RJ, Bokan A, Ramjug S. Updates in pulmonary hypertension and other pulmonary vascular diseases. Breathe (Sheff) 2019; 15:241-243. [PMID: 31508162 PMCID: PMC6717623 DOI: 10.1183/20734735.0187-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Pulmonary vascular disease (PVD) is a dynamic field that comprises of a spectrum of disorders such as pulmonary hypertension (PH), pulmonary embolism (PE) and chronic thromboembolic disease (CTED). Despite having different pathophysiologies, these disorders primarily affect the pulmonary circulation, with variable effects on pulmonary vascular resistance (PVR) and right ventricular (RV) function. Update on studies related to pulmonary vascular disease published during 2018, addressing different topics in pulmonary hypertension, pulmonary embolism and chronic thromboembolic diseasehttp://bit.ly/2JJUnUP
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Affiliation(s)
- Roberto J Bernardo
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Aleksandar Bokan
- Institute for Pulmonary Diseases of Vojvodina, Emergency Pulmonology Clinic, Sremska Kamenica, Republic of Serbia.,University of Novi Sad, Medical Faculty Novi Sad, Novi Sad, Republic of Serbia
| | - Sheila Ramjug
- Manchester University NHS Foundation Trust, Manchester, UK
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Baird W, Hannah E, Feenan M, Byrne C, Burke M, Dougan J, Haaijer D, Smyth J. Introducing an ambulatory PE pathway with no extra resource. Clin Med (Lond) 2019. [DOI: 10.7861/clinmedicine.19-3s-s94] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Baird W, Hannah E, Feenan M, Byrne C, Burke M, Dougan J, Haaijer D, Smyth J. Introducing an ambulatory PE pathway with no extra resource. Clin Med (Lond) 2019. [DOI: 10.7861/clinmedicine.19-3-s94] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Pulmonary embolism, despite being common, often remains elusive as a diagnosis, and clinical suspicion needs to remain high when seeing a patient with cardiopulmonary symptoms. Once suspected, diagnosis is usually straightforward; however, optimal treatment can be difficult. Risk stratification with clinical scores, biomarkers and imaging helps to refine the best treatment strategy, but the position of thrombolysis in intermediate risk (submassive) pulmonary embolism remains a grey area. Pulmonary embolism response teams are on the increase to provide advice in such cases. Direct oral anticoagulants have been a major advance in treatment this decade, but are not appropriate for all patients. Follow-up of patients with pulmonary embolism should be mandatory to determine duration of anticoagulation and to assess for serious long-term complications.
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Peacock WF, Singer AJ. Reducing the hospital burden associated with the treatment of pulmonary embolism. J Thromb Haemost 2019; 17:720-736. [PMID: 30851227 PMCID: PMC6849869 DOI: 10.1111/jth.14423] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- W. Frank Peacock
- Department of Emergency MedicineBaylor College of MedicineHoustonTXUSA
| | - Adam J. Singer
- Department of Emergency MedicineStony Brook School of MedicineStony BrookNYUSA
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Reschen ME, Raby J, Bowen J, Singh S, Lasserson D, O'Callaghan CA. A retrospective analysis of outcomes in low- and intermediate-high-risk pulmonary embolism patients managed on an ambulatory medical unit in the UK. ERJ Open Res 2019; 5:00184-2018. [PMID: 30972349 PMCID: PMC6452043 DOI: 10.1183/23120541.00184-2018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/28/2019] [Indexed: 12/16/2022] Open
Abstract
Pulmonary embolism (PE) is common and guidelines recommend outpatient care only for PE patients with low predicted mortality. Outcomes for patients with intermediate-to-high predicted mortality managed as outpatients are unknown. Electronic records were analysed for adults with PE managed on our ambulatory care unit over 2 years. Patients were stratified into low or intermediate-to-high mortality risk groups using the Pulmonary Embolism Severity Index (PESI). Primary outcomes were the proportion of patients ambulated, 30-day all-cause mortality, 30-day PE-specific mortality and 30-day re-admission rate. Of 199 PE patients, 74% were ambulated and at 30 days, all-cause mortality was 2% (four out of 199) and PE-specific mortality was 1% (two out of 199). Ambulated patients had lower PESI scores, better vital signs and lower troponin levels (morning attendance favoured ambulation). Over a third of ambulated patients had an intermediate-to-high risk PESI score but their all-cause mortality rate was low at 1.9% (one out of 52). In patients with intermediate-to-high risk, oxygen saturation was higher and pulse rate lower in those who were ambulated. Re-admission rate did not differ between ambulated and admitted patients. Two-thirds of patients with intermediate-to-high risk PE were ambulated and their mortality rate remained low. It is possible for selected patients with intermediate-to-high risk PESI scores to be safely ambulated.
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Affiliation(s)
- Michael E. Reschen
- Dept of Acute General Medicine, John Radcliffe Hospital, Oxford University NHS Hospitals Foundation Trust, Oxford, UK
| | - Jonathan Raby
- Dept of Acute General Medicine, John Radcliffe Hospital, Oxford University NHS Hospitals Foundation Trust, Oxford, UK
| | - Jordan Bowen
- Dept of Acute General Medicine, John Radcliffe Hospital, Oxford University NHS Hospitals Foundation Trust, Oxford, UK
| | - Sudhir Singh
- Dept of Acute General Medicine, John Radcliffe Hospital, Oxford University NHS Hospitals Foundation Trust, Oxford, UK
| | - Daniel Lasserson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Yoo HHB, Nunes‐Nogueira VS, Fortes Villas Boas PJ, Broderick C. Outpatient versus inpatient treatment for acute pulmonary embolism. Cochrane Database Syst Rev 2019; 3:CD010019. [PMID: 30839095 PMCID: PMC6402388 DOI: 10.1002/14651858.cd010019.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) is a common life-threatening cardiovascular condition, with an incidence of 23 to 69 new cases per 100,000 people each year. For selected low-risk patients with acute PE, outpatient treatment might provide several advantages over traditional inpatient treatment, such as reduction of hospitalisations, substantial cost savings, and improvements in health-related quality of life. This is an update of the review first published in 2014. OBJECTIVES To compare the efficacy and safety of outpatient versus inpatient treatment in low-risk patients with acute PE for the outcomes of all-cause and PE-related mortality; bleeding; adverse events such as haemodynamic instability; recurrence of PE; and patients' satisfaction. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers, to 26 March 2018. We also undertook reference checking to identify additional studies. SELECTION CRITERIA We included randomised controlled trials of outpatient versus inpatient treatment of adults (aged 18 years and over) diagnosed with low-risk acute PE. DATA COLLECTION AND ANALYSIS Two review authors selected relevant trials, assessed methodological quality, and extracted and analysed data. We calculated effect estimates using risk ratio (RR) with 95% confidence intervals (CIs), or mean differences (MDs) with 95% CIs. We used standardised mean differences (SMDs) to combine trials that measured the same outcome but used different methods. We assessed the quality of the evidence using GRADE criteria. MAIN RESULTS One new study was identified for this 2018 update, bringing the total number of included studies to two and the total number of participants to 451. Both trials discharged patients randomised to the outpatient group within 36 hours of initial triage and both followed participants for 90 days. One study compared the same treatment regimens in both outpatient and inpatient groups, and the other study used different treatment regimes. There was no clear difference in treatment effect for the outcomes of short-term mortality (30 days) (RR 0.33, 95% CI 0.01 to 7.98, P = 0.49; low-quality evidence), long-term mortality (90 days) (RR 0.98, 95% CI 0.06 to 15.58, P = 0.99, low-quality evidence), major bleeding at 14 days (RR 4.91, 95% CI 0.24 to 101.57, P = 0.30; low-quality evidence) and at 90 days (RR 6.88, 95% CI 0.36 to 132.14, P = 0.20; low-quality evidence), minor bleeding (RR 1.08, 95% CI 0.07 to 16.79; P = 0.96, low-quality evidence), recurrent PE within 90 days (RR 2.95, 95% CI 0.12 to 71.85, P = 0.51, low-quality evidence), and participant satisfaction (RR 0.97, 95% CI 0.90 to 1.04, P = 0.39; moderate-quality evidence). We downgraded the quality of the evidence because the CIs were wide and included treatment effects in both directions, the sample sizes and numbers of events were small, and because the effect of missing data and the absence of publication bias could not be verified. PE-related mortality, and adverse effects such as haemodynamic instability and compliance, were not assessed by the included studies. AUTHORS' CONCLUSIONS Currently, only low-quality evidence is available from two published randomised controlled trials on outpatient versus inpatient treatment in low-risk patients with acute PE. The studies did not provide evidence of any clear difference between the interventions in overall mortality, bleeding and recurrence of PE.
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Affiliation(s)
- Hugo HB Yoo
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Vania Santos Nunes‐Nogueira
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Paulo J Fortes Villas Boas
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Cathryn Broderick
- University of EdinburghUsher Institute of Population Health Sciences and InformaticsTeviot PlaceEdinburghUKEH8 9AG
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Stansby G, Donald I. Reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism in medical inpatients. Clin Med (Lond) 2019; 19:100-103. [PMID: 30872288 PMCID: PMC6454363 DOI: 10.7861/clinmedicine.19-2-100] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Gerard Stansby
- University of Newcastle and Freeman Hospital, Newcastle upon Tyne, UK
| | - Ian Donald
- Elderly Care Unit, Gloucestershire Royal NHS Trust, Gloucester, UK
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Ramjug S, Adão R, Lewis R, Coste F, de Man F, Jimenez D, Sitbon O, Delcroix M, Vonk-Noordegraaf A. Highlights from the ERS International Congress 2018: Assembly 13 - Pulmonary Vascular Diseases. ERJ Open Res 2019; 5:00202-2018. [PMID: 30895188 PMCID: PMC6421363 DOI: 10.1183/23120541.00202-2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 01/25/2019] [Indexed: 11/29/2022] Open
Abstract
The 2018 European Respiratory Society (ERS) International Congress in Paris, France, highlighted the subject of pulmonary vascular disease (PVD). 2018 was an exciting year for the PVD community as it was the first ERS International Congress since the formation of Assembly 13, which is dedicated to PVD, pulmonary embolism and the right ventricle. This article aims to summarise the high-quality studies presented at the 2018 Congress into four subject areas: the use of risk stratification in pulmonary arterial hypertension, the molecular mechanisms and treatment of pulmonary hypertension (PH), understanding and improving the right ventricle in PH, and finally, advances in the field of acute pulmonary embolus.
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Affiliation(s)
- Sheila Ramjug
- Dept of Respiratory Medicine, Manchester University NHS Foundation Trust, Wythenshawe, UK
| | - Rui Adão
- Dept of Surgery and Physiology, Cardiovascular Research and Development Center – UnIC, Faculty of Medicine of the University of Porto, Porto, Portugal
| | | | - Florence Coste
- University Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux U1045, Bordeaux, France
| | - Frances de Man
- VU University Medical Center, Dept of Pulmonary Medicine, Amsterdam, The Netherlands
| | - David Jimenez
- Respiratory Dept, Ramon y Cajal Hospital, IRYCIS, Alcaia Henares University, Madrid, Spain
| | | | - Marion Delcroix
- Pneumology Dept, Universitarie Ziekenhuizen, Leuven, Belgium
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Vinson DR, Mark DG, Chettipally UK, Huang J, Rauchwerger AS, Reed ME, Lin JS, Kene MV, Wang DH, Sax DR, Pleshakov TS, McLachlan ID, Yamin CK, Elms AR, Iskin HR, Vemula R, Yealy DM, Ballard DW. Increasing Safe Outpatient Management of Emergency Department Patients With Pulmonary Embolism: A Controlled Pragmatic Trial. Ann Intern Med 2018; 169:855-865. [PMID: 30422263 DOI: 10.7326/m18-1206] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many low-risk patients with acute pulmonary embolism (PE) in the emergency department (ED) are eligible for outpatient care but are hospitalized nonetheless. One impediment to home discharge is the difficulty of identifying which patients can safely forgo hospitalization. OBJECTIVE To evaluate the effect of an integrated electronic clinical decision support system (CDSS) to facilitate risk stratification and decision making at the site of care for patients with acute PE. DESIGN Controlled pragmatic trial. (ClinicalTrials.gov: NCT03601676). SETTING All 21 community EDs of an integrated health care delivery system (Kaiser Permanente Northern California). PATIENTS Adult ED patients with acute PE. INTERVENTION Ten intervention sites selected by convenience received a multidimensional technology and education intervention at month 9 of a 16-month study period (January 2014 to April 2015); the remaining 11 sites served as concurrent controls. MEASUREMENTS The primary outcome was discharge to home from either the ED or a short-term (<24-hour) outpatient observation unit based in the ED. Adverse outcomes included return visits for PE-related symptoms within 5 days and recurrent venous thromboembolism, major hemorrhage, and all-cause mortality within 30 days. A difference-in-differences approach was used to compare pre-post changes at intervention versus control sites, with adjustment for demographic and clinical characteristics. RESULTS Among 881 eligible patients diagnosed with PE at intervention sites and 822 at control sites, adjusted home discharge increased at intervention sites (17.4% pre- to 28.0% postintervention) without a concurrent increase at control sites (15.1% pre- and 14.5% postintervention). The difference-in-differences comparison was 11.3 percentage points (95% CI, 3.0 to 19.5 percentage points; P = 0.007). No increases were seen in 5-day return visits related to PE or in 30-day major adverse outcomes associated with CDSS implementation. LIMITATION Lack of random allocation. CONCLUSION Implementation and structured promotion of a CDSS to aid physicians in site-of-care decision making for ED patients with acute PE safely increased outpatient management. PRIMARY FUNDING SOURCE Garfield Memorial National Research Fund and The Permanente Medical Group Delivery Science and Physician Researcher Programs.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group and Kaiser Permanente Northern California, Oakland, and Kaiser Permanente Sacramento Medical Center, Sacramento, California (D.R.V.)
| | - Dustin G Mark
- The Permanente Medical Group, Kaiser Permanente Northern California, and Kaiser Permanente Oakland Medical Center, Oakland, California (D.G.M.)
| | - Uli K Chettipally
- The Permanente Medical Group, Oakland, and Kaiser Permanente South San Francisco Medical Center, South San Francisco, California (U.K.C.)
| | - Jie Huang
- Kaiser Permanente Northern California, Oakland, California (J.H., A.S.R., M.E.R.)
| | - Adina S Rauchwerger
- Kaiser Permanente Northern California, Oakland, California (J.H., A.S.R., M.E.R.)
| | - Mary E Reed
- Kaiser Permanente Northern California, Oakland, California (J.H., A.S.R., M.E.R.)
| | - James S Lin
- The Permanente Medical Group, Oakland, and Kaiser Permanente Santa Clara Medical Center, Sacramento, California (J.S.L.)
| | - Mamata V Kene
- The Permanente Medical Group, Oakland, and Kaiser Permanente San Leandro Medical Center, Sacramento, California (M.V.K.)
| | | | - Dana R Sax
- The Permanente Medical Group and Kaiser Permanente Oakland Medical Center, Oakland, California (D.R.S., C.K.Y.)
| | - Tamara S Pleshakov
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California (T.S.P.)
| | - Ian D McLachlan
- The Permanente Medical Group, Oakland, and Kaiser Permanente San Francisco Medical Center, San Francisco, California (I.D.M.)
| | - Cyrus K Yamin
- The Permanente Medical Group and Kaiser Permanente Oakland Medical Center, Oakland, California (D.R.S., C.K.Y.)
| | - Andrew R Elms
- The Permanente Medical Group, Oakland, and Kaiser Permanente South Sacramento Medical Center, Sacramento, California (A.R.E.)
| | - Hilary R Iskin
- University of Michigan Medical School, Ann Arbor, Michigan (H.R.I.)
| | - Ridhima Vemula
- University of Cincinnati College of Medicine, Cincinnati, Ohio (R.V.)
| | - Donald M Yealy
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (D.M.Y.)
| | - Dustin W Ballard
- The Permanente Medical Group and Kaiser Permanente Northern California, Oakland, and Kaiser Permanente San Rafael Medical Center, San Rafael, California (D.W.B.)
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Barrett TW, Freeman CL. Outpatient Pulmonary Embolism Management: If You Walk Into the Emergency Department With a Pulmonary Embolism, Maybe You Should Also Walk Out. Ann Emerg Med 2018; 72:725-730. [DOI: 10.1016/j.annemergmed.2018.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Howard LS. BTS guidelines for the initial outpatient management of pulmonary embolism: there’s no place like home. Thorax 2018. [DOI: 10.1136/thoraxjnl-2018-211646] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
This article provides an overview of the highlights and key points of the new BTS guideline for the initial outpatient management of pulmonary embolism.
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Howard LS, Barden S, Condliffe R, Connolly V, Davies C, Donaldson J, Everett B, Free C, Horner D, Hunter L, Kaler J, Nelson-Piercy C, O'Dowd E, Patel R, Preston W, Sheares K, Tait C. British Thoracic Society Guideline for the initial outpatient management of pulmonary embolism. BMJ Open Respir Res 2018; 5:e000281. [PMID: 29955362 PMCID: PMC6018844 DOI: 10.1136/bmjresp-2018-000281] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Indexed: 11/23/2022] Open
Abstract
The following is a summary of the recommendations and good practice points for the BTS Guideline for the initial outpatient management of pulmonary embolism. Please refer to the full guideline for full information about each section.
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Affiliation(s)
- Luke S Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Robin Condliffe
- Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | | | | | - Catherine Free
- Department of Respiratory Medicine, George Eliot Hospital NHS Trust, Nuneaton, UK
| | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK
- The Royal College of Emergency Medicine, London, UK
| | | | - Jasvinder Kaler
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Emma O'Dowd
- Department of Respiratory Medicine, Nottingham City Hospital, Nottingham, UK
| | - Raj Patel
- King's College Hospital NHS Foundation Trust, London, UK
| | - Wendy Preston
- Department of Respiratory Medicine, George Eliot Hospital NHS Trust, Nuneaton, UK
| | - Karen Sheares
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Campbell Tait
- Department of Haematology, Glasgow Royal Infirmary, Glasgow, Scotland
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