Perceptions and Barriers Related to Outpatient Management of Low-Risk PE Patients: A Community Center Experience

Abstract

Introduction: Pulmonary emboli (PEs) exert a significant morbidity and mortality burden worldwide, with an increasing incidence of diagnosis over the past two decades. This has relayed to an increase in hospitalizations for PE, with a mean length of stay of 4 days, and a mean cost of $8674. Despite the increased incidence, the mortality associated with PE has been decreasing over the past two decades, and this has led to the development of many risk prognostication indices to better assess the need of hospitalization versus home management. Patients identified as low-risk using extensively validated prognostication models such as the PE severity index (PESI) or simplified PESI have been found to be safely managed at home. Despite the change in recommendations and guidelines, many low-risk patients continue to be hospitalized. Current literature is sparse on the barriers faced by providers in different specialties involved in the care of patients with PE, and in particular low-risk PEs. We conducted an anonymous survey across our hospital system to identify barriers and perceptions revolving around home management of low-risk PE patients. Methods: A short multiple choice survey was created and distributed to both teaching and non-teaching personnel of our hospital system, using an anonymous platform. The survey included residents and attendings across the specialties of internal medicine, primary care and emergency medicine. 150 invitations to the survey were sent out, and 44 responses were received. Results: 43 of the 44 responses were from teaching attendings or residents, whereas 1 response was recorded from a primary care practitioner in a non-teaching setting. 63.6% of the survey-takers reported being in practice <3 years, while 9.1% of this group reported being in practice >10 years. 81.8% believed that not all patients with PE warrant admission. 33 providers, or 75% were aware of risk-stratification models like the PE Severity Index (PESI) or simplified PESI index, and 31 (70.5%) stated they use these risk stratification models to assess a patient's need for admission, once they are diagnosed with a PE. Lack of social work/case management support to send patients home emerged as the primary barrier to out-patient management (61.4% or n= 27), followed by beliefs about consequences of not admitting patients with PE (45.5%, n=20). Fear of litigation was another prominent reported barrier (31.8%, n=14), followed by lack of knowledge on current guidelines (38.6%, n=17) and finally lack of knowledge regarding anticoagulation options (27.3%, n=12). Of 27 participating physicians that practice in an outpatient setting, 25 (92.6%) reported sending patients to the ED strictly to get immediate definitive testing done, and were comfortable managing the patient once a diagnosis was achieved. Conclusions: Several barriers to outpatient management of low-risk patients diagnosed with PE exist in the community setting. They mainly consist of lack of social work support, false beliefs about consequences of not admitting patients with PE, and fear of litigation. Integrated education for various medicine specialties regarding anticoagulation and management guidelines should be instituted, with emphasis on utilization of risk-prognostication tools like sPESI. In addition, maximum utilization of social work and case management may further mitigate some of the barriers encountered in the community setting.