Home Treatment Of Pulmonary Embolism Research Articles

Healthcare resource utilisation and associated costs after low-risk pulmonary embolism: pre-specified analysis of the Home Treatment of Pulmonary Embolism (HoT-PE) study.

Pulmonary embolism (PE) and its sequelae impact healthcare systems globally. Low-risk PE patients can be managed with early discharge strategies leading to cost savings, but post-discharge costs are undetermined. To define healthcare resource utilisation and overall costs during follow-up of low-risk PE. We used an incidence-based, bottom-up approach and calculated direct and indirect costs over 3-month follow-up after low-risk PE, with data from the Home Treatment of Patients with Low-Risk Pulmonary Embolism (HoT-PE) cohort study. Average 3-month costs per patient having suffered low-risk PE were 7029.62 €; of this amount, 4872.93 € were associated with PE, accounting to 69.3% of total costs. Specifically, direct costs totalled 3019.33 €, and of those, 862.64 € (28.6%) were associated with PE. Anticoagulation (279.00 €), rehospitalisations (296.83 €), and ambulatory visits (194.95 €) comprised the majority of the 3-month direct costs. The remaining costs amounting to 4010.29 € were indirect costs due to loss of productivity. In a patient cohort with acute low-risk PE followed over 3months, the majority of costs were indirect costs related to productivity loss, whereas direct, PE-specific post-discharge costs were low. Effective interventions are needed to reduce the burden of PE and associated costs, especially those related to productivity loss.

Home treatment versus early discharge for the outpatient management of acute pulmonary embolism: A non-interventional, post-hoc cohort analysis

IntroductionWe prospectively investigated whether home treatment of pulmonary embolism (PE), is as effective and safe as the recommended early discharge management in terms of outcomes at 3 months. MethodsWe performed a post hoc analysis of prospectively and consecutively recorded data in acute PE patients from a tertiary care facility between January 2012 and November 2021. Home treatment was defined as discharge to home directly from the emergency department (ED) after <24 h stay. Early discharge was defined as in-hospital stay of ≥24 h and ≤48 h. Primary efficacy and safety outcomes were a composite of PE-related death or recurrent venous thrombo-embolism, and major bleeding, respectively. Outcomes between groups were compared using penalized multivariable models. ResultsIn total, 181 patients (30.6 %) were included in the home treatment group and 463 (69.4 %) patients in the early discharge group. Median duration of ED stay was 8.1 h (IQR, 3.6–10.2 h) in the home treatment group, and median length of hospital stay was 36.4 h (IQR, 28.7–40.2) in the early discharge group. The adjusted rate of the primary efficacy outcome was 1.90 % (95 % CI, 0.16–15.2) vs 2.05 % (95 % CI, 0.24–10.1) for home treatment vs early discharge (hazard ratio (HR) 0.86 (95 % CI, 0.27–2.74). The adjusted rates of the primary safety outcome did not differ between groups at 3 months. ConclusionsIn a non-randomized cohort of selected acute PE patients, home treatment provided comparable rates of adverse VTE and bleeding events to the recommended early discharge management, and appears to have similar clinical outcomes at 3 months.

Home Treatment Compared to Initial Hospitalization in Normotensive Patients with Acute Pulmonary Embolism in the Netherlands: A Cost Analysis.

Venous thromboembolism constitutes substantial health care costs amounting to approximately 60 million euros per year in the Netherlands. Compared with initial hospitalization, home treatment of pulmonary embolism (PE) is associated with a cost reduction. An accurate estimation of cost savings per patient treated at home is currently lacking. The aim of this study was to compare health care utilization and costs during the first 3 months after a PE diagnosis in patients who are treated at home versus those who are initially hospitalized. Patient-level data of the YEARS cohort study, including 383 normotensive patients diagnosed with PE, were used to estimate the proportion of patients treated at home, mean hospitalization duration in those who were hospitalized, and rates of PE-related readmissions and complications. To correct for baseline differences within the two groups, regression analyses was performed. The primary outcome was the average total health care costs during a 3-month follow-up period for patients initially treated at home or in hospital. Mean hospitalization duration for the initial treatment was 0.69 days for those treated initially at home (n = 181) and 4.3 days for those initially treated in hospital (n = 202). Total average costs per hospitalized patient were €3,209 and €1,512 per patient treated at home. The adjusted mean difference was €1,483 (95% confidence interval: €1,181-1,784). Home treatment of hemodynamically stable patients with acute PE was associated with an estimated net cost reduction of €1,483 per patient. This difference underlines the advantage of triage-based home treatment of these patients.

Home treatment of fragile patients with acute pulmonary embolism: a subgroup analysis of the multinational home treatment of pulmonary embolism (HoT-PE) trial

Abstract Background and aims Subgroup analyses of randomized trials and cohort studies on direct oral anticoagulants (DOACs) suggested that single direct drug treatment may be effective and safe in elderly and “fragile” patients with acute pulmonary embolism (PE). In a post-hoc analysis of HoT-PE, a prospective multicenter management trial, we studied whether early discharge and home treatment of acute PE is effective and safe in these patients. Methods HoT-PE enrolled patients with acute PE classified as being at low risk based on the modified Hestia criteria and the absence of right ventricular dysfunction. The primary efficacy outcome was symptomatic recurrent VTE, or PE-related death within 3 months of enrolment. The safety outcome included major bleeding. Fragility was defined as age &amp;gt;75 years, a creatinine clearance level &amp;lt;50 ml/min, or a body mass index &amp;lt;18.5 kg/cm2. Results A total of 524 patients were included; of these, 112 (21.4%) were fragile. Mean age was 77 (range 74–80) years. A total of 104 (92.9%) fragile and 372 (90.3%) non-fragile patients spent two nights or less in hospital corresponding to a median hospital stay of 42 (Q1-Q3: 25–47) and 32 (Q1-Q3: 23–46) hours, respectively. The primary efficacy outcome occurred in one (0.9%) fragile and one (0.5%) non-fragile patient (absolute risk difference [ARD] +0.4%; 95% CI: −1.1%; +4.4%). Major bleeding occurred in three (2.7%) fragile and three (0.7%) non-fragile patients; ARD +2.0% (+0.3%; +6.9%). All-cause 3-month mortality was low in both groups (0.9% vs. 0.2%; ARD +0.7%, −0.7%; +4.7%). Conclusion Early discharge and home treatment of fragile patients with acute PE appears to be feasible and acceptably safe. The HoT-PE trial supports the notion that these patients should not be a priori excluded from early discharge, but caution is warranted due to a possibly higher risk of major bleeding on DOAC treatment. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503).

Home treatment of pulmonary embolism: are all the questions answered now after the HOME-PE trial?

Home treatment of pulmonary embolism: are all the questions answered now after the HOME-PE trial?

National Trends in Home Treatment of Acute Pulmonary Embolism.

Management of patients with acute pulmonary embolism has evolved from obligatory hospitalization to home treatment of carefully selected low-risk patients. The purpose of this investigation is to determine national trends in the prevalence of home treatment of pulmonary embolism. The Nationwide Emergency Department Sample was used to determine the number of patients seen in emergency departments throughout the United States with a primary (first-listed) diagnosis of pulmonary embolism and the proportion hospitalized according to age, from 2007 to 2012. The National (Nationwide) Inpatient Sample was used to determine in-hospital all-cause mortality and length of stay of hospitalized patients. Patients were adults (≥18 years) of both genders and all races from all regions of the United States. Excluded patients were those in shock or on ventilator support. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify patients and comorbid conditions. Home treatment was selected for 54 494 (6.0%) of 915 702 stable patients with acute pulmonary embolism. The proportion of patients treated at home was age-dependent, highest in those aged 30 years or younger, 12.1%, and lowest in those >80 years, 2.9%. Most patients treated at home, 66.8%, and had no comorbid conditions. In-hospital all-cause deaths were 2.6%. Deaths were ≤0.9% in those ≤40 years and 4.8% in those >80 years. Length of stay was 6 days or longer in 37.6% of patients. In view of the lower death rate among younger patients, they might be a group in whom home treatment would be more advantageous than in elderly patients.

Home Treatment of Pulmonary Embolism in the Era of Novel Oral Anticoagulants

BackgroundOutpatient therapy of patients with acute pulmonary embolism has been shown to be safe in carefully selected patients. Problems related to the injection of low-molecular-weight heparin at home can be overcome by use of novel oral anticoagulants. The purpose of this investigation is to assess the prevalence of home treatment in the era of novel oral anticoagulants. MethodsThis was a retrospective cohort study of patients aged ≥18 years with acute pulmonary embolism seen in 5 emergency departments from January 2013 to December 2014. ResultsPulmonary embolism was diagnosed in 983 patients. Among these, 237 were considered ineligible for home treatment because of instability or hypoxia. Home treatment was selected for 13 of 746 (1.7%) patients who were potentially eligible. Anticoagulant treatment for those treated at home was low-molecular-weight heparin or warfarin in 9 (69.2%) and novel oral anticoagulants in 4 (30.8%). Hospitalization was chosen for 733 of 746 (98.3%). Discharge in ≤2 days was in 119 patients (16.2%). Treatment of these patients was low-molecular-weight heparin or warfarin in 76 (63.9%), novel oral anticoagulants in 34 (28.6%), and in 9 (7.6%), anticoagulants were not given because of metastatic cancer or treatment was not known. ConclusionEven in the era of novel oral anticoagulants, the vast majority of patients with acute pulmonary embolism were hospitalized, and only a small proportion were discharged in ≤2 days. Although home treatment has been found to be safe in carefully selected patients, and scoring systems have been derived to identify those at low risk of adverse events, home treatment was infrequently selected.

Outpatient treatment of low-risk venous thromboembolism with monotherapy oral anticoagulation: patient quality of life outcomes and clinician acceptance.

BackgroundOral monotherapy anticoagulation has facilitated home treatment of venous thromboembolism (VTE) in outpatients.ObjectivesThe aim of this study was to measure efficacy, safety, as well as patient and physician perceptions produced by a protocol that selected VTE patients as low-risk patients by the Hestia criteria, and initiated home anticoagulation with an oral factor Xa antagonist.MethodsPatients were administered the Venous Insufficiency Epidemiological and Economic Study Quality of life/Symptoms questionnaire [VEINEs QoL/Sym] and the physical component summary [PCS] from the Rand 36-Item Short Form Health Survey [SF36]). The primary outcomes were VTE recurrence and hemorrhage at 30 days. Secondary outcomes compared psychometric test scores between patients with deep vein thrombosis (DVT) to those with pulmonary embolism (PE). Patient perceptions were abstracted from written comments and physician perceptions specific to PE outpatient treatment obtained from structured survey.ResultsFrom April 2013 to September 2015, 253 patients were treated, including 67 with PE. Within 30 days, 2/253 patients had recurrent DVT and 2/253 had major hemorrhage; all four had DVT at enrollment. The initial PCS scores did not differ between DVT and PE patients (37.2±13.9 and 38.0±12.1, respectively) and both DVT and PE patients had similar improvement over the treatment period (42.2±12.9 and 43.4±12.7, respectively), consistent with prior literature. The most common adverse event was menorrhagia, present in 15% of women. Themes from patient-written responses reflected satisfaction with increased autonomy. Physicians’ (N=116) before-to-after protocol comfort level with home treatment of PE increased 48% on visual analog scale.ConclusionHestia-negative VTE patients treated with oral monotherapy at home had low rates of VTE recurrence and bleeding, as well as quality of life measurements similar to prior reports.

Is it time for home treatment of pulmonary embolism?

Acute pulmonary embolism (PE) is a frequent cause of death, but not all patients are at high risk of an adverse early outcome. It has been proposed that selected patients may be considered for early discharge and home treatment, but it was only recently that improved risk assessment strategies permitted advances in the identification of low-risk PE. Clinical prediction rules, such as the Pulmonary Embolism Severity Index (PESI), and laboratory biomarkers, particularly natriuretic peptides and cardiac troponins, appeared capable of excluding severe PE and serious comorbidity. Recently, two randomised trials and two prospective cohort studies investigated the feasibility and safety of outpatient treatment. All excluded patients with haemodynamic instability and serious comorbidity, but only one trial used a validated clinical score (PESI) for patient inclusion, and only one cohort study employed a biomarker test. Overall, 90-day outcome was favourable and the results appear promising. To optimise patient selection, future trials will need to test simplified clinical scores combined with high-sensitivity biomarker assays, and it will have to be determined whether echocardiography and/or compression ultrasonography are also required before discharge. Furthermore, ongoing trials will show whether new oral anticoagulants are a safe and cost-effective option for managing patients out of hospital.

Diagnosis and management of venous thromboembolism: Results of a survey on current clinical practice

Background The implementation of evidence from clinical studies into daily clinical practice is not a straightforward process. We developed a standardized questionnaire to explore clinical practice patterns in the management of VTE, in particular about the use of pre-clinical probability and D-dimer testing and on the home treatment of pulmonary embolism (PE). Methods The standardized questionnaire was sent to all 394 physician members of the Italian Society of Thrombosis and Haemostasis (SISET) by e-mail. The questionnaire contained three groups of questions: about general information, about the diagnostic process for both deep venous thrombosis (DVT) and PE, and about home-therapy of PE. Results One hundred and twenty-eight (32.5%) physicians responded the questionnaire. For DVT diagnosis 69 (54.3%) physicians answered that they always use the D-dimer test; 4 (3.1%) do never use it; whereas only 11 (8.7%) take notice of the D-dimer result before visiting the patients; 38 (29.9%) use only clinical judgment to assess pre-clinical probability of disease. For the diagnosis of PE 80 (66.1%) physicians always use the D-dimer test, whereas 3 (2.5%) do never use it; whereas 14 (11.7%) take notice of the D-dimer result before visiting the patients; 50 (41.3%) use only clinical judgment to assess pre-clinical probability. Sixty-six (59.5%) clinicians declared to treat patients with PE at home, when feasible. Conclusion The diagnostic approach to VTE among expert physicians appears to be heterogeneous; in particular there is no widespread use of clinical prediction rules. The majority of expert physicians appear to consider the possibility of treating at home patients with PE.