Low-risk Pulmonary Embolism Patients Research Articles

Direct Oral Anticoagulants for Pulmonary Embolism.

Venous thromboembolism (VTE) is the third most common cardiovascular disease. For most patients, the standard of treatment has long consisted on low-molecular-weight heparin followed by vitamin K antagonists, but a number of clinical trials and, subsequently, post-marketing studies have shown that direct oral anticoagulants (DOACs) with or without lead-in heparin therapy are effective alternatives with fewer adverse effects. This evidence has led to important changes in the guidelines on the treatment of VTE, including pulmonary embolism (PE), with the DOACs being now recommended as the first therapeutic choice. Additional research has contributed to identifying low-risk PE patients who can benefit from outpatient management or from early discharge from the emergency department with DOAC treatment. There is evidence to support the use of DOACs in intermediate-risk PE patients as well as in high-risk patients receiving thrombolytic treatment. The use of DOACs has also been proven to be safe and effective in special populations of PE patients, such as patients with renal impairment, liver impairment, and cancer.

The Role of IVC Filters in the Management of Acute Pulmonary Embolism.

Venous thromboembolism (VTE), comprising deep venous thrombosis (DVT) and pulmonary embolism (PE), is a prevalent cardiovascular condition, ranking third globally after myocardial infarction and stroke. The risk of VTE rises with age, posing a growing concern in aging populations. Acute PE, with its high morbidity and mortality, emphasizes the need for early diagnosis and intervention. This review explores prognostic factors for acute PE, categorizing it into low-risk, intermediate-risk, and high-risk based on hemodynamic stability and right ventricular strain. Timely classification is crucial for triage and treatment decisions. In the contemporary landscape, low-risk PE patients are often treated with Direct Oral Anticoagulants (DOACS) and rapidly discharged for outpatient follow-up. Intermediate- and high-risk patients may require advanced therapies, such as systemic thrombolysis, catheter-directed thrombolysis, mechanical thrombectomy, and IVC filter placement. The latter, particularly IVC filters, has witnessed increased usage, with evolving types like retrievable and convertible filters. However, concerns arise regarding complications and the need for timely retrieval. This review delves into the role of IVC filters in acute PE management, addressing their indications, types, complications, and retrieval considerations. The ongoing debate surrounding IVC filter use, especially in patients with less conventional indications, reflects the need for further research and data. Despite complications, recent studies suggest that clinically significant issues are rare, sparking discussions on the appropriate and safe utilization of IVC filters in select PE cases. The review concludes by highlighting current trends, gaps in knowledge, and potential avenues for advancing the role of IVC filters in future acute PE management.

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.

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

BackgroundThe RIETE score could be specifically useful for identification of low-risk pulmonary embolism (PE) patients for home treatment. However, the external validation of the RIETE score has been limited. MethodsThe COMMAND VTE Registry is a multicenter registry enrolling consecutive patients with acute symptomatic venous thromboembolism (VTE). The current study population consisted of 1479 patients with acute PE, who were divided into 2 groups; RIETE scores of 0 (N = 260) and ≥ 1 (N = 1219). ResultsThe cumulative 10-day and 30-day incidences of a composite endpoint of all-cause death, recurrent PE, or major bleeding were lower in patients with the RIETE score of 0 than in those with the RIETE score of ≥1 (10-day: 0.4 % vs. 6.7 %, P < 0.001, and 30-day: 0.4 % vs. 10.0 %, P < 0.001). The area under the receiver-operating characteristic curve (AUC) in the RIETE score for the 10-day composite endpoint showed numerically better predictive ability than that in the sPESI score (0.77 vs. 0.73, P = 0.07), and the AUC in the RIETE score for the 30-day composite endpoint showed significantly better predictive ability than that in the sPESI score (0.77 vs. 0.71, P = 0.003). ConclusionsThe RIETE score was well validated in the current large real-world registry. The RIETE score of 0 could identify patients with reasonably low risks of the 10-day and 30-day composite endpoint of all-cause death, recurrent PE, or major bleeding.

Impact of an Institutional Clinical Pathway on Emergency Physicians' Stated Preferences in Treating Patients with Low-Risk Pulmonary Embolism.

Evidence continues to accumulate that select patients with acute low-risk pulmonary embolism (PE) can be safely discharged from the emergency department. Despite this, outpatient management continues to be uncommon. We report changes in emergency providers' stated preferences on low-risk acute PE management before and after the development and implementation of an institutional clinical pathway and decision tool. We performed an observational analysis of attending emergency physicians' stated preferences towards the management of low-risk acute PE using survey results before and after the development and implementation of an electronic health record-embedded institutional low-risk acute PE pathway. Attending emergency medicine providers reported feeling more comfortable using PE risk stratification scores to identify dischargeable low-risk PE patients and also reported that they would be more likely to discharge a hypothetical patient with low-risk acute PE. Our results suggest that the implementation of an institutional clinical pathway with integration into the electronic health record was associated with a change in emergency physicians' stated preferences for managing patients with acute low-risk PE in the emergency department. Implementation of an evidence-based standard pathway was associated with increased comfort and familiarity with PE risk stratification, and an increased comfort with and preference for early outpatient management of low-risk PE.

Clinical and Economic Outcomes in Low-risk Pulmonary Embolism Patients Treated with Rivaroxaban versus Standard of Care

BackgroundL Rivaroxaban, a fixed-dose oral direct factor Xa inhibitor, does not require continuous monitoring and thus reduces the hospital stay and economic burden in low-risk pulmonary embolism (LRPE) patients. Study Question: What is the effectiveness of rivaroxaban versus the standard of care (SOC; low-molecular-weight heparin, unfractionated heparin, warfarin) among LRPE patients in the Veterans Health Administration? Study Design: Adult patients with continuous health plan enrollment for ≥12 months pre- and 3 months post-inpatient PE diagnosis (index date=discharge date) between October 1, 2011- June 30, 2015 and an anticoagulant claim during the index hospitalization were included. Measures and Outcomes Patients scoring 0 points on the simplified Pulmonary Embolism Stratification Index were considered low-risk and were stratified into SOC and rivaroxaban cohorts. Propensity score matching (PSM) was used to compare hospital-acquired complications (HACs), PE-related outcomes (recurrent venous thromboembolism, major bleeding, and death), and healthcare utilization and costs between the rivaroxaban and SOC cohorts. Results: Among 6746 PE patients, 1918 were low-risk; of these, 73 were prescribed rivaroxaban, 1546 were prescribed SOC, and 299 were prescribed other anticoagulants during the index hospitalization. After 1:3 PSM, 64 rivaroxaban and 192 SOC patients were included. During the index hospitalization, rivaroxaban users (versus SOC) had similar inpatient length of stay (LOS; 7.0 vs 6.7 days, standardized difference [STD]=1.8) but fewer HACs (4.7% vs 10.4%; STD: 21.7). In the 90-day post-discharge period, PE-related outcome rates were similar between the cohorts (all p&gt;0.05). However, rivaroxaban users had fewer outpatient (15.9 vs 20.4; p=0.0002) visits per patient as well as lower inpatient ($765 vs $2,655; p&lt;0.0001), pharmacy ($711 vs $1,086; p=0.0033), and total costs ($6,270 vs $9,671; p=0.0027). Conclusions: LRPE patients prescribed rivaroxaban had similar index LOS and PE-related outcomes, but fewer HACs, and lower total costs than those prescribed SOC.

Home Treatment of Patients with Pulmonary Embolism: A Single Center 10-Year Experience from Ljubljana Registry.

Current guidelines suggest careful risk stratification using a structured clinical approach when selecting patients with pulmonary embolism (PE) for home treatment. The aim of our study was to assess whether PE patients referred to home treatment are appropriately risk-stratified according to guidelines prior to referral and what the real-life course of the disease in these patients is. We included patients with confirmed PE referred to outpatient management and treated with anticoagulants between 2010 and 2019, whose data were collected in a prospective management registry. Using simplified PE severity index and/or signs of right ventricular strain, we classified patients to either appropriate or inappropriate low-risk classes for outpatient management. We compared 30-day mortality, overall mortality, and rates of recurrent thromboembolism or major bleeding between both classes. Among 278 patients, 188 (67.6%) and 90 (32.4%) were classified as appropriate or inappropriate class, respectively. In total, 30-day mortality was low in both groups: 0% in appropriate class and 1.1% in inappropriate class. The overall mortality rate was higher in the inappropriate than in the appropriate class (12.1 vs 0.9/100 patient-years, respectively, P < .001). Rates of recurrent thromboembolism and major bleeding were similar for both classes. We conclude that in real-life, a significant proportion of inappropriate low-risk class PE patients are referred to outpatient management. However, with careful follow-up, early mortality is low, even in home-treated patients inappropriately classified as low-risk.

Predicting factors for pulmonary embolism response team activation in a general pulmonary embolism population.

Pulmonary embolism response teams (PERT) aim to improve treatment of acute pulmonary embolism (PE). PERT focus on intermediate- and high-risk PE patients, but recent multicenter studies show that low-risk PE patients compose one in five of all PERT cases. Conversely, not all intermediate- and high-risk PE patients elicit a PERT activation. The factors leading to PERT activations remain unknown. This study aims to describe the patient characteristics associated with PERT activation for low-risk PE patients and characteristics precluding PERT activation for intermediate/high-risk PE patients. We analysed data from all patients with confirmed PE diagnosed in the Massachusetts General Hospital Emergency Department from August 2013 to February 2017 and cross-referred these data with patients who received a PERT activation and patients who did not. Patients were stratified into low-risk or intermediate/high-risk PE. Univariate analyses were performed within each risk group comparing patients with a PERT activation and patients without. Fifteen percent (56/374) of low-risk PE patients triggered a PERT activation. Patient characteristics associated with PERT activation were: (1) vascular disease, (2) pulmonary diseases, (3) thrombophilia, (4) current use of anticoagulants, (5) central PE and (6) concurrent DVT. Thirty-five percent (110/283) of intermediate/high-risk PE patients did not elicit a PERT activation. Patient characteristics precluding a PERT activation were: (1) vascular disease, (2) malignancies and (3) asymptomatic presentation. Low-risk PE patients with PERT activations had more extensive clot burden, complex comorbidities, or had failed anticoagulation treatment. Intermediate/high-risk PE patients without PERT activations tended to have malignancies or vascular disease.

D-dimer-based screening for early diagnosis of venous thromboembolism after hepatectomy.

The aim of this study was to evaluate the clinical utility of a novel diagnostic algorithm based on serum D-dimer levels for venous thromboembolism (VTE) after hepatectomy. We retrospectively analyzed 742 consecutive patients who underwent hepatectomy in our hospital from 2009 to 2019. From 2015, we routinely measured serum D-dimer level postoperatively and computed tomography was performed when D-dimer level was ≥ 20 μg/mL. VTE was diagnosed in 26 patients and pulmonary embolism (PE) was diagnosed in 18 patients. Multivariate analysis revealed that resected liver weight ≥ 120 g is a significant predictor of VTE (P = 0.011). The incidence of VTE from 2015 to 2019 was greater than that from 2009 to 2014 (5.0% versus 2.1%, P = 0.044). The number of low-risk PE patients between 2015 and 2019 was significantly greater than that between 2009 and 2014 (P = 0.013). There was no in-hospital mortality of patients with PE from 2015 to 2019. Patients who undergo hepatectomy are at high risk for VTE, especially when the resected liver weight is high. The proposed diagnostic algorithm based on serum D-dimer levels for VTE after hepatectomy can be useful for early diagnosis.

Safety, efficacy, length of stay and patient satisfaction with outpatient management of low-risk pulmonary embolism patients - a meta-analysis.

IntroductionAnnual health expense of hospital admissions, due to venous thromboembolism including pulmonary embolism, exceeds 10 billion dollars in the United States. Most of these patients still get admitted to the hospital despite the advent of novel oral anticoagulants. Our aim is to show that low-risk pulmonary embolism patients can safely be discharged from the emergency department with similar patient satisfaction and lower length of stay.MethodsA comprehensive search in Medline indexed and non-indexed, Embase, and Cochrane Central was performed to search for all the randomized controlled trials that compared inpatient treatment of low-risk pulmonary embolism to outpatient treatment.ResultsOf 68 potentially relevant studies, a total of 2 studies (453 participants) met our inclusion criteria and had data available on patient satisfaction, length of stay, efficacy, and patient safety. The pooled estimate of the included studies showed that at 3-month follow-up, there was no statistically significant difference between inpatient and outpatient treatment of these low-risk patients.ConclusionsIn conclusion, our meta-analysis of 2 randomized controlled trials shows that low-risk pulmonary embolism patients can safely be discharged from the emergency departments in the limited studies available. We need more randomized controlled trials to confirm these findings.

Upregulation of Inflammatory Cytokines in Pulmonary Embolism Using Biochip-Array Profiling.

The complex pathophysiology of pulmonary embolism (PE) involves hemostatic activation, inflammatory processes, cellular dysfunction, and hemodynamic derangements. Due to the heterogeneity of this disease, risk stratification and diagnosis remains challenging. Biochip-array technology provides an integrated high throughput method for analyzing blood plasma samples for the simultaneous measurement of multiple biomarkers for potential risk stratification. Using biochip-array method, this study aimed to quantify the inflammatory biomarkers such as interleukin (IL)-1α, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, vascular endothelial growth factor (VEGF), interferon gamma (IFN-γ), tumor necrosis factor alpha (TNF-α), monocyte chemoattractant protein-1 (MCP-1), and epidermal growth factor (EGF) in 109 clinically confirmed PE patients in comparison to the control group comprised of plasma samples collected from 48 healthy subjects. Cytokines IL-4, IL-6, IL-8, IL-10, IL-1β, and MCP-1 demonstrated varying level of significant increase (P < 0.05) in massive-risk PE patients compared to submassive- and low-risk PE patients. The upregulation of inflammatory cytokines in PE patients observed in this study suggest that inflammation plays an important role in the overall pathophysiology of this disease. The application of biochip-array technology may provide a useful approach to evaluate these biomarkers to understand the pathogenesis and risk stratification of PE patients.

Cost-effectiveness of managing low-risk pulmonary embolism patients without hospitalization. The low-risk pulmonary embolism prospective management study

Evaluate the cost-effectiveness and difference in length-of-stay when patients in the ED diagnosed with low-risk pulmonary embolism (PE) are managed with early discharge or observation. Single cohort prospective management study from January 2013 to October 2016 of patients with PE diagnosed in the ED and evaluated for a primary composite endpoint of mortality, recurrent venous thromboembolism, and/or major bleeding event at 90days. Low-risk patients had a PE Severity Index score<86, no evidence of proximal deep vein thrombosis on venous compression ultrasonography of both lower extremities, and no evidence of right heart strain on echocardiography. Patients were managed either in the ED or in the hospital on observation status. Primary outcomes were total length of stay, total encounter costs, and 30-day costs. 213 patients were enrolled. 13 were excluded per the study protocol. Of the remaining 200, 122 were managed with emergency department observation (EDO) and 78 with hospital observation (HO). One patient managed with EDO met the composite outcome due to a major bleeding event on day 61. The mean length of stay for EDO was 793.4min (SD -169.7, 95% CI:762-823) and for HO was 1170 (SD -211.4, 95% CI:1122-1218) with a difference of 376.8 (95% CI: 430-323, p<0.0001). Total encounter mean costs for EDO were $1982.95 and $2759.59 for HO, with a difference of $776.64 (95% CI: 972-480, p>0.0001). 30-day total mean costs for EDO were $2864.14 and $3441.52 for HO, with a difference of $577.38 (95% CI: -1372-217, p=0.15). Patients with low-risk PE managed with ED-based observation have a shorter length of stay and lower total encounter costs than patients managed with Hospital-based observation.

Prothrombotic fibrin clot properties associated with NETs formation characterize acute pulmonary embolism patients with higher mortality risk

Venous thromboembolism is associated with formation of denser fibrin clots resistant to lysis. We investigated whether prothrombotic plasma clot properties are associated with the severity of acute pulmonary embolism (PE). We enrolled 126 normotensive acute PE patients (aged 58 ± 14 years) and 25 age- and sex-matched healthy controls. Plasma fibrin clot permeability (Ks), clot lysis time (CLT), endogenous thrombin potential (ETP), plasminogen activator inhibitor-1 (PAI-1), and citrullinated histone H3 (citH3) were evaluated on admission. PE patients compared to controls had 370% higher citH3 levels, 41% higher ETP, 16.5% reduced Ks, and 25.6% prolonged CLT. Patients with intermediate-high (n = 29) and intermediate-low (n = 77) PE mortality risk had reduced Ks and prolonged CLT, increased PAI-1 and ETP as compared to low-risk PE (n = 20) patients. Prolonged CLT was predicted by PAI-1 and citH3, while low Ks by C-reactive protein. During a 12-month follow-up 9 (7.1%) patients who had 24% higher ETP, 45% higher citH3 levels, and 18% prolonged CLT at baseline died. High ETP combined with elevated citH3 levels and prolonged CLT was associated with eightfold increased risk of PE-related death. Prothrombotic fibrin clot properties and enhanced neutrophil extracellular traps formation are associated with higher early mortality risk in acute PE patients, which suggests a prognostic role of these biomarkers.

Need for Transthoracic Echocardiogram in Patients with Low-Risk Pulmonary Thromboembolism: A Systematic Review and Meta-Analysis

IntroductionIt is unclear whether low-risk patients with acute symptomatic pulmonary embolism (PE) should undergo echocardiogram. MethodsWe performed a meta-analysis of studies that enrolled patients with acute low-risk PE to assess the prognostic value of echocardiographic diagnosis of right ventricular (RV) dysfunction for the primary outcome of short-term all-cause mortality, and the secondary outcome of short-term PE-related mortality. We used a random-effects model to pool study results, a Begg rank correlation method to evaluate for publication bias, and I2 testing to assess heterogeneity. ResultsThe meta-analysis included a total of 11 studies with 1868 low-risk PE patients. Ten of the 447 (2.2%; 1.1%–4.1%) low-risk patients with echocardiographic RV dysfunction died soon after the diagnosis of PE compared with 10 of 1421 (0.7%; 0.3%–1.3%) patients without RV dysfunction. RV dysfunction was not significantly associated with short-term all-cause mortality (odds ratio 2.0; 95% confidence interval, 0.8–5.1, P=.14; I2=8%). RV dysfunction was significantly associated with short-term PE-related mortality (odds ratio 5.2; 95% confidence interval, 1.7–16, P<.01; I2=0%). ConclusionsIn patients with low-risk PE, echocardiographic RV dysfunction is not associated with all-cause mortality, but identifies patients with an increased risk for short-term PE-related mortality.

Outpatient Treatment in Low-Risk Pulmonary Embolism Patients Receiving Direct Acting Oral Anticoagulants Is Associated With Cost Savings.

Direct oral anticoagulants (DOAC) are first line treatment for pulmonary embolism (PE). Treatment of acute PE is traditionally hospital based and associated with high costs. The aims of this study were to evaluate potential cost savings with outpatient DOAC treatment compared to inpatient DOAC treatment in patients with low risk PE. A retrospective study in patients with DOAC treated low risk PE (simplified pulmonary severity index [sPESI] ≤ 1) admitted to 8 hospitals during 2013-2015. Health care costs were compared in 223(44%) patients treated as outpatients and 287(56%) treated in hospital. Total cost per patient was 8293 EUR in the inpatient group, and 2176 EUR in the outpatient group (p < 0.001). Total costs for inpatients were higher (p < 0.001) compared to outpatients in both subgroups with sPESI 0 and 1. In multivariate analysis, type of treatment (in- or outpatient, p = < 0.001) and sPESI group (0 or 1, p = < 0.001) were associated with total cost below or above median, whereas age (p = 0.565) and gender (p = 0.177) was not. Adherence to guidelines recommending outpatient treatment with DOAC in patients with low risk PE enables significant savings.

Assessment of Utilization of Outpatient Based Treatment for Low Risk Patients with Pulmonary Embolism in Two Community Teaching Hospitals

OBJECTIVE: Several randomized controlled trials and meta-analysis has proven safety and efficacy of outpatient based treatment in appropriately selected low-risk patients with pulmonary embolism (PE). Despite the fact that outpatient treatment has been proven safe, prior studies have shown that it is not commonly practiced. Our current multi-center study focuses on identifying practices of outpatient versus inpatient treatment of low risk PE patients in two community hospitals between 2018-2019. METHODS: A retrospective chart review of the patients in two community hospitals with the principal discharge diagnosis of pulmonary embolism aged 18 years or older was conducted. The study period included February 2018 to February 2019. The high risk patients defined as simplified pulmonary embolism severity index (PESI) score of 1 or above were excluded from the study. Low risk patients were defined as with a simplified PESI score of 0. Criteria were established to determine the appropriateness of inpatient admission for low risk patients with PE. The group of low risk patients with thrombocytopenia (platelets less than 70,000/mm3), glomerular filtration rate (GFR) of less than 30 ml/ minute, international normalized ratio (INR) greater than 1.5, pregnancy, active bleeding as documented in the medical records, total bilirubin greater than 3.0 mg/dl, extreme obesity (weight greater than 150 kg), diagnosis of acute PE while on oral anticoagulation, requiring narcotics for chest pain, need for supplemental oxygen , poor social support or presence of concomitant extensive deep vein thrombosis were deemed appropriate for inpatient treatment. The patients without these baseline characteristics were considered appropriate for outpatient treatment. RESULTS: The cohort comprised of 442 patients in two community hospitals. Among these, 172 patients had a simplified PESI score of 1 or above and were excluded from the study. The remaining 270 patients had a simplified PESI score of 0 and were considered low risk. Based on the study criteria, 54% (145 patients out of 270) of the low risk patients were deemed appropriate for outpatient treatment. Out of these, only 16% (23 patients out of 145) were treated at home. The remaining 84% (122 patients out of 145) of the low risk PE patients considered safe for outpatient treatment were actually treated as inpatient. The mean length of hospital stay for this group of patients was 3 days. Anti-coagulation therapy for those treated on outpatient basis was novel oral anticoagulants in 79% (18 patients out of 23) and low molecular weight heparin or warfarin in 21% (5 patients out of 23). CONCLUSION: Our study demonstrates that majority of low risk PE patients deemed appropriate for outpatient based treatment are treated on inpatient basis. This study shows that there is a need to implement interventions to improve practices of outpatient management of appropriately selected low-risk PE patients. Disclosures No relevant conflicts of interest to declare.

Clinical and Economic Outcomes in Low-risk Pulmonary Embolism Patients Treated with Rivaroxaban versus Standard of Care.

BackgroundRivaroxaban, a fixed-dose oral direct factor Xa inhibitor, does not require continuous monitoring and thus reduces the hospital stay and economic burden in low-risk pulmonary embolism (LRPE) patients. Study Question: What is the effectiveness of rivaroxaban versus the standard of care (SOC; low-molecular-weight heparin, unfractionated heparin, warfarin) among LRPE patients in the Veterans Health Administration?Study DesignAdult patients with continuous health plan enrollment for ≥12 months pre- and 3 months post-inpatient PE diagnosis (index date=discharge date) between October 1, 2011–June 30, 2015 and an anticoagulant claim during the index hospitalization were included.Measures and OutcomesPatients scoring 0 points on the simplified Pulmonary Embolism Stratification Index were considered low-risk and were stratified into SOC and rivaroxaban cohorts. Propensity score matching (PSM) was used to compare hospital-acquired complications (HACs), PE-related outcomes (recurrent venous thromboembolism, major bleeding, and death), and healthcare utilization and costs between the rivaroxaban and SOC cohorts.ResultsAmong 6746 PE patients, 1918 were low-risk; of these, 73 were prescribed rivaroxaban, 1546 were prescribed SOC, and 299 were prescribed other anticoagulants during the index hospitalization. After 1:3 PSM, 64 rivaroxaban and 192 SOC patients were included. During the index hospitalization, rivaroxaban users (versus SOC) had similar inpatient length of stay (LOS; 7.0 vs 6.7 days, standardized difference [STD]=1.8) but fewer HACs (4.7% vs 10.4%; STD: 21.7). In the 90-day post-discharge period, PE-related outcome rates were similar between the cohorts (all p>0.05). However, rivaroxaban users had fewer outpatient (15.9 vs 20.4; p=0.0002) visits per patient as well as lower inpatient ($765 vs $2,655; p<0.0001), pharmacy ($711 vs $1,086; p=0.0033), and total costs ($6,270 vs $9,671; p=0.0027).ConclusionsLRPE patients prescribed rivaroxaban had similar index LOS and PE-related outcomes, but fewer HACs, and lower total costs than those prescribed SOC.

Predictors of Hospital Length of Stay among Patients with Low-risk Pulmonary Embolism.

BackgroundIncreased hospital length of stay is an important cost driver in hospitalized low-risk pulmonary embolism (LRPE) patients, who benefit from abbreviated hospital stays. We sought to measure length-of-stay-associated predictors among Veterans Health Administration LRPE patients.MethodsAdult patients (aged ≥18 years) with ≥1 inpatient pulmonary embolism (PE) diagnosis (index date = discharge date) between 10/2011–06/2015 and continuous enrollment for ≥12 months pre- and 3 months post-index were included. PE patients with simplified Pulmonary Embolism Stratification Index score 0 were considered low risk; all others were considered high risk. LRPE patients were further stratified into short (≤2 days) and long length of stay cohorts. Logistic regression was used to identify predictors of length of stay among low-risk patients.ResultsAmong 6746 patients, 1918 were low-risk (28.4%), of which 688 (35.9%) had short and 1230 (64.1%) had long length of stay. LRPE patients with computed tomography angiography (Odds ratio [OR]: 4.8, 95% Confidence interval [CI]: 3.82–5.97), lung ventilation/perfusion scan (OR: 3.8, 95% CI: 1.86–7.76), or venous Doppler ultrasound (OR: 1.4, 95% CI: 1.08–1.86) at baseline had an increased probability of short length of stay. Those with troponin I (OR: 0.7, 95% CI: 0.54–0.86) or natriuretic peptide testing (OR: 0.7, 95% CI: 0.57–0.90), or more comorbidities at baseline, were less likely to have short length of stay.ConclusionUnderstanding the predictors of length of stay can help providers deliver efficient treatment and improve patient outcomes which potentially reduces the length of stay, thereby reducing the overall burden in LRPE patients.

Predictors of Hospital Length of Stay among Patients with Low-risk Pulmonary Embolism

Background: Increased hospital length of stay is an important cost driver in hospitalized low-risk pulmonary embolism (LRPE) patients, who benefit from abbreviated hospital stays. We sought to measure length-of-stay associated predictors among Veterans Health Administration LRPE patients. Methods: Adult patients (aged ≥18 years) with ≥1 inpatient pulmonary embolism (PE) diagnosis (index date = discharge date) between 10/2011-06/2015 and continuous enrollment for ≥12 months pre- and 3 months post-index were included. PE patients with simplified Pulmonary Embolism Stratification Index score 0 were considered low risk; all others were considered high risk. LRPE patients were further stratified into short (≤2 days) and long length of stay cohorts. Logistic regression was used to identify predictors of length of stay among low-risk patients. Results: Among 6746 patients, 1918 were low-risk (28.4%), of which 688 (35.9%) had short and 1230 (64.1%) had long length of stay. LRPE patients with computed tomography angiography (Odds ratio [OR]: 4.8, 95% Confidence interval [CI]: 3.82-5.97), lung ventilation/perfusion scan (OR: 3.8, 95% CI: 1.86-7.76), or venous Doppler ultrasound (OR: 1.4, 95% CI: 1.08-1.86) at baseline had an increased probability of short length of stay. Those with troponin I (OR: 0.7, 95% CI: 0.54-0.86) or natriuretic peptide testing (OR: 0.7, 95% CI: 0.57-0.90), or more comorbidities at baseline, were less likely to have short length of stay. Conclusion: Understanding the predictors of length of stay can help providers deliver efficient treatment and improve patient outcomes which potentially reduces the length of stay, thereby reducing the overall burden in LRPE patients.

Medically Clear

pulmonary embolism: pulmonary embolismFigureFigureChanging practice can be difficult. Not only do we have to learn a new way of doing things, we also have to unlearn old ways and unprogram heuristics that may be well established. Translation of new evidence into practice can take years. Take, for example, managing acute hemodynamically stable pulmonary embolism (PE). Disposing this patient has always been simple: anticoagulate and admit. From the EP's mindset, this formula seems like a win-win: clean disposition and a clean conscience that the patient would be safe in the hospital. But what is a win for one might not be for the other. The other in this case is the hospitalist who has one more patient to round on, the hospital supervisor who has one fewer inpatient bed available, the hospital administrator who may have to write off unreimbursed admission costs. And data suggest that lower-risk PE patients who have a longer length of stay also have a much higher rate of hospital-acquired complications, most notably pneumonia. (PLoS One 2017;12[10]:e0185022; http://bit.ly/2PqtZQh.) Is our longstanding clinical practice of admitting acute PE patients really the winner that it has seemed? Sending Patients Home Outpatient management of ED patients with PE is nothing new. Several hospitals in Canada launched an outpatient pathway in the late 1990s, publishing their reassuring results in 2000, and a number of prospective studies followed. (Ann Emerg Med 2012;60[5]:651; http://bit.ly/2yawtM8.) The most rigorous was a multinational trial of low-risk ED patients who lacked contraindications to home care and who were stratified using the PE Severity Index (PESI). Patients were randomized to outpatient v. inpatient care and followed for 90 days. (Lancet 2011;378[9785]:41.) Patients not hospitalized were observed for about 24 hours from presentation to home discharge; hospitalized patients stayed a mean of 4.5 days. The outcomes at 90 days for the outpatient cohort were found to be noninferior to their inpatient counterparts: symptomatic recurrent venous thromboembolism (VTE) (0.6% v. 0%), major bleeding (1.8% v. 0%), and all-cause mortality (0.6% v. 0.6%). The prospective evidence supporting safe outpatient management of adults with acute PE continues to mount. One prospective study of an outpatient treatment pathway included 200 explicitly defined low-risk patients with acute PE, and their 90-day results were excellent: No patients had a recurrent VTE or died, and only one suffered a major bleed. (Chest 2018;154[2]:249.) Despite this evidence, the prevalence of home discharge in most medical centers around the world is low, ranging from one percent to eight percent. Managing PE patents without hospitalization can be accomplished using several approaches to risk stratification. The best-studied validated tool is the PESI, which estimates 30-day all-cause mortality, which, when linked with outpatient exclusion criteria, has been used successfully to select patients for home care. (Lancet 2011;378[9785]:41; Chest 2018;154[2]:249; Am J Respir Crit Care Med 2005;172[8]:1041; http://bit.ly/2QBPEoA.). The PESI can be used strictly, where only low-risk classes (I & II) are deemed home-eligible, or more loosely, when the risk classes simply inform a more holistic assessment of eligibility. (Vinson, et al. Ann Intern Med [Epub Nov. 14, 2018].) A simplified PESI has been studied but underperforms the original. Another approach to patient identification uses the Hestia criteria, a list of contraindications to outpatient management that builds on the earlier Ottawa criteria. (J Thromb Haemost 2011;9[8]:1500; Thromb Haemost 2000;83[2]:209.) The two tools, however, address different facets of risk and are perhaps best integrated to inform clinical judgment. (Vinson, et al. Ann Intern Med [Epub Nov. 14, 2018].) High Rate of Satisfaction A body of evidence certainly suggests that home discharge of low-risk PE patients is safe and cost-effective, so the challenge is changing practice. We at Kaiser Permanente Northern California developed an electronic clinical decision support tool called RISTRA (RIsk STRAtification) to facilitate practice change. The tool automatically populates the PESI with patient-specific data and provides a list of outpatient contraindications (including the Hestia criteria). (Images.) Use of the tool, which was supported by clinical champions at 10 facilities, was high (nearly 70% of eligible patients) and well received by physicians. It was also associated with a 60 percent increase in home discharge and short stay ED observation compared with concurrent controls (28% v. 17%, p=0.007 for the difference in differences analysis) without an increase in major adverse events after discharge. (Ann Intern Med 2018 Nov 13; doi: 10.7326/M18-1206.) A follow-up phone survey revealed high rates of satisfaction among patients who were admitted, discharged, or had a short stay. (West J Emerg Med 2018;19[6]:938; http://bit.ly/2Rxg8sr.) Using these tools, shared decision-making, and a safety net for follow-up are practice-changers, and we should be able to find some acute PE patients—maybe one in three—who can safely go home. This may lead to a less heursitic and more contemplative dispostion dynamic, but we can take heart in having the support of evidence-based medicine.