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Requests for reprints should be addressed to Paul D. Stein, MD, Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, 909 Fee Road, East Lansing, MI 48824.
Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East LansingDepartment of Medical Education, Summa Akron City Hospital, OhioDepartment of Emergency Medicine, McLaren Oakland Hospital, Pontiac, Mich
Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East LansingDepartment of Emergency Medicine, Sparrow Health System, Lansing, Mich
Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East LansingDepartment of Emergency Medicine, St. Mary Mercy Hospital, Livonia, Mich
Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East LansingDepartment of Emergency Medicine, Sparrow Health System, Lansing, Mich
Outpatient 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.
Methods
This 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.
Results
Pulmonary 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.
Conclusion
Even 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.
showed that outpatient therapy of acute pulmonary embolism is safe in low-risk, carefully selected compliant patients who have access to outpatient care if necessary. Investigations of outpatient treatment of acute pulmonary embolism have been reported since 2000.
Immediate discharge and home treatment with rivaroxaban of low-risk venous thromboembolism diagnosed in two U.S. emergency departments: a one-year preplanned analysis.
Among these patients, death from pulmonary embolism occurred in 0.06% and nonfatal recurrent pulmonary embolism occurred in 1.5%. Fatal bleeding occurred in 0.11% and nonfatal major bleeding occurred in 1.5%. All patients treated entirely at home or after early discharge were considered to be at low risk of dying from pulmonary embolism and low risk of bleeding. Typical exclusions were patients in shock, those who required oxygen, parenteral treatment for pain, and those with concomitant medical conditions. Most of these patients (1713) were treated with low-molecular-weight heparin followed by warfarin.
Immediate discharge and home treatment with rivaroxaban of low-risk venous thromboembolism diagnosed in two U.S. emergency departments: a one-year preplanned analysis.
A possible hesitancy in the use of home treatment may relate to logistic problems. Problems related to the injection of low-molecular-weight heparin at home can be overcome by the use of novel oral anticoagulants. The oral factor Xa inhibitors rivaroxaban and apixaban were approved for treatment of deep venous thrombosis and pulmonary embolism by the US Food and Drug Administration on November 2, 2012 and August 21, 2014, respectively.
Whether the availability of novel oral anticoagulants has resulted in physicians selecting home treatment for patients with pulmonary embolism is not known. The purpose of this investigation is to assess the prevalence of home treatment of acute pulmonary embolism in the era of novel oral anticoagulants.
Methods
This 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. Collaborating sites were McLaren Oakland Hospital, Pontiac, Mich.; Summa Akron City Hospital, Akron, Ohio; St. Mary Mercy Hospital, Livonia, Mich., University of Toledo, Medical Center of Ohio, Toledo, Ohio; and Sparrow Hospital, Lansing, Mich. The medical records of patients aged 18 years or older with pulmonary embolism seen on the emergency service were manually reviewed. These records were identified by searching for patients discharged from the emergency service with International Classification of Diseases, Ninth Edition, Clinical Modification code 415.1. Comorbid conditions were largely those identified by the Charlson Index.
This investigation was approved by the Institutional Review Boards of each of the participating centers.
Results
Pulmonary embolism was diagnosed in the emergency departments January 2013-December 2014 in 983 patients. Among these, 80 were hypotensive (systolic blood pressure <90 mm Hg), on vasopressors, or on ventilator support. In addition, 157 had an arterial oxygen saturation of ≤90%. These patients were considered ineligible for home treatment, and therefore, excluded. There remained 746 patients who were potentially eligible for home treatment of pulmonary embolism. The diagnosis of pulmonary embolism was made by computed tomographic angiography in 695, ventilation-perfusion lung scan in 37, positive venous ultrasound with clinical findings of pulmonary embolism in 5, and in 9 the method of diagnosis was not stated.
Home treatment was chosen for 13 of 746 (1.7%) stable patients with pulmonary embolism who were not hypoxic. Anticoagulant treatment for those treated at home was low-molecular-weight heparin or warfarin (or both) in 9 (69.2%) and novel oral anticoagulants in 4 (30.8%). Patients treated at home were aged 56 ± 17 years (mean ± standard deviation); 8 (61.5%) were male. Among those treated at home, 10 had no comorbid conditions and 3 had cancer. Two (15.4%) were considered at high risk of bleeding. One patient was dyspneic at rest.
Hospitalization was chosen for 733 of 746 (98.3%). Patients treated in the hospital were aged 59 ± 18 years; 340 (46.4%) were male. No comorbid conditions were present in 319 of 733 (43.5%). Comorbid conditions in hospitalized patients are shown in the Table. A high risk of bleeding was assessed in 128 of 733 (17.5%). Dyspnea at rest was present in 260 of 733 (35.5%).
TableComorbid Conditions in 733 Hospitalized Patients with Pulmonary Embolism
Comorbid Condition
Number (%)
Heart failure
21 (2.9)
History of myocardial infarction
7 (1.0)
Peripheral vascular disease
25 (3.4)
Cerebrovascular disease
40 (5.5)
Dementia
33 (4.5)
Chronic obstructive pulmonary disease
79 (10.8)
Rheumatologic disease
30 (4.1)
Ulcer disease
12 (1.5)
Acute or chronic liver disease
8 (1.1)
Diabetes mellitus
118 (16.1)
Hemiplegia and hemiparesis
5 (4.1)
Moderate or severe renal disease
37 (5.0)
Any neoplasms, leukemia, lymphoma
161 (22.0)
Metastatic cancer
53 (7.2)
Patients may have had more than one comorbid condition.
Discharge in ≤2 days was in 119 of 733 patients (16.2%). The length of stay of hospitalized patients is shown in the Figure. Treatment of those discharged in ≤2 days was low-molecular-weight heparin or warfarin (or both) in 76 of 119 (63.9%) and novel oral anticoagulants in 34 of 119 (28.6%). In 4 (3.4%), no treatment anticoagulant treatment was given at discharge because of metastatic cancer, and in 5 (4.2%), treatment was not known.
FigureLength of hospital stay of stable, nonhypoxic patients with pulmonary embolism.
Only a small proportion, 1.7%, of patients with acute pulmonary embolism who were not unstable and not hypoxic, were treated entirely at home. An additional 16.2% of patients were discharged in ≤2 days. Novel oral anticoagulants were administered to less than one-third of patients treated entirely at home and less than one-third of patients discharged in ≤2 days.
Several scoring systems have been derived to identify patients with pulmonary embolism who are at low risk of adverse events and may be candidates for home treatment. Among these are the Pulmonary Embolism Severity Index (PESI) score,
On behalf of the Protect Investigators Derivation and validation of multimarker prognostication for normotensive patients with acute symptomatic pulmonary embolism.
Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) investigators A clinical prognostic model for the identification of low-risk patients with acute symptomatic pulmonary embolism and active cancer.
It had been suggested that wide acceptance of outpatient treatment of pulmonary embolism may be hindered in the absence of explicit criteria to accurately identify patients who are at low risk of adverse outcomes.
It seems that scoring systems have had little impact on use of outpatient therapy.
In 2012, the American College of Chest Physicians in their Evidence-Based Clinical Practice Guidelines, suggested early discharge of patients with low-risk pulmonary embolism whose home circumstances are adequate.
In 2016, the recommendation was modified to state that appropriately selected patients may be treated entirely at home rather than just discharged early.
The British Thoracic Society, in their 2003 guidelines, suggested that outpatient treatment of pulmonary embolism may be considered if the patient is not unduly breathless, there are no medical or social contraindications, and there is an efficient protocol in place.
British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development Group British Thoracic Society guidelines for the management of suspected acute pulmonary embolism.
There is a longer experience with home treatment of deep venous thrombosis than with pulmonary embolism. Between 1990 and 1995, it had been suggested that home treatment of deep venous thrombosis was safe, effective, and cost-effective in carefully selected patients.
In the era of novel oral anticoagulants, a case series showed only 11 of 96 (11.5%) patients with acute deep venous thrombosis were treated entirely at home.
A strength of this investigation is that it is the only one of which we are aware that assesses the prevalence of home treatment of pulmonary embolism in the era of novel oral anticoagulants. The number of included patients is substantial. A weakness is lack of follow-up of patients treated at home. Also, as with any retrospective investigation, some information is missing from the records. The local practice patterns of the physicians in the emergency departments in the hospitals included in this investigation may not be representative of all hospitals throughout the US.
In conclusion, even in the era of availability 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. Novel oral anticoagulants were administered to less than one-third of those treated entirely at home or discharged early. 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.
References
Hull R.D.
Treatment of pulmonary embolism. The use of low-molecular-weight heparin in the inpatient and outpatient settings.
Immediate discharge and home treatment with rivaroxaban of low-risk venous thromboembolism diagnosed in two U.S. emergency departments: a one-year preplanned analysis.
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