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Improvements in treatment yield decreases in all-cause, pulmonary embolism-related death
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In patients with pulmonary embolism, temporal improvements in hospital length of stay and initial pharmacological intervention appear to have yielded significant reductions in short-term all-cause and pulmonary embolism-specific mortality, according to new data from the RIETE registry.
In the retrospective cohort study, Manuel Monreal, PhD, from the Hospital Universitari Germans Trias i Pujol in Barcelona, Spain, and colleagues gathered data on 23,858 patients with pulmonary embolism at 272 hospitals enrolled in the RIETE registry between 2001 and 2013. The researchers evaluated patterns over time in the length of hospital stay and pharmacological and interventional therapy use. The primary outcome was 30-day all-cause mortality, which was defined as death from any cause within 30 days of pulmonary embolism diagnosis. The researchers also analyzed temporal trends in pulmonary embolism-specific mortality between 7 and 30 days after diagnosis. Multivariable regression models were constructed to evaluate mortality rates over time.
During the 13-year study period, mean length of hospital stay decreased from 13.6 days to 9.3 days, a 32% relative reduction (P < .001). From 2001 to 2005, 0.03% of patients were managed as outpatients; from 2006 to 2009, 0.6% were managed as outpatients; and from 2010 to 2013, 1.7% of patients were managed as outpatients.
In terms of in-hospital treatments, there was an increase in the use of heparin (from 77% in 2001 to 84% in 2013) and direct oral anticoagulants (from 0% in 2001 to 2.2% in 2013). Conversely, the use of unfractionated heparin decreased, from 22% in 2001 to 8.4% in 2013 (P < .001 for trend for all comparisons). An increase was observed in thrombolysis during the study period, from 0.7% to 1% (P = .07 for trends), and in surgical embolectomy, from 0.3% to 0.6% (P < .01 for trends), whereas a nonstatistically significant downward trend was seen in filter insertion, from 3.4% in 2001 to 2.3% in 2013.
In the entire cohort, the 30-day all-cause mortality rate was 5.9% (n = 1,418). A significant trend toward reduced mortality was seen during the study for all patients. An analysis adjusting for temporal trends in patient characteristics around the time of pulmonary embolism diagnosis revealed an overall decrease in mortality, from 6.65 between 2001 and 2005 to 4.9 between 2010 and 2013 (adjusted rate ratio per period = 0.84; 95% CI, 0.73-0.97).
Rates of 7-day all-cause mortality also decreased temporally, from a risk-adjusted rate of 2.9% between 2001 and 2005 to 1.9% between 2010 and 2013 (adjusted rate ratio per period = 0.81; 95% CI, 0.67-0.98).
Pulmonary embolism-related mortality rates demonstrated a temporal reduction, with a risk-adjusted rate of 3.3% from 2001 to 2005 and a 1.8% risk-adjusted rate from 2010 to 2013 (P < .01 for trend).
“Improvements in the initial treatment of [pulmonary embolism] have been accompanied by reductions in length of hospital stay, as well as short-term all-cause and [pulmonary embolism]-specific mortality,” the researchers wrote. “Future studies should evaluate the relative effect of pharmacological therapy and catheter-directed interventions on clinical outcomes across a variety of treatment settings over a long period of time.” – by Jennifer Byrne
Disclosure: Monreal reports receiving grants and/or consulting and speaker fees from Bayer, Boehringer Ingelheim, Daiichi-Sankyo, Leo Pharma, Pfizer and Sanofi. Please see the full study for a list of all other researchers’ relevant financial disclosures.
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