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Computer tool increases safe outpatient management of pulmonary embolism

An internet-based clinical decision support system allowed physicians to quickly and easily identify patients with pulmonary embolism eligible for home treatment without the risk of rehospitalization or major adverse events, according to findings published in Annals of Internal Medicine.

“Many low-risk patients with acute pulmonary embolism (PE) in the emergency department (ED) are eligible for outpatient care but are hospitalized nonetheless,” David R. Vinson, MD, from the Permanente Medical Group and Kaiser Permanente Northern California, and colleagues wrote. “One impediment to home discharge is the difficulty of identifying which patients can safely forgo hospitalization.”

Vinson and colleagues conducted a controlled pragmatic trial to determine if an integrated electronic clinical decision support system facilitates risk stratification and decision-making for adults in the ED with acute PE. The study was performed in 21 community EDs, of which 10 were intervention sites, including 881 patients, and 11 were concurrent controls, including 822 patients. The intervention sites received a multidimensional technology and education program over 16 months with an 8-month preintervention period and an 8-month postintervention period.

The researchers documented whether patients were discharged to home from either the ED or a short-term, defined as less than 24 hours, outpatient observation unit based in the ED. They measured adverse outcomes such as return visits for PE-related symptoms within 5 days and recurrent venous thromboembolism, major hemorrhage and all-cause mortality within 30 days.

Intervention sites demonstrated a relative increase of 60.9% in adjusted home discharge from preintervention (17.4%) to postintervention (28%). Control sites did not show an increase in home discharge (15.1% preintervention vs. 14.5% postintervention). There was an 11.3 percentage points (95% CI, 3-19.5) greater increase in home discharge at intervention sites than control sites.

Five-day return visits related to PE did not increase. There was also no increase in 30-day major adverse outcomes associated with clinical decision support system implementation observed.

“Identifying the most appropriate venue of care for patients with acute medical conditions is a key priority for transforming U.S. health care,” Vinson and colleagues concluded. “The use of clinical decision support systems to bring validated risk-stratification tools to the ED bedside could help advance this agenda and could be expanded beyond PE to improve care and resource use for other clinical conditions.”

In a related editorial, Paul D. Stein, MD, and Mary J. Hughes, DO, both from Michigan State University College of Osteopathic Medicine, wrote that there are challenges to implementing the clinical decision support system, but also benefits, such as reduced health care costs by as much as $1 billion per year if all eligible patients with PE were treated at home rather than the hospital.

“The investigators are to be congratulated for showing the effectiveness of this computer tool that, when intensively promoted, enabled physicians to knowledgeably select a larger proportion of patients for home treatment,” they wrote. – by Alaina Tedesco

Disclosures: Hughes, Stein and Vinson reports no relevant financial disclosures. Please see study for all other authors’ relevant financial disclosures.