Two-thirds of patients with low-risk pulmonary embolism hospitalized after ED visit

Key takeaways:

• ED discharge rates for acute PE visits remained consistent over time between 2012 to 2020.
• Outpatient management of low-risk acute PE is probably underutilized, researchers said.

A significant number of low-risk patients who visited the ED for acute pulmonary embolism were hospitalized despite evidence supporting outpatient management, according to a recent study.

“In recent years, it has become increasingly clear that outpatient management for select low-risk patients with acute [pulmonary embolism (PE)] is a safe and feasible approach,” Nathan W. Watson, BS, from Harvard Medical School, and colleagues wrote in the Annals of Internal Medicine. “Despite this increasing evidence, recent work has suggested that many patients with low-risk PE are still managed with inpatient hospitalization.”

The researchers determined whether the proportion of ED discharges for acute PE changed between 2012 to 2020 — and what baseline characteristics were associated with discharge — by examining National Hospital Ambulatory Medical Care Survey data from 1,635,300 patient visits.

They found that ED discharge rates were consistent over time, with rates of:

• 38.2% (95% CI, 17.9%-64%) between 2012 and 2014; and
• 33.4% (95% CI, 21%-49%) between 2018 and 2020 (adjusted RR = 1.01; 95% CI, 0.89-1.14).

Over the total study period, the percentage of patients discharged was:

• 35.9% (95% CI, 23.9%-50%) among those considered low risk based on their Pulmonary Embolism Severity Index (PESI) score;
• 33.1% (95% CI, 21.6%-47%) among those considered low risk based on their simplified PESI score; and
• 34.8% (95% CI, 23.3%-48%) among those considered low risk based on their hemodynamic stability.

Notably, Watson and colleagues did not identify any baseline characteristics associated with increased odds for discharge.

“However, we did find that patients treated at teaching hospitals and those with private insurance had higher rates of oral anticoagulant prescription at discharge, which may partially explain the observed trends,” they wrote.

The researchers suggested that increasing the availability of anticoagulants could help support the implementation of outpatient treatment.

“Altogether, these findings suggest that outpatient management of acute PE remains underutilized despite clinical evidence and guideline recommendations,” they wrote.

Watson and colleagues concluded that further research is needed because of the likelihood of multiple factors influencing hospitalization, “including provider discomfort with outpatient management, poor clinical systems to allow for short-term follow-up and management of these patients, and medicolegal concerns.”