Outpatient management of acute pulmonary embolism low, varies across U.S. hospitals

In a study of patients with acute pulmonary embolism treated at 740 U.S. hospitals, fewer than 5% were discharged home from the ED, researchers reported in Academic Emergency Medicine.

Moreover, rates of outpatient management for acute PE varied widely between institutions.

“Although patients with PE have historically been admitted to the hospital for initial treatment, clinical trials have demonstrated the safety of treating carefully selected patients with acute PE as outpatients,” Lauren M. Westafer, DO, MPH, assistant professor in the Institute for Healthcare Delivery and Population Science and the department of emergency medicine at the University of Massachusetts Medical School, and colleagues wrote. “Protocols to manage patients with acute PE as outpatients were introduced in the late 1990s, and over the past 6 years an increasing number of international society guidelines recommended outpatient treatment of ED patients with low-risk PE.”

The retrospective cohort study included 61,070 adults (mean age, 61.6 years; 52.5% women) with newly diagnosed acute PE who were treated at 740 acute care hospitals in the U.S. from July 2016 to June 2018.

The primary outcome was initial disposition after an ED visit for acute PE. Secondary outcomes included hospital cost and the 30-day ED revisit rate.

Only 4.1% of newly diagnosed PE cases were discharged from the ED. The median hospital-specific proportion of patients who were discharged was 3.1% (interquartile range, 0.8% to 6.8%). Of those who were discharged, 3.2% returned home against medical advice.

The median OR for the primary outcome was 2.21 (95% CI, 2.05-2.37), which represented the importance of the hospital in initial disposition decisions. This OR was greater than any patient-level factor, excluding concurrent ED diagnosis of hypoxemia/respiratory failure (OR = 0.06; 95% CI, 0.04-0.07), shock (OR = 0.17; 95% CI, 0-0.48) or hypotension (OR = 0.07; 95% CI, 0-0.14).

During the 30 days after discharge, 17.9% of discharged cases returned to the ED only and 10.3% were hospitalized. Among patients initially managed as outpatients who revisited the ED, 1.3% experienced a bleeding-associated diagnosis and 1.2% required hospitalization.

The researchers also analyzed 568 hospitals with 20 or more cases of acute PE. At these hospitals, the median proportion of patients discharged from the ED was 3.1%. Proportions varied between institutions, from 0% to 13%. The median proportion of discharge ranged from 7.5% at small hospitals to 4% at medium hospitals to 3.1% at large hospitals. Rural hospitals had a higher proportion of patients discharged compared with urban hospitals (6.7% vs. 4.4%). Regionally, hospitals in the western U.S. had the highest proportion of patients managed as outpatients (7.1%), according to the results.

“Given the significant variation in discharge proportions between hospitals, these findings demonstrate a need to understand the organizational and contextual factors that contribute to this variability and to develop and test strategies to increase the outpatient management of low-risk PE in eligible patients,” the researchers wrote.