Hospitalization Is Less Common in Ambulatory Patients With Acute Pulmonary Embolism Diagnosed Before Emergency Department Referral Than After Arrival.
Adult
Aged
Ambulatory Care Facilities
/ statistics & numerical data
Emergency Service, Hospital
/ statistics & numerical data
Female
Hospitalization
/ statistics & numerical data
Humans
Male
Middle Aged
Pulmonary Embolism
/ diagnosis
Referral and Consultation
/ statistics & numerical data
Retrospective Studies
Severity of Illness Index
Journal
Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
ISSN: 1553-2712
Titre abrégé: Acad Emerg Med
Pays: United States
ID NLM: 9418450
Informations de publication
Date de publication:
07 2020
07 2020
Historique:
received:
18
01
2020
revised:
28
04
2020
accepted:
19
05
2020
pubmed:
30
5
2020
medline:
5
1
2021
entrez:
30
5
2020
Statut:
ppublish
Résumé
Emergency department (ED) patients with acute pulmonary embolism (PE) may undergo diagnostic pulmonary imaging as an outpatient before referral to the ED for definitive management. This population has not been well characterized. This retrospective cohort study included ambulatory adults with acute objectively confirmed PE across 21 EDs in an integrated health care system from January 1, 2013, through April 30, 2015. We excluded patients arriving by ambulance. We compared outpatients with diagnostic pulmonary imaging in the 12 hours prior to ED arrival (the clinic-based cohort) with those receiving imaging for PE only after ED arrival. We reported adjusted odds ratio (aOR) with 95% confidence intervals (CIs) for hospitalization, adjusted for race, presyncope or syncope, proximal clot location, and PE Severity Index class. Among 2,352 eligible ED patients with acute PE, 344 (14.6%) had a clinic-based diagnosis. This cohort had lower PE Severity Index classification and were less likely to be hospitalized than their counterparts with an ED-based diagnosis: 80.8% vs. 92.0% (p < 0.0001). The inverse association with hospitalization persisted after adjusting for the above patient characteristics with aOR of 0.36 (95% CI = 0.26 to 0.50). In the study setting, ambulatory outpatients with acute PE are commonly diagnosed before ED arrival. A clinic-based diagnosis of PE identifies ED patients less likely to be hospitalized. Research is needed to identify which patients with a clinic-based PE diagnosis may not require transfer to the ED before home discharge.
Sections du résumé
BACKGROUND
Emergency department (ED) patients with acute pulmonary embolism (PE) may undergo diagnostic pulmonary imaging as an outpatient before referral to the ED for definitive management. This population has not been well characterized.
METHODS
This retrospective cohort study included ambulatory adults with acute objectively confirmed PE across 21 EDs in an integrated health care system from January 1, 2013, through April 30, 2015. We excluded patients arriving by ambulance. We compared outpatients with diagnostic pulmonary imaging in the 12 hours prior to ED arrival (the clinic-based cohort) with those receiving imaging for PE only after ED arrival. We reported adjusted odds ratio (aOR) with 95% confidence intervals (CIs) for hospitalization, adjusted for race, presyncope or syncope, proximal clot location, and PE Severity Index class.
RESULTS
Among 2,352 eligible ED patients with acute PE, 344 (14.6%) had a clinic-based diagnosis. This cohort had lower PE Severity Index classification and were less likely to be hospitalized than their counterparts with an ED-based diagnosis: 80.8% vs. 92.0% (p < 0.0001). The inverse association with hospitalization persisted after adjusting for the above patient characteristics with aOR of 0.36 (95% CI = 0.26 to 0.50).
CONCLUSION
In the study setting, ambulatory outpatients with acute PE are commonly diagnosed before ED arrival. A clinic-based diagnosis of PE identifies ED patients less likely to be hospitalized. Research is needed to identify which patients with a clinic-based PE diagnosis may not require transfer to the ED before home discharge.
Types de publication
Comparative Study
Journal Article
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
588-599Informations de copyright
© 2020 by the Society for Academic Emergency Medicine.
Références
Peacock WF, Singer AJ. Reducing the hospital burden associated with the treatment of pulmonary embolism. J Thromb Haemost 2019;17:720-36.
Howard LS, Steven B, Robin C, et al. British Thoracic Society Guideline for the initial outpatient management of pulmonary embolism (PE). Thorax 2018;73:ii1-29.
Konstantinides SV, Meyer G, Becattini C, et al. ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Respir J 2019;54:1901647.
Raja AS, Greenberg JO, Qaseem A, et al. Evaluation of patients with suspected acute pulmonary embolism: best practice advice from the clinical guidelines committee of the American College of Physicians. Ann Intern Med 2015;163:701-11.
Vinson DR, Aujesky D, Geersing GJ, Roy PM. Comprehensive outpatient management of low-risk pulmonary embolism: can primary care do this? A narrative review. Perm J 2020;24:163.
Vinson DR, Ballard DW, Huang J, et al. Outpatient management of emergency department patients with acute pulmonary embolism: variation, patient characteristics, and outcomes. Ann Emerg Med 2018;72:62-72.e63.
Vinson DR, Ballard DW, Mark DG, et al. Risk stratifying emergency department patients with acute pulmonary embolism: does the simplified Pulmonary Embolism Severity Index perform as well as the original? Thromb Res 2016;148:1-8.
Vinson DR, Mark DG, Chettipally UK, et al. Increasing safe outpatient management of emergency department patients with pulmonary embolism: a controlled pragmatic trial. Ann Intern Med 2018;169:855-65.
Vinson DR, Mark DG, Ballard DW. Outpatient management of patients with pulmonary embolism. Ann Intern Med 2019;171:228.
Gordon N, Lin T. The Kaiser Permanente Northern California adult member health survey. Perm J 2016;20:34-42.
Vinson DR, Ballard DW, Huang J, et al. Timing of discharge follow-up for acute pulmonary embolism: retrospective cohort study. West J Emerg Med 2015;16:55-61.
Vinson DR, Englehart DC, Bahl D, et al. Presyncope is associated with intensive care unit admission in ED patients with acute pulmonary embolism. West J Emerg Med 2020;21:703-13.
Bastani A, Su E, Adler DH, et al. Comparison of 30-day serious adverse clinical events for elderly patients presenting to the emergency department with near-syncope versus syncope. Ann Emerg Med 2019;73:274-80.
Barco S, Ende-Verhaar YM, Becattini C, et al. Differential impact of syncope on the prognosis of patients with acute pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 2018;39:4186-95.
Jaff MR, McMurtry MS, Archer SL, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011;123:1788-830.
Aujesky D, Roy PM, Verschuren F, et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet 2011;378:41-8.
Vinson DR, Zehtabchi S, Yealy DM. Can selected patients with newly diagnosed pulmonary embolism be safely treated without hospitalization? A systematic review. Ann Emerg Med 2012;60:651-662.e4.
Vinson DR, Drenten CE, Huang J, et al. Impact of relative contraindications to home management in emergency department patients with low-risk pulmonary embolism. Ann Am Thorac Soc 2015;12:666-73.
Smith SB, Geske JB, Kathuria P, et al. Analysis of national trends in admissions for pulmonary embolism. Chest 2016;150:35-45.
Kabrhel C, Sacco W, Liu S, Hariharan P. Outcomes considered most important by emergency physicians when determining disposition of patients with pulmonary embolism. Int J Emerg Med 2010;3:239-64.
Schulman S, Kearon C; Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost 2005;3:692-4.
Bikdeli B, Jimenez D, Hawkins M, et al. Rationale, design and methodology of the computerized registry of patients with venous thromboembolism (RIETE). Thromb Haemost 2018;118:214-24.
Pollack CV, Schreiber D, Goldhaber SZ, et al. Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry). J Am Coll Cardiol 2011;57:700-6.
Barco S, Schmidtmann I, Ageno W, et al. Early discharge and home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban: an international multicentre single-arm clinical trial. Eur Heart J 2020;41:509-18.
Bledsoe JR, Woller SC, Stevens SM, et al. Management of low-risk pulmonary embolism patients without hospitalization: the low-risk pulmonary embolism prospective management study. Chest 2018;154:249-56.
Ghazvinian R, Gottsater A, Elf JL. Efficacy and safety of outpatient treatment with direct oral anticoagulation in pulmonary embolism. J Thromb Thrombolysis 2018;45:319-24.
Walen S, Katerberg B, Boomsma MF, van den Berg JW. Safety, feasibility and patient reported outcome measures of outpatient treatment of pulmonary embolism. Thromb Res 2017;156:172-6.
Roy PM, Corsi DJ, Carrier M, et al. Net clinical benefit of hospitalization versus outpatient management of patients with acute pulmonary embolism. J Thromb Haemost 2017;15:685-94.
den Exter PL, Zondag W, Klok FA, et al. Efficacy and safety of outpatient treatment based on the hestia clinical decision rule with or without N-terminal pro-brain natriuretic peptide testing in patients with acute pulmonary embolism. A randomized clinical trial. Am J Respir Crit Care Med 2016; 194:998-1006.
Beam DM, Kahler ZP, Kline JA. Immediate discharge and home treatment with rivaroxaban of low-risk venous thromboembolism diagnosed in two u.s. emergency departments: a one-year preplanned analysis. Acad Emerg Med 2015;22:788-95.
Elf JE, Jogi J, Bajc M. Home treatment of patients with small to medium sized acute pulmonary embolism. J Thromb Thrombolysis 2015;39:166-72.
Zondag W, Mos IC, Creemers-Schild D, et al. Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb Haemost 2011;9:1500-7.
Agterof MJ, Schutgens RE, Snijder RJ, et al. Out of hospital treatment of acute pulmonary embolism in patients with a low NT-proBNP level. J Thromb Haemost 2010;8:1235-41.
Rodriguez-Cerrillo M, Alvarez-Arcaya A, Fernandez-Diaz E, Fernandez-Cruz A. A prospective study of the management of non-massive pulmonary embolism in the home. Eur J Intern Med 2009;20:598-600.
Beer JH, Burger M, Gretener S, Bernard-Bagattini S, Bounameaux H. Outpatient treatment of pulmonary embolism is feasible and safe in a substantial proportion of patients. J Thromb Haemost 2003;1:186-7.
Sax DR, Vinson DR, Yamin CK, et al. Tele-triage outcomes for patients with chest pain: comparing physicians and registered nurses. Health Aff (Millwood) 2018;37:1997-2004.
Barco S, Konstantinides SV. Optimizing the personalized, risk-adjusted management of pulmonary embolism: an integrated clinical trial programme. Hamostaseologie 2019;39:117-27.
Tritschler T, Kraaijpoel N, Le Gal G, Wells PS. Venous thromboembolism: advances in diagnosis and treatment. JAMA 2018;320:1583-94.
Isaacs DJ, Johnson EJ, Vinson DR. Comprehensive management of acute pulmonary embolism in the primary clinic setting without transfer of care: a case report. Am J Respir Crit Care Med 2020;201:A7257.
Greene SJ, Mentz RJ, Felker GM. Outpatient worsening heart failure as a target for therapy: a review. JAMA Cardiol 2018;3:252-9.
Fonarow GC, Liang L, Thomas L, et al. Assessment of home-time after acute ischemic stroke in medicare beneficiaries. Stroke 2016;47:836-42.
Vinson DR, Berman DA. Outpatient treatment of deep venous thrombosis: a clinical care pathway managed by the emergency department. Ann Emerg Med 2001;37:251-8.
Vinson DR, Berman DR, Patel PB, Hickey DO. Outpatient management of deep venous thrombosis: 2 models of integrated care. Am J Manag Care 2006;12:405-10.
Othieno R, Okpo E, Forster R. Home versus in-patient treatment for deep vein thrombosis. Cochrane Database Syst Rev 2018;1:CD003076.