Management of high-risk pulmonary embolism in an “unstable medical environment”: Not only a matter of hemodynamic

Social determinants of health in pulmonary embolism management and outcome in hospitals: Insights from the United States nationwide inpatient sample

Background

The role of social determinants in the treatment and course of acute pulmonary embolism (PE) is understudied.

Objective

To investigate the association between social determinants of health with in-hospital management and early clinical outcomes following acute PE.

Methods

We identified hospitalizations of adults with acute PE discharge diagnosis from the nationwide inpatient sample (2016-2018). Multivariable regression was used to investigate the association between race/ethnicity, type of expected primary payer, and income with the use of advanced PE therapies (thrombolysis, catheter-directed treatment, surgical embolectomy, extracorporeal membrane oxygenation), length of stay, hospitalization charges, and in-hospital death.

Results

A total of 1,124,204 hospitalizations with a PE diagnosis were estimated from the 2016-2018 nationwide inpatient sample, corresponding to a hospitalization rate of 14.9/10,000 adult persons-year. The use of advanced therapies was lower in Black and Asian/Pacific Islander (vs. White patients: adjusted odds ratio [OR_adjusted], 0.87; 95% confidence interval [CI], 0.81-0.92 and OR_adjusted 0.76; 95% CI, 0.59-0.98) and in Medicare- or Medicaid-insured (vs. privately-insured; OR_adjusted, 0.73; 95% CI, 0.69-0.77 and OR_adjusted, 0.68; 95% CI, 0.63-0.74), although they had the greatest length of stay and hospitalization charges. In-hospital mortality was higher in the lowest income quartile (vs. highest quartile; OR_adjusted, 1.09; 95% CI, 1.02-1.17). Among high-risk PE, patients of other than the White race had the highest in-hospital mortality.

Conclusion

We observed inequalities in advanced therapies used for acute PE and higher in-hospital mortality in races other than White. Low socioeconomic status was also associated with lesser use of advanced treatment modalities and greater in-hospital mortality. Future studies should further explore and consider the long-term impact of social inequities in PE management.

Interhospital Transfer of Patients With Acute Pulmonary Embolism (PE): Challenges and Opportunities

Acute pulmonary embolism (PE) is associated with significant morbidity and mortality. The management paradigm for acute PE has evolved in recent years with wider availability of advanced treatment modalities ranging from catheter-directed reperfusion therapies to mechanical circulatory support. This evolution has coincided with the development and implementation of institutional pulmonary embolism response teams (PERT) nationwide and internationally. Because most institutions are not equipped or staffed for advanced PE care, patients often require transfer to centers with more comprehensive resources, including PERT expertise. One of the unmet needs in current PE care is an organized approach to the process of interhospital transfer (IHT) of critically ill PE patients. In this review, we discuss medical optimization and support of patients before and during transfer, transfer checklists, defined roles of emergency medical services, and the roles and responsibilities of referring and receiving centers involved in the IHT of acute PE patients.