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Tratar G, Batič A, Svetina K. Home Treatment of Patients with Pulmonary Embolism: A Single Center 10-Year Experience from Ljubljana Registry. Clin Appl Thromb Hemost 2023; 29:10760296231203209. [PMID: 37807770 PMCID: PMC10563459 DOI: 10.1177/10760296231203209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 08/28/2023] [Accepted: 09/08/2023] [Indexed: 10/10/2023] Open
Abstract
Current guidelines suggest careful risk stratification using a structured clinical approach when selecting patients with pulmonary embolism (PE) for home treatment. The aim of our study was to assess whether PE patients referred to home treatment are appropriately risk-stratified according to guidelines prior to referral and what the real-life course of the disease in these patients is. We included patients with confirmed PE referred to outpatient management and treated with anticoagulants between 2010 and 2019, whose data were collected in a prospective management registry. Using simplified PE severity index and/or signs of right ventricular strain, we classified patients to either appropriate or inappropriate low-risk classes for outpatient management. We compared 30-day mortality, overall mortality, and rates of recurrent thromboembolism or major bleeding between both classes. Among 278 patients, 188 (67.6%) and 90 (32.4%) were classified as appropriate or inappropriate class, respectively. In total, 30-day mortality was low in both groups: 0% in appropriate class and 1.1% in inappropriate class. The overall mortality rate was higher in the inappropriate than in the appropriate class (12.1 vs 0.9/100 patient-years, respectively, P < .001). Rates of recurrent thromboembolism and major bleeding were similar for both classes. We conclude that in real-life, a significant proportion of inappropriate low-risk class PE patients are referred to outpatient management. However, with careful follow-up, early mortality is low, even in home-treated patients inappropriately classified as low-risk.
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Affiliation(s)
- Gregor Tratar
- Department of Vascular Diseases, University Medical Center Ljubljana, Ljubljana, Slovenia
- University of Ljubljana Faculty of Medicine, Ljubljana, Slovenia
| | - Anteja Batič
- University of Ljubljana Faculty of Medicine, Ljubljana, Slovenia
| | - Klara Svetina
- University of Ljubljana Faculty of Medicine, Ljubljana, Slovenia
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Vinson DR, Hofmann ER, Johnson EJ, Rangarajan S, Huang J, Isaacs DJ, Shan J, Wallace KL, Rauchwerger AS, Reed ME, Mark DG. Management and Outcomes of Adults Diagnosed with Acute Pulmonary Embolism in Primary Care: Community-Based Retrospective Cohort Study. J Gen Intern Med 2022; 37:3620-3629. [PMID: 35020167 PMCID: PMC9585133 DOI: 10.1007/s11606-021-07289-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The management and outcomes of patients diagnosed with acute pulmonary embolism in primary care have not been characterized. OBJECTIVE To describe 30-day outcomes stratified by initial site-of-care decisions DESIGN: Multicenter retrospective cohort study PARTICIPANTS: Adults diagnosed with acute pulmonary embolism in primary care in a large, diverse community-based US health system (2013-2019) MAIN MEASURES: The primary outcome was a composite of 30-day serious adverse events (recurrent venous thromboembolism, major bleeding, and all-cause mortality). The secondary outcome was 7-day pulmonary embolism-related hospitalization, either initial or delayed. KEY RESULTS Among 652 patient encounters (from 646 patients), median age was 64 years; 51.5% were male and 70.7% identified as non-Hispanic white. Overall, 134 cases (20.6%) were sent home from primary care and 518 cases (79.4%) were initially referred to the emergency department (ED) or hospital. Among the referred, 196 (37.8%) were discharged home from the ED without events. Eight patients (1.2%; 95% CI 0.5-2.4%) experienced a 30-day serious adverse event: 4 venous thromboemboli (0.6%), 1 major bleed (0.2%), and 3 deaths (0.5%). Seven of these patients were initially hospitalized, and 1 had been sent home from primary care. All 3 deaths occurred in patients with known metastatic cancer initially referred to the ED, hospitalized, then enrolled in hospice following discharge. Overall, 328 patients (50.3%) were hospitalized within 7 days: 322 at the time of the index diagnosis and 6 following initial outpatient management (4 clinic-only and 2 clinic-plus-ED patients). CONCLUSIONS Patients diagnosed with acute pulmonary embolism in this primary care setting uncommonly experienced 30-day adverse events, regardless of initial site-of-care decisions. Over 20% were managed comprehensively by primary care. Delayed 7-day pulmonary embolism-related hospitalization was rare among the 51% treated as outpatients. Primary care management of acute pulmonary embolism appears to be safe and could have implications for cost-effectiveness and patient care experience.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, CA, USA.
- Kaiser Permanente Division of Research, Oakland, CA, USA.
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, 1600 Eureka Road, Roseville, CA, 95661, USA.
| | - Erik R Hofmann
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | | | - Suresh Rangarajan
- The Permanente Medical Group, Oakland, CA, USA
- Department of Adult and Family Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Jie Huang
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Dayna J Isaacs
- School of Medicine, University of California, Davis, Sacramento, CA, USA
- Internal Medicine Residency Program, University of California Los Angeles, Los Angeles, CA, USA
| | - Judy Shan
- Kaiser Permanente Division of Research, Oakland, CA, USA
- University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Karen L Wallace
- The Permanente Medical Group, Oakland, CA, USA
- Department of Radiology, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | | | - Mary E Reed
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Dustin G Mark
- The Permanente Medical Group, Oakland, CA, USA
- Kaiser Permanente Division of Research, Oakland, CA, USA
- Departments of Emergency and Critical Care Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
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