1
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Watson NW, Carroll BJ, Krawisz A, Schmaier A, Secemsky EA. Trends in Discharge Rates for Acute Pulmonary Embolism in U.S. Emergency Departments. Ann Intern Med 2024; 177:134-143. [PMID: 38285986 DOI: 10.7326/m23-2442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Outpatient management of select patients with low-risk acute pulmonary embolism (PE) has been proven to be safe and effective, yet recent evidence suggests that patients are still managed with hospitalization. Few studies have assessed contemporary real-world trends in discharge rates from U.S. emergency departments (EDs) for acute PE. OBJECTIVE To evaluate whether the proportion of discharges from EDs for acute PE changed between 2012 and 2020 and which baseline characteristics are associated with ED discharge. DESIGN Serial cross-sectional analysis. SETTING U.S. EDs participating in the National Hospital Ambulatory Medical Care Survey. PATIENTS Patients with ED visits for acute PE between 2012 and 2020. MEASUREMENTS National trends in the proportion of discharges for acute PE and factors associated with ED discharge. RESULTS Between 2012 and 2020, there were approximately 1 635 300 visits for acute PE. Overall, ED discharge rates remained constant over time, with rates of 38.2% (95% CI, 17.9% to 64.0%) between 2012 and 2014 and 33.4% (CI, 21.0% to 49.0%) between 2018 and 2020 (adjusted risk ratio, 1.01 per year [CI, 0.89 to 1.14]). No baseline characteristics, including established risk stratification scores, were predictive of an increased likelihood of ED discharge; however, patients at teaching hospitals and those with private insurance were more likely to receive oral anticoagulation at discharge. Only 35.9% (CI, 23.9% to 50.0%) of patients who were considered low-risk according to their Pulmonary Embolism Severity Index (PESI) class, 33.1% (CI, 21.6% to 47.0%) according to simplified PESI score, and 34.8% (CI, 23.3% to 48.0%) according to hemodynamic stability were discharged from the ED setting. LIMITATIONS Cross-sectional survey design and inability to adjudicate diagnoses. CONCLUSION In a representative nationwide sample, rates of discharge from the ED for acute PE appear to have remained constant between 2012 and 2020. Only one third of low-risk patients were discharged for outpatient management, and rates seem to have stabilized. Outpatient management of low-risk acute PE may still be largely underutilized in the United States. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Nathan W Watson
- Harvard Medical School, and Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (N.W.W.)
| | - Brett J Carroll
- Harvard Medical School; Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center; and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (B.J.C., A.K., E.A.S.)
| | - Anna Krawisz
- Harvard Medical School; Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center; and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (B.J.C., A.K., E.A.S.)
| | - Alec Schmaier
- Harvard Medical School, and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (A.S.)
| | - Eric A Secemsky
- Harvard Medical School; Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center; and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (B.J.C., A.K., E.A.S.)
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2
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Nopp S, Bohnert J, Mayr T, Steiner D, Prosch H, Lang I, Behringer W, Janata-Schwatczek K, Ay C. Early discharge and home treatment of patients with acute pulmonary embolism in the tertiary care setting. Intern Emerg Med 2024; 19:191-199. [PMID: 37670173 PMCID: PMC10827840 DOI: 10.1007/s11739-023-03415-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/26/2023] [Indexed: 09/07/2023]
Abstract
Acute pulmonary embolism (PE) is a potentially life-threatening disease. Current guidelines suggest risk-adapted management. Hospitalization is required for intermediate- and high-risk patients. Early discharge and home treatment are considered safe in the majority of low-risk patients. In this study, we describe characteristics, discharge, and outcome of outpatients diagnosed with acute PE at a tertiary care center. All outpatients undergoing computed tomography pulmonary angiography or ventilation/perfusion lung scan between 01.01.2016 and 31.12.2019 at the University Hospital Vienna, Austria, were screened for a PE diagnosis. Electronic patient charts were used to extract characteristics, clinical course, and outcomes. Within the 4-year period, 709 outpatients (median age: 62 years, 50% women) were diagnosed with PE. Thirty-three (5%) patients were classified as high-risk, 159 (22%) as intermediate-high, 332 (47%) as intermediate-low, and 185 (26%) as low-risk PE according to the European Society of Cardiology risk stratification. In total, 156 (22%) patients (47% with low-risk and 20% with intermediate-low-risk PE) were discharged as outpatients and received home treatment. Rates for home treatment increased 2.4-fold during the study period. Thirty-day mortality in the entire population was 4.9%. All low-risk patients and all but one patient with home treatment survived the first 30 days. Home treatment significantly increased over time and seems to be safe in routine clinical practice. Notably, one in five intermediate-low-risk patients was discharged immediately, suggesting that a subpopulation of intermediate-low-risk patients may also be eligible for home treatment.
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Affiliation(s)
- Stephan Nopp
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Julia Bohnert
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas Mayr
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Daniel Steiner
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Helmut Prosch
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Irene Lang
- Clinical Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Wilhelm Behringer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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3
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Hsu SH, Ko CH, Chou EH, Herrala J, Lu TC, Wang CH, Chang WT, Huang CH, Tsai CL. Pulmonary embolism in United States emergency departments, 2010-2018. Sci Rep 2023; 13:9070. [PMID: 37277498 DOI: 10.1038/s41598-023-36123-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 05/30/2023] [Indexed: 06/07/2023] Open
Abstract
Little is known about pulmonary embolism (PE) in the United States emergency department (ED). This study aimed to describe the disease burden (visit rate and hospitalization) of PE in the ED and to investigate factors associated with its burden. Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2010 to 2018. Adult ED visits with PE were identified using the International Classification of Diseases codes. Analyses used descriptive statistics and multivariable logistic regression accounting for the NHAMCS's complex survey design. Over the 9-year study period, there were an estimated 1,500,000 ED visits for PE, and the proportion of PE visits in the entire ED population increased from 0.1% in 2010-2012 to 0.2% in 2017-2018 (P for trend = 0.002). The mean age was 57 years, and 40% were men. Older age, obesity, history of cancer, and history of venous thromboembolism were independently associated with a higher proportion of PE, whereas the Midwest region was associated with a lower proportion of PE. The utilization of chest computed tomography (CT) scan appeared stable, which was performed in approximately 43% of the visits. About 66% of PE visits were hospitalized, and the trend remained stable. Male sex, arrival during the morning shift, and higher triage levels were independently associated with a higher hospitalization rate, whereas the fall and winter months were independently associated with a lower hospitalization rate. Approximately 8.8% of PE patients were discharged with direct-acting oral anticoagulants. The ED visits for PE continued to increase despite the stable trend in CT use, suggesting a combination of prevalent and incident PE cases in the ED. Hospitalization for PE remains common practice. Some patients are disproportionately affected by PE, and certain patient and hospital factors are associated with hospitalization decisions.
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Affiliation(s)
- Shu-Hsien Hsu
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd, Taipei, 100, Taiwan
| | - Chia-Hsin Ko
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd, Taipei, 100, Taiwan
| | - Eric H Chou
- Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, TX, USA
| | - Jeffrey Herrala
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA, USA
| | - Tsung-Chien Lu
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd, Taipei, 100, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd, Taipei, 100, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd, Taipei, 100, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd, Taipei, 100, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chu-Lin Tsai
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd, Taipei, 100, Taiwan.
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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4
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Vinson DR, Casey SD, Vuong PL, Huang J, Ballard DW, Reed ME. Sustainability of a Clinical Decision Support Intervention for Outpatient Care for Emergency Department Patients With Acute Pulmonary Embolism. JAMA Netw Open 2022; 5:e2212340. [PMID: 35576004 PMCID: PMC9112064 DOI: 10.1001/jamanetworkopen.2022.12340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Physicians commonly hospitalize patients presenting to the emergency department (ED) with acute pulmonary embolism (PE), despite eligibility for safe outpatient management. Risk stratification using electronic health record-embedded clinical decision support systems can aid physician site-of-care decision-making and increase safe outpatient management. The long-term sustainability of early improvements after the cessation of trial-based, champion-led promotion is uncertain. OBJECTIVE To evaluate the sustainability of recommended site-of-care decision-making support 4 years after initial physician champion-led interventions to increase outpatient management for patients with acute PE. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted in 21 US community hospitals in an integrated health system. Participants included adult patients presenting to the ED with acute PE. Study sites had participated in an original decision-support intervention trial 4 years prior to the current study period: 10 sites were intervention sites, 11 sites were controls. In that trial, decision support with champion promotion resulted in significantly higher outpatient management at intervention sites compared with controls. After trial completion, all study sites were given continued access to a modified decision-support tool without further champion-led outreach. Data were analyzed from January 2019 to February 2020. EXPOSURES ED treatment with a modified clinical decision support tool. MAIN OUTCOMES AND MEASURES The main outcome was frequency of outpatient management, defined as discharge home directly from the ED, stratified by the PE Severity Index. The safety measure of outpatient care was 7-day PE-related hospitalization. RESULTS This study included 1039 patients, including 533 (51.3%) women, with a median (IQR) age of 65 (52-74) years. Nearly half (474 patients [45.6%]) were rated lower risk on the PE Severity Index. Overall, 278 patients (26.8%) were treated as outpatients, with only four 7-day PE-related hospitalizations (1.4%; 95% CI, 0.4%-3.6%). The practice gap in outpatient management created by the earlier trial persisted in the outpatient management for patients with lower risk: 109 of 236 patients (46.2%) at former intervention sites vs 81 of 238 patients (34.0%) at former control sites (difference, 12.2; [95% CI, 3.4-20.9] percentage points; P = .007), with wide interfacility variation (range, 7.1%-47.1%). CONCLUSIONS AND RELEVANCE In this cohort study, a champion-led, decision-support intervention to increase outpatient management for patients presenting to the ED with acute pulmonary embolism was associated with sustained higher rates of outpatient management 4 years later. The application of our findings to improving sustainability of practice change for other clinical conditions warrants further study.
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Affiliation(s)
- David R. Vinson
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Division of Research, Oakland, California
- The Kaiser Permanente CREST Network
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California
| | - Scott D. Casey
- The Kaiser Permanente CREST Network
- Department of Emergency Medicine, UC Davis Health, University of California, Davis, Sacramento
| | - Peter L. Vuong
- Department of Emergency Medicine, Kaiser Permanente Modesto Medical Center, Modesto, California
| | - Jie Huang
- Kaiser Permanente Division of Research, Oakland, California
- The Kaiser Permanente CREST Network
| | - Dustin W. Ballard
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Division of Research, Oakland, California
- The Kaiser Permanente CREST Network
- Department of Emergency Medicine, Kaiser Permanente San Rafael Medical Center, San Rafael, California
| | - Mary E. Reed
- Kaiser Permanente Division of Research, Oakland, California
- The Kaiser Permanente CREST Network
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5
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Lutsey PL, Walker RF, MacLehose RF, Norby FL, Evensen LH, Alonso A, Zakai NA. Inpatient Versus Outpatient Acute Venous Thromboembolism Management: Trends and Postacute Healthcare Utilization From 2011 to 2018. J Am Heart Assoc 2021; 10:e020428. [PMID: 34622678 PMCID: PMC8751864 DOI: 10.1161/jaha.120.020428] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Acute outpatient management of venous thromboembolism (VTE), which includes pulmonary embolism (PE) and deep vein thrombosis (DVT), is perceived to be as safe as inpatient management in some settings. How widely this strategy is used is not well documented. Methods and Results Using MarketScan administrative claims databases for years 2011 through 2018, we identified patients with International Classification of Diseases (ICD) codes indicating incident VTE and trends in the use of acute outpatient management. We also evaluated healthcare utilization and hospitalized bleeding events in the 6 months following the incident VTE event. A total of 200 346 patients with VTE were included, of whom 50% had evidence of PE. Acute outpatient management was used for 18% of those with PE and 57% of those with DVT only, and for both DVT and PE its use increased from 2011 to 2018. Outpatient management was less prevalent among patients with cancer, higher Charlson comorbidity index scores, and whose primary treatment was warfarin as compared with a direct oral anticoagulant. Healthcare utilization in the 6 months following the incident VTE event was generally lower among patients managed acutely as outpatients, regardless of initial presentation. Acute outpatient management was associated with lower hazard ratios of incident bleeding risk for both patients who initially presented with PE (0.71 [95% CI, 0.61, 0.82]) and DVT only (0.59 [95% CI, 0.54, 0.64]). Conclusions Outpatient management of VTE is increasing. In the present analysis, it was associated with lower subsequent healthcare utilization and fewer bleeding events. However, this may be because healthier patients were managed on an outpatient basis.
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Affiliation(s)
- Pamela L Lutsey
- Division of Epidemiology and Community Health School of Public Health University of Minnesota Minneapolis MN
| | - Rob F Walker
- Division of Epidemiology and Community Health School of Public Health University of Minnesota Minneapolis MN
| | - Richard F MacLehose
- Division of Epidemiology and Community Health School of Public Health University of Minnesota Minneapolis MN
| | - Faye L Norby
- Division of Epidemiology and Community Health School of Public Health University of Minnesota Minneapolis MN
| | - Line H Evensen
- K.G. Jebsen - Thrombosis Research and Expertise Center (TREC) Department of Clinical Medicine UiT The Arctic University of Norway Tromsø Norway
| | - Alvaro Alonso
- Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA
| | - Neil A Zakai
- Division of Hematology/Oncology Department of Medicine and Department of Pathology and Laboratory Medicine Larner College of Medicine at the University of Vermont Burlington VT
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6
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Roy PM, Penaloza A, Hugli O, Klok FA, Arnoux A, Elias A, Couturaud F, Joly LM, Lopez R, Faber LM, Daoud-Elias M, Planquette B, Bokobza J, Viglino D, Schmidt J, Juchet H, Mahe I, Mulder F, Bartiaux M, Cren R, Moumneh T, Quere I, Falvo N, Montaclair K, Douillet D, Steinier C, Hendriks SV, Benhamou Y, Szwebel TA, Pernod G, Dublanchet N, Lapebie FX, Javaud N, Ghuysen A, Sebbane M, Chatellier G, Meyer G, Jimenez D, Huisman MV, Sanchez O. Triaging acute pulmonary embolism for home treatment by Hestia or simplified PESI criteria: the HOME-PE randomized trial. Eur Heart J 2021; 42:3146-3157. [PMID: 34363386 PMCID: PMC8408662 DOI: 10.1093/eurheartj/ehab373] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/02/2021] [Accepted: 06/02/2021] [Indexed: 12/13/2022] Open
Abstract
AIMS The aim of this study is to compare the Hestia rule vs. the simplified Pulmonary Embolism Severity Index (sPESI) for triaging patients with acute pulmonary embolism (PE) for home treatment. METHODS AND RESULTS Normotensive patients with PE of 26 hospitals from France, Belgium, the Netherlands, and Switzerland were randomized to either triaging with Hestia or sPESI. They were designated for home treatment if the triaging tool was negative and if the physician-in-charge, taking into account the patient's opinion, did not consider that hospitalization was required. The main outcomes were the 30-day composite of recurrent venous thrombo-embolism, major bleeding or all-cause death (non-inferiority analysis with 2.5% absolute risk difference as margin), and the rate of patients discharged home within 24 h after randomization (NCT02811237). From January 2017 through July 2019, 1975 patients were included. In the per-protocol population, the primary outcome occurred in 3.82% (34/891) in the Hestia arm and 3.57% (32/896) in the sPESI arm (P = 0.004 for non-inferiority). In the intention-to-treat population, 38.4% of the Hestia patients (378/984) were treated at home vs. 36.6% (361/986) of the sPESI patients (P = 0.41 for superiority), with a 30-day composite outcome rate of 1.33% (5/375) and 1.11% (4/359), respectively. No recurrent or fatal PE occurred in either home treatment arm. CONCLUSIONS For triaging PE patients, the strategy based on the Hestia rule and the strategy based on sPESI had similar safety and effectiveness. With either tool complemented by the overruling of the physician-in-charge, more than a third of patients were treated at home with a low incidence of complications.
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Affiliation(s)
- Pierre-Marie Roy
- Emergency Department, CHU Angers, 4 rue Larrey, Angers, France, F-49000.,Univ. Angers, INSERM, CNRS, MITOVASC, Equipe CARME, SFR ICAT, Angers, France.,F-CRIN, INNOVTE, Saint-Etienne, France
| | - Andrea Penaloza
- F-CRIN, INNOVTE, Saint-Etienne, France.,Emergency Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,UCLouvain, Brussels, Belgium
| | - Olivier Hugli
- Emergency Department, University Hospital of Lausanne, Lausanne, Switzerland
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, DTN, Leiden University Medical Center, Leiden, the Netherlands
| | - Armelle Arnoux
- Computing, Statistics and Public Health & CIC1418, Hôpital Européen Georges Pompidou, APHP, Paris, France.,University of Paris, Paris, France
| | - Antoine Elias
- F-CRIN, INNOVTE, Saint-Etienne, France.,Department of Cardiology and Vascular Medicine, CH Sainte Musse - Toulon, Toulon, France
| | - Francis Couturaud
- F-CRIN, INNOVTE, Saint-Etienne, France.,Department of Internal Medicine and Chest Disease, CHU Brest, Brest, France.,EA3878-GETBO, CIC-INSERM1412, Univ-Brest, Brest, France
| | - Luc-Marie Joly
- Emergency Department, CHU Rouen, Normandy Univ, UNIROUEN, Rouen, France
| | - Raphaëlle Lopez
- Emergency Department, Sart Tilman University Hospital, Liège, Belgium
| | - Laura M Faber
- Department of Internal Medicine, Rode Kruis Hospital, Beverwijk, DTN, the Netherlands
| | - Marie Daoud-Elias
- Department of Cardiology and Vascular Medicine, CH Sainte Musse - Toulon, Toulon, France
| | - Benjamin Planquette
- F-CRIN, INNOVTE, Saint-Etienne, France.,Department of Pneumology and Intensive Care, Hôpital Europeen Georges Pompidou, APHP, Paris, France.,University of Paris, INSERM UMR-S 1140 Innovaties Therapies in Haemostasis, Paris, France
| | - Jérôme Bokobza
- Emergency Department, Hôpital Cochin, APHP, Paris, France
| | - Damien Viglino
- Emergency Department, CHU Grenoble Alpes, Grenoble, France.,HP2 INSERM U 1042 Laboratory, University of Grenoble-Alpes, Grenoble, France
| | - Jeannot Schmidt
- F-CRIN, INNOVTE, Saint-Etienne, France.,Emergency Department, CHU Clermont-Ferrand, University of Clermont Auvergne, Clermont-Ferrand, France
| | - Henry Juchet
- Emergency Department, CHU Toulouse, Toulouse, France
| | - Isabelle Mahe
- F-CRIN, INNOVTE, Saint-Etienne, France.,Internal Medicine Department, HU Paris Nord, Louis Mourier Hospital, APHP, Colombes, France.,Inserm UMR_S1140 Hemostasis Therapeutical Innovations, University of Paris, Colombes, France
| | - Frits Mulder
- Department of Internal Medicine, Tergooi Hospital, Hilversum, the Netherlands
| | - Magali Bartiaux
- Emergency Department, Saint-Pierre Hospital, Brussels, Belgium
| | - Rosen Cren
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Thomas Moumneh
- Emergency Department, CHU Angers, 4 rue Larrey, Angers, France, F-49000.,Univ. Angers, INSERM, CNRS, MITOVASC, Equipe CARME, SFR ICAT, Angers, France.,F-CRIN, INNOVTE, Saint-Etienne, France
| | - Isabelle Quere
- F-CRIN, INNOVTE, Saint-Etienne, France.,Vascular Medicine Department, CHU Montpellier, EA2992, CIC 1001, University of Montpellier, Montpellier, France
| | - Nicolas Falvo
- Vascular Medicine Department, CHU Dijon, Dijon, France
| | - Karine Montaclair
- F-CRIN, INNOVTE, Saint-Etienne, France.,Department of Cardiology, CH Le Mans, Le Mans, France
| | - Delphine Douillet
- Emergency Department, CHU Angers, 4 rue Larrey, Angers, France, F-49000.,Univ. Angers, INSERM, CNRS, MITOVASC, Equipe CARME, SFR ICAT, Angers, France.,F-CRIN, INNOVTE, Saint-Etienne, France
| | - Charlotte Steinier
- Emergency Department, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Stephan V Hendriks
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Ygal Benhamou
- Department of Internal Medicine, CHU Charles Nicolle, Rouen, France.,Normandie University, UNIROUEN, INSERM U1096 EnVI, Rouen, France
| | - Tali-Anne Szwebel
- Department of Internal Medicine, Cochin Hospital, APHP, Paris, France
| | - Gilles Pernod
- F-CRIN, INNOVTE, Saint-Etienne, France.,Department of Vascular Medicine, CHU Grenoble Alpes, Grenoble, France.,University Grenoble Alpes, CNRS / TIMC-IMAG UMR 5525 / Themas, Grenoble, France
| | - Nicolas Dublanchet
- Emergency Department, CHU Clermont-Ferrand, University of Clermont Auvergne, Clermont-Ferrand, France
| | | | - Nicolas Javaud
- Emergency Department, CréAk, Louis Mourier Hospital, APHP, University of Paris, Colombes, France
| | - Alexandre Ghuysen
- Emergency Department, Sart Tilman University Hospital, Liège, Belgium
| | - Mustapha Sebbane
- F-CRIN, INNOVTE, Saint-Etienne, France.,Emergency Department, Lapeyronie Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Gilles Chatellier
- Computing, Statistics and Public Health & CIC1418, Hôpital Européen Georges Pompidou, APHP, Paris, France.,University of Paris, Paris, France
| | - Guy Meyer
- Department of Pneumology and Intensive Care, Hôpital Europeen Georges Pompidou, APHP, Paris, France.,University of Paris, INSERM UMR-S 1140 Innovaties Therapies in Haemostasis, Paris, France
| | - David Jimenez
- Respiratory Department and Medicine Department, Ramon y Cajal Hospital IRYCIS Alcal de Henares University, Madrid, Spain
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Olivier Sanchez
- F-CRIN, INNOVTE, Saint-Etienne, France.,University of Paris, INSERM UMR-S 1140 Innovaties Therapies in Haemostasis, Paris, France.,Pneumology Department and Intensive Care, Hôpital Européen Georges Pompidou, APHP, 20-40 rue Leblanc, Paris, France, F-75908
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7
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Kwok CS, Wong CW, Ravindran R, Michos ED, Khan SU, Abudayyeh I, Mohamed M, Parwani P, Thamman R, Elgendy IY, Van Spall HGC, Mamas MA. Location of death among patients presenting with cardiovascular disease to the emergency department in the United states. Int J Clin Pract 2021; 75:e13798. [PMID: 33474781 DOI: 10.1111/ijcp.13798] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/23/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In-hospital deaths are an important outcome and little is known about deaths in the emergency department (ED). Among patients who died of cardiovascular diseases (CVD), we assessed causes of death, temporal trends and the relative distribution of deaths in the ED versus hospital. METHODS Using the United States Nationwide Emergency Department Sample, we conducted a retrospective study of patients presenting to the ED with a primary diagnosis of CVD between 2006 and 2014. We used descriptive statistics to describe causes of deaths, temporal trends and location of death. RESULTS During the study period, there were 27 144 508 visits to the ED with CVD diagnoses (~2% of all ED visits,). The most common CVD diagnoses were heart failure (n = 8 571 598), acute myocardial infarction (n = 4 827 518) and atrial fibrillation/flutter (n = 4 713 241). There were a total of 2.2 million deaths caused by the CVD, with the majority (57.6%) occurring in the ED. Cardiac arrest was the most common cause of in-hospital death (n = 1 225 095, 55.3%), followed by acute myocardial infarction (n = 279 310, 12.6%), heart failure (n = 217 367, 9.8%), intracranial hemorrhage (n = 168 009, 7.6%) and ischemic stroke (n = 151 615, 6.8%). The proportion of deaths in the ED for these causes were 91.9% cardiac arrest (n = 1 173 471), 3.6% acute myocardial infarction (n = 46 909), 1.0% heart failure (n = 12 599) and 1.1% intracranial hemorrhage (n = 13 579). There was a decrease in death for most CVDs over time. CONCLUSIONS Inpatient CVD admissions and their associated death may not be a robust measure of the national burden of CVD since ED death-which are common for some conditions-are not captured.
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Affiliation(s)
- Chun Shing Kwok
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Chun Wai Wong
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Roshini Ravindran
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Erin D Michos
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Safi U Khan
- Department of Medicine, West Virginia University, Morgantown, WV, USA
| | - Islam Abudayyeh
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Mohamed Mohamed
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Purvi Parwani
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Ritu Thamman
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Islam Y Elgendy
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Harriette G C Van Spall
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
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8
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García Sanz M, Doval Oubiña L, González Barcala FJ. Hospitalización a domicilio en neumología: gestión eficiente con elevada satisfacción de los pacientes. Arch Bronconeumol 2020; 56:479-480. [DOI: 10.1016/j.arbres.2019.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/03/2019] [Accepted: 10/17/2019] [Indexed: 10/25/2022]
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9
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Outpatient management of incidental pulmonary embolism in cancer patient. Clin Transl Oncol 2019; 22:612-615. [DOI: 10.1007/s12094-019-02153-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 06/05/2019] [Indexed: 10/26/2022]
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10
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Peacock WF, Singer AJ. Reducing the hospital burden associated with the treatment of pulmonary embolism. J Thromb Haemost 2019; 17:720-736. [PMID: 30851227 PMCID: PMC6849869 DOI: 10.1111/jth.14423] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Indexed: 12/14/2022]
Abstract
Pulmonary embolism (PE) is the most feared clinical presentation of venous thromboembolism (VTE). Patients with PE have traditionally been treated in hospital; however, many are at low risk of adverse outcomes and current guidelines suggest outpatient treatment as an option. Outpatient treatment of PE offers several advantages, including reduced risk of hospital-acquired conditions and potential cost savings. Despite this, patients with low-risk PE are still frequently hospitalized for treatment. This narrative review summarizes current guideline recommendations for the identification of patients with low-risk PE who are potentially suitable for outpatient treatment, using prognostic assessment tools (e.g. the Pulmonary Embolism Severity Index [PESI] and simplified PESI) and clinical exclusion criteria (e.g. Hestia criteria) alone or in combination with additional cardiac assessments. Treatment options are discussed along with recommendations for the follow-up of patients managed in the non-hospital environment. The available data on outpatient treatment of PE are summarized, including details on patient selection, anticoagulant choice, and short-term outcomes in each study. Accumulating evidence suggests that outcomes in patients with low-risk PE treated as outpatients are at least as good as, if not better than, those of patients treated in the hospital. With mounting pressures on health care systems worldwide, increasing the proportion of patients with PE treated as outpatients has the potential to reduce health care burdens associated with VTE.
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Affiliation(s)
- W. Frank Peacock
- Department of Emergency MedicineBaylor College of MedicineHoustonTXUSA
| | - Adam J. Singer
- Department of Emergency MedicineStony Brook School of MedicineStony BrookNYUSA
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11
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Stein PD, Hughes MJ. Mounting Evidence for Safe Home Treatment of Selected Patients With Acute Pulmonary Embolism. Ann Intern Med 2018; 169:881-882. [PMID: 30422280 DOI: 10.7326/m18-2869] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Paul D Stein
- Michigan State University College of Osteopathic Medicine, East Lansing, Michigan (P.D.S., M.J.H.)
| | - Mary J Hughes
- Michigan State University College of Osteopathic Medicine, East Lansing, Michigan (P.D.S., M.J.H.)
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12
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Vinson DR, Mark DG, Chettipally UK, Huang J, Rauchwerger AS, Reed ME, Lin JS, Kene MV, Wang DH, Sax DR, Pleshakov TS, McLachlan ID, Yamin CK, Elms AR, Iskin HR, Vemula R, Yealy DM, Ballard DW. Increasing Safe Outpatient Management of Emergency Department Patients With Pulmonary Embolism: A Controlled Pragmatic Trial. Ann Intern Med 2018; 169:855-865. [PMID: 30422263 DOI: 10.7326/m18-1206] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many low-risk patients with acute pulmonary embolism (PE) in the emergency department (ED) are eligible for outpatient care but are hospitalized nonetheless. One impediment to home discharge is the difficulty of identifying which patients can safely forgo hospitalization. OBJECTIVE To evaluate the effect of an integrated electronic clinical decision support system (CDSS) to facilitate risk stratification and decision making at the site of care for patients with acute PE. DESIGN Controlled pragmatic trial. (ClinicalTrials.gov: NCT03601676). SETTING All 21 community EDs of an integrated health care delivery system (Kaiser Permanente Northern California). PATIENTS Adult ED patients with acute PE. INTERVENTION Ten intervention sites selected by convenience received a multidimensional technology and education intervention at month 9 of a 16-month study period (January 2014 to April 2015); the remaining 11 sites served as concurrent controls. MEASUREMENTS The primary outcome was discharge to home from either the ED or a short-term (<24-hour) outpatient observation unit based in the ED. Adverse outcomes included return visits for PE-related symptoms within 5 days and recurrent venous thromboembolism, major hemorrhage, and all-cause mortality within 30 days. A difference-in-differences approach was used to compare pre-post changes at intervention versus control sites, with adjustment for demographic and clinical characteristics. RESULTS Among 881 eligible patients diagnosed with PE at intervention sites and 822 at control sites, adjusted home discharge increased at intervention sites (17.4% pre- to 28.0% postintervention) without a concurrent increase at control sites (15.1% pre- and 14.5% postintervention). The difference-in-differences comparison was 11.3 percentage points (95% CI, 3.0 to 19.5 percentage points; P = 0.007). No increases were seen in 5-day return visits related to PE or in 30-day major adverse outcomes associated with CDSS implementation. LIMITATION Lack of random allocation. CONCLUSION Implementation and structured promotion of a CDSS to aid physicians in site-of-care decision making for ED patients with acute PE safely increased outpatient management. PRIMARY FUNDING SOURCE Garfield Memorial National Research Fund and The Permanente Medical Group Delivery Science and Physician Researcher Programs.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group and Kaiser Permanente Northern California, Oakland, and Kaiser Permanente Sacramento Medical Center, Sacramento, California (D.R.V.)
| | - Dustin G Mark
- The Permanente Medical Group, Kaiser Permanente Northern California, and Kaiser Permanente Oakland Medical Center, Oakland, California (D.G.M.)
| | - Uli K Chettipally
- The Permanente Medical Group, Oakland, and Kaiser Permanente South San Francisco Medical Center, South San Francisco, California (U.K.C.)
| | - Jie Huang
- Kaiser Permanente Northern California, Oakland, California (J.H., A.S.R., M.E.R.)
| | - Adina S Rauchwerger
- Kaiser Permanente Northern California, Oakland, California (J.H., A.S.R., M.E.R.)
| | - Mary E Reed
- Kaiser Permanente Northern California, Oakland, California (J.H., A.S.R., M.E.R.)
| | - James S Lin
- The Permanente Medical Group, Oakland, and Kaiser Permanente Santa Clara Medical Center, Sacramento, California (J.S.L.)
| | - Mamata V Kene
- The Permanente Medical Group, Oakland, and Kaiser Permanente San Leandro Medical Center, Sacramento, California (M.V.K.)
| | | | - Dana R Sax
- The Permanente Medical Group and Kaiser Permanente Oakland Medical Center, Oakland, California (D.R.S., C.K.Y.)
| | - Tamara S Pleshakov
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California (T.S.P.)
| | - Ian D McLachlan
- The Permanente Medical Group, Oakland, and Kaiser Permanente San Francisco Medical Center, San Francisco, California (I.D.M.)
| | - Cyrus K Yamin
- The Permanente Medical Group and Kaiser Permanente Oakland Medical Center, Oakland, California (D.R.S., C.K.Y.)
| | - Andrew R Elms
- The Permanente Medical Group, Oakland, and Kaiser Permanente South Sacramento Medical Center, Sacramento, California (A.R.E.)
| | - Hilary R Iskin
- University of Michigan Medical School, Ann Arbor, Michigan (H.R.I.)
| | - Ridhima Vemula
- University of Cincinnati College of Medicine, Cincinnati, Ohio (R.V.)
| | - Donald M Yealy
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (D.M.Y.)
| | - Dustin W Ballard
- The Permanente Medical Group and Kaiser Permanente Northern California, Oakland, and Kaiser Permanente San Rafael Medical Center, San Rafael, California (D.W.B.)
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13
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Kabrhel C, Rosovsky R, Baugh C, Parry BA, Deadmon E, Kreger C, Giordano N. The creation and implementation of an outpatient pulmonary embolism treatment protocol. Hosp Pract (1995) 2017; 45:123-129. [PMID: 28402686 DOI: 10.1080/21548331.2017.1318651] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The ability to rapidly and accurately risk-stratify patients with venous thromboembolism (VTE), and the availability of direct acting oral anticoagulants have reduced the need for intravenous anticoagulation for patients with deep vein thrombosis (DVT) and pulmonary embolism (PE). Emergency physicians are generally reluctant to discharge patients with VTE without defined and reliable follow up in place, and VTE patients treated with anticoagulants can be at risk for complications related to recurrent VTE and bleeding. In addition, screening for associated diseases (e.g. cancer, hypercoagulable states) may be indicated. Therefore, the outpatient treatment of low risk VTE requires coordinated effort and reliable follow up. By leveraging detailed outcome data and collaborative relationships, we have created a protocol for the safe outpatient treatment of patients with low risk DVT and PE. Our protocol is data driven and designed to address barriers to outpatient VTE management. We expect our protocol to result in improved patient satisfaction, more efficient emergency department (ED) throughput, and decreased cost. Applied nationally, the outpatient treatment of select patients with DVT and PE could have major public health and economic impact.
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Affiliation(s)
- Christopher Kabrhel
- a Center for Vascular Emergencies, Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Rachel Rosovsky
- b Division of Hematology and Oncology, Department of Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Christopher Baugh
- c Department of Emergency Medicine , Brigham and Women's Hospital , Boston , MA , USA
| | - Blair Alden Parry
- a Center for Vascular Emergencies, Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Erin Deadmon
- a Center for Vascular Emergencies, Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Charlotte Kreger
- a Center for Vascular Emergencies, Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Nicholas Giordano
- a Center for Vascular Emergencies, Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA
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