External validation of prognostic rules for early post-pulmonary embolism mortality: assessment of a claims-based and three clinical-based approaches

Prognostic Performance of Hestia Criteria in Acute Pulmonary Embolism: A Systematic Review and Meta-Analysis

Previous studies have suggested that Hestia criteria could effectively identifying patients with acute pulmonary embolism (PE) who were at low risk of mortality for outpatient treatment or early discharge. But the performance of Hestia criteria in stratifying patients at different risk class is still unknown. We sought to comprehensively evaluate the prognostic impact of Hestia criteria for PE. The literatures search was conducted in PubMed, Web of Science and EMBASE from 1 August 2011 to 31 October 2021. Finally, Eight studies with 4110 patients were included in our meta-analysis. Overall, the pool percentage of patients classified as low-risk group and high-risk group were 41.4%% and 58.6% respectively, and the all-course mortality rates of each group were 2.3% and 10.6%, respectively. The pooled rate of PE-related composite adverse outcomes in high-risk group was increasingly higher than in low-risk group (15.7% vs 4.4%). High risk group was also markedly associated with overall mortality (OR: 7.21, 95%CI: 4.96-10.46, p < 0.00001), and PE-related adverse outcomes (OR:5.38, 95% CI:3.95-7.32, p < 0.00001). The pooled sensitivity, specificity, PLR, NLR of Hestia criteria for overall mortality were 0.90 (95% CI:0.83-0.94), 0.43 (95% CI:0.31-0.55), 1.6 (95% CI:1.3-1.9), 0.23 (95% CI: 0.15-0.35), respectively. The area under SROC curve (AUC) was 0.81 (95% CI: 0.77-0.84). The result of our meta-analysis indicate that Hestia criteria can effectively identify PE patients at low risk of poor prognosis with high sensitivity and NPV, but its prognostic role in patients with higher risk class still need to be verified.

A retrospective analysis of outcomes in low- and intermediate-high-risk pulmonary embolism patients managed on an ambulatory medical unit in the UK

Pulmonary embolism (PE) is common and guidelines recommend outpatient care only for PE patients with low predicted mortality. Outcomes for patients with intermediate-to-high predicted mortality managed as outpatients are unknown. Electronic records were analysed for adults with PE managed on our ambulatory care unit over 2 years. Patients were stratified into low or intermediate-to-high mortality risk groups using the Pulmonary Embolism Severity Index (PESI). Primary outcomes were the proportion of patients ambulated, 30-day all-cause mortality, 30-day PE-specific mortality and 30-day re-admission rate. Of 199 PE patients, 74% were ambulated and at 30 days, all-cause mortality was 2% (four out of 199) and PE-specific mortality was 1% (two out of 199). Ambulated patients had lower PESI scores, better vital signs and lower troponin levels (morning attendance favoured ambulation). Over a third of ambulated patients had an intermediate-to-high risk PESI score but their all-cause mortality rate was low at 1.9% (one out of 52). In patients with intermediate-to-high risk, oxygen saturation was higher and pulse rate lower in those who were ambulated. Re-admission rate did not differ between ambulated and admitted patients. Two-thirds of patients with intermediate-to-high risk PE were ambulated and their mortality rate remained low. It is possible for selected patients with intermediate-to-high risk PESI scores to be safely ambulated.

Systematic Review of Real-World Studies Evaluating Characteristics Associated With or Programs Designed to Facilitate Outpatient Management of Deep Vein Thrombosis

Select patients with acute deep vein thrombosis (DVT) can be managed as outpatients. We sought to conduct a systematic review of real-world studies describing either (1) the clinical characteristics associated with outpatient DVT treatment in all-comers or (2) emergency department (ED) programs designed to facilitate outpatient DVT treatment. MEDLINE and SCOPUS were searched (January 1, 2012, to May 1, 2018) to identify citations meeting the aforementioned criteria. Twenty-one real-world studies were included. The proportion of all-comer patients with DVT managed as outpatients was ≤50% in 11 of 15 studies. With the exception of younger age, no characteristics were consistently associated with outpatient treatment across the 13 studies reporting these characteristics. We identified 8 studies describing ED programs aimed at facilitating DVT outpatient treatment, all of which provided education and included measures to encourage early outpatient follow-up after ED discharge. In conclusion, the proportion of patients with DVT managed as outpatients across real-world studies was low. Several ED programs aimed at facilitating this treatment have been described. It is possible that programs similar to these will increase the proportion of patients with DVT that can be safely managed as outpatients.

External validation of a claims-based and clinical approach for predicting post-pulmonary embolism outcomes among United States veterans

The In-hospital Mortality for PulmonAry embolism using Claims daTa (IMPACT) rule can accurately identify pulmonary embolism (PE) patients at low risk of early complications using claims data. We sought to externally validate the IMPACT and simplified Pulmonary Embolism Severity Index (sPESI) tools for predicting all-cause mortality and readmission. We used Veteran Health Administration data (10/1/2010-9/30/2015) to identify adults with ≥1 inpatient diagnosis code for acute PE, ≥12 months continuous medical and pharmacy benefits prior to the index PE, ≥90 days of post-event follow-up (unless death occurred) and ≥1 claim for an anticoagulant during the index PE stay. Prognostic accuracies of IMPACT and sPESI for 30- and 90-day all-cause mortality and 90-day readmission were estimated. Of 6,746 PE patients, 7.5 and 12.6% died at 30 and 90 days. Within 90 days, 20.1% were readmitted for any reason. Hospitalization for recurrent VTE and major bleeding occurred in 5.6 and 1.7% of patients. IMPACT classified 15.2% as low risk, while 28.4% were low risk per sPESI. Both tools displayed sensitivity >90% and negative predictive values (NPVs) >97% for 30-day mortality, but low specificity (range 16.2-30.0) and positive predictive values (PPVs) (range 8.7-9.5); with similar results observed for 90-day mortality. IMPACT's sensitivity for all-cause readmission was numerically higher than sPESI (88.2 vs. 79.0%), but both had comparable NPVs (85.1 vs. 84.2%). Similar trends were observed for VTE or major bleeding readmissions. IMPACT classified patients for post-PE outcomes with similar accuracy as sPESI. IMPACT appears useful for identifying PE patients at low risk for early mortality or readmission in claims-based studies.

Hospital length-of-stay and costs among pulmonary embolism patients treated with rivaroxaban versus parenteral bridging to warfarin

We sought to compare length-of-stay (LOS), total hospital costs, and readmissions among pulmonary embolism (PE) patients treated with rivaroxaban versus parenterally bridged warfarin. We identified adult PE (primary diagnostic code = 415.1x) patients in the Premier Database (11/2012-9/2015), and included those with ≥1 PE diagnostic test on days 0-2. Rivaroxaban users (allowing ≤2 days of prior parenteral therapy) were 1:1 propensity score matched to patients parenterally bridged to warfarin. LOS, total costs, and readmission for venous thromboembolism (VTE) or major bleeding within the same or subsequent 2 months were compared between cohorts. Separate analyses were performed in low-risk PE patients. Rivaroxaban use was associated with a 1.4-day [95 % confidence interval (CI) -1.47 to -1.28] shorter LOS, and $2322 (95 % CI -$2499 to -$2146) reduction in costs compared to parenterally bridged warfarin (p < 0.001 for both). There was no difference in readmission for VTE (1.5 versus 1.7 %) or major bleeding (0.3 versus 0.2 %) between the rivaroxaban and parenterally bridged warfarin cohorts (p ≥ 0.27 for both). Results were similar in low-risk patients (0.2-1.0 day and $251-$1751 reductions in LOS and costs, respectively, p ≤ 0.01 for all). In patients with PE, rivaroxaban was associated with reduced LOS and costs, without increased risk of readmission versus parenterally bridged warfarin. Similar results were observed in low-risk PE patients.

Observation management of pulmonary embolism and agreement with claims-based and clinical risk stratification criteria in United States patients: a retrospective analysis

Background

Guidelines suggest observation stays are appropriate for pulmonary embolism (PE) patients at low-risk for early mortality. We sought to assess agreement between United States (US) observation management of PE and claims-based and clinical risk stratification criteria.

Methods

Using US Premier data from 11/2012 to 3/2015, we identified adult observation stay patients with a primary diagnosis of PE, ≥1 PE diagnostic test claim and evidence of PE treatment. The proportion of patients at high-risk was assessed using the In-hospital Mortality for PulmonAry embolism using Claims daTa (IMPACT) equation and high-risk characteristics (age > 80 years, heart failure, chronic lung disease, renal or liver disease, high-risk for bleeding, cancer or need for thrombolysis/embolectomy).

Results

We identified 1633 PE patients managed through an observation stay. Despite their observation status, IMPACT classified 46.4% as high-risk for early mortality and 33.3% had ≥1 high-risk characteristic. Co-morbid heart failure, renal or liver disease, high-risk for major bleeding, cancer and hemodynamic instability were low (each <4.5%), but 7.8% were >80 years-of-age and 19.4% had chronic lung disease.

Conclusion

Many PE patients selected for management in observation stay units appeared to have clinical characteristics suggestive of higher-risk for mortality based upon published claims-based and clinical risk stratification criteria.

External validation of a multivariable claims-based rule for predicting in-hospital mortality and 30-day post-pulmonary embolism complications

BACKGROUND

Low-risk pulmonary embolism (PE) patients may be candidates for outpatient treatment or abbreviated hospital stay. There is a need for a claims-based prediction rule that payers/hospitals can use to risk stratify PE patients. We sought to validate the In-hospital Mortality for PulmonAry embolism using Claims daTa (IMPACT) prediction rule for in-hospital and 30-day outcomes.

METHODS

We used the Optum Research Database from 1/2008-3/2015 and included adults hospitalized for PE (415.1x in the primary position or secondary position when accompanied by a primary code for a PE complication) and having continuous medical and prescription coverage for ≥6-months prior and 3-months post-inclusion or until death. In-hospital and 30-day mortality and 30-day complications (recurrent venous thromboembolism, rehospitalization or death) were assessed and prognostic accuracies of IMPACT with 95 % confidence intervals (CIs) were calculated.

RESULTS

In total, 47,531 PE patients were included. In-hospital and 30-day mortality occurred in 7.9 and 9.4 % of patients and 20.8 % experienced any complication within 30-days. Of the 19.5 % of patients classified as low-risk by IMPACT, 2.0 % died in-hospital, resulting in a sensitivity and specificity of 95.2 % (95 % CI, 94.4-95.8) and 20.7 % (95 % CI, 20.4-21.1). Only 1 additional low-risk patient died within 30-days of admission and 12.2 % experienced a complication, translating into a sensitivity and specificity of 95.9 % (95 % CI, 95.3-96.5) and 21.1 % (95 % CI, 20.7-21.5) for mortality and 88.5 % (95 % CI, 87.9-89.2) and 21.6 % (95 % CI, 21.2-22.0) for any complication.

CONCLUSION

IMPACT had acceptable sensitivity for predicting in-hospital and 30-day mortality or complications and may be valuable for retrospective risk stratification of PE patients.