Outpatient Management of Acute PE Remains Underused

The proportion of patients with acute pulmonary embolism (PE) discharged home from the emergency department (ED) did not change significantly over a recent 9-year period, highlighting that outpatient management strategies, which have been shown to be safe and effective in select groups, are still underused.

In a nationally representative US sample, 30.7% of patients presenting with acute PE were sent home from the ED, with the rest being hospitalized for further treatment, lead author Nathan Watson, BS (Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA), and colleagues report in a study published online in the Annals of Internal Medicine. Rates were only slightly higher among those deemed to be low risk.

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In recent years, a lot of attention has been paid to optimizing inpatient care pathways for acute PE, as reflected by the proliferation of pulmonary embolism response teams (PERTs), senior author Eric Secemsky, MD (Beth Israel Deaconess Medical Center and Harvard Medical School), told TCTMD. But less attention, he said, has been given to the outpatient management of lower-risk patients, an approach that has been bolstered by studies demonstrating safety and feasibility and is endorsed in international guidelines.

The current study indicates that there remains room for improvement in that area, Secemsky indicated, pointing to the need to make clinicians comfortable with the idea of outpatient management in lower-risk patients and to provide reassurances to patients who feel anxious about it.

“My charge from this is really for us to look holistically, not only at those more acutely sick who are hospitalized but also at all patients, to make sure that we’re supporting those who do not need to be hospitalized as well as [supporting] our clinicians who are seeing them but may not be following them into the outpatient setting,” he said.

No Predictors of ED Discharge

To explore what’s happening across US emergency departments in terms of managing acute PE, the investigators examined data from the National Hospital Ambulatory Medical Care Survey. The analysis included more than 1.6 million visits for acute PE between 2012 and 2020. Patients had a mean age of 57.7 years, and 39.1% were men.

The percentage of patients discharged from the ED remained relatively stable, with a rate of 38.2% in 2012-2014 and 33.4% in 2018-2020. After adjustment, there was no significant change over time (adjusted risk ratio 1.01 per year; 95% CI 0.89-1.14).

If I had a low-risk PE, I would appreciate avoiding the risks, costs, and inconveniences of an unnecessary hospitalization. David Vinson

Findings were similar in the subset of patients who had a CT scan during the initial visit to the ED. Among patients with acute PE listed as the first coded diagnosis, however, there was a significant increase in the rate of discharge from the ED—from 9.65% at the start of the study period to 20.6% by the end. But, the authors note, “overall rates remained low, which is consistent with the primary findings.”

Even among patients considered to be low risk according to various definitions, a minority (33.1% to 35.9%) were discharged home from the ED.

“These patients were still routinely being admitted to the point that probably there were a number of patients that really would have done fine in an outpatient pathway, probably saving healthcare systems a fair amount of money, and we’ve lost that opportunity when they’re being admitted instead of sent home,” Secemsky said.

There were no baseline clinical characteristics that were associated with the likelihood of ED discharge, although patients treated at teaching hospitals and those covered by private insurance were more likely to receive oral anticoagulation at discharge. “Our emphasis here is it’s not about the patients. It’s about the infrastructure and what support hospital systems can provide to allow for outpatient management,” Secemsky said.

‘Disappointing’ Lack of Progress

The study “shows that little progress had been made in implementing ‘PE best practices’ at the time of ED disposition,” David Vinson, MD (Kaiser Permanente Division of Research, Oakland, CA), commented via email. “This lack of progress is disappointing: it suggests that mounting evidence that outpatient care is safe and effective for many patients with low-risk PE has failed to overcome the inertia associated with long-held practice patterns of hospitalization.”

Vinson’s team has looked into the factors influencing the use of outpatient management for PE, and he said they’ve identified several barriers, including “uncertainty about the safety of the practice and unawareness of support from professional societies, coupled with medicolegal concerns; lack of confidence in identifying eligible patients and avoidance of perceived complexity and hassle; and social concerns about being seen as an outlier in one’s own department.”

To spur greater use of outpatient management, these physician concerns need to be addressed, Vinson said, noting that an intervention combining physician education and electronic clinical decision support tools safely boosted use of outpatient management within the Kaiser Permanente Northern California system.

“Once the transformation began, outpatient PE management snowballed, becoming a standard practice across our 21 community EDs. ED discharges directly home increased safely over 6 years: from 7% in 2013 to 27% in 2019,” Vinson said.

“For the sake of our patients and our hospitals, physicians should design and implement facility-specific and system-wide care pathways that better match hospitalization to individual patient risks and needs,” he added. “If I had a low-risk PE, I would appreciate avoiding the risks, costs, and inconveniences of an unnecessary hospitalization. Many diverse healthcare systems have implemented successful outpatient PE pathways. Common components include physician education, tools to help identify low-risk patients, and systems to facilitate patient access to anticoagulation and timely follow-up.”