Benefit of early discharge among patients with low-risk pulmonary embolism

Abstract

Clinical guidelines recommend early discharge of patients with low-risk pulmonary embolism (LRPE). This study measured the overall impact of early discharge of LRPE patients on clinical outcomes and costs in the Veterans Health Administration population. Adult patients with ≥1 inpatient diagnosis for pulmonary embolism (PE) (index date) between 10/2011-06/2015, continuous enrollment for ≥12 months pre- and 3 months post-index date were included. PE risk stratification was performed using the simplified Pulmonary Embolism Stratification Index. Propensity score matching (PSM) was used to compare 90-day adverse PE events (APEs) [recurrent venous thromboembolism, major bleed and death], hospital-acquired complications (HACs), healthcare utilization, and costs among short (≤2 days) versus long length of stay (LOS). Net clinical benefit was defined as 1 minus the combined rate of APE and HAC. Among 6,746 PE patients, 95.4% were men, 22.0% were African American, and 1,918 had LRPE. Among LRPE patients, only 688 had a short LOS. After 1:1 PSM, there were no differences in APE, but short LOS had fewer HAC (1.5% vs 13.3%, 95% CI: 3.77–19.94) and bacterial pneumonias (5.9% vs 11.7%, 95% CI: 1.24–3.23), resulting in better net clinical benefit (86.9% vs 78.3%, 95% CI: 0.84–0.96). Among long LOS patients, HACs (52) exceeded APEs (14 recurrent DVT, 5 bleeds). Short LOS incurred lower inpatient ($2,164 vs $5,100, 95% CI: $646.8-$5225.0) and total costs ($9,056 vs $12,544, 95% CI: $636.6-$6337.7). LRPE patients with short LOS had better net clinical outcomes at lower costs than matched LRPE patients with long LOS.

Predictors of hospital stay in normotensive acute pulmonary embolism: a retrospective pilot study

“…During the acute phase, it is of supreme importance to stratify the severity of the disease because it may help guide decision-making in terms of appropriate setting of treatment. In a study conducted by Wang et al [11], LRPE patients with a short LOS had better clinical outcomes than those with long LOS which was complicated with a higher rate of hospital-acquired morbidities. Our investigation about the association between the parameters and LOS is unique as it allowed us to determine the factors which lead to prolonged LOS.…”

Emergency Department Discharge of Pulmonary Embolus Patients

“…The advantage of potentially shorter inpatient hospitalization portends much greater benefits than simply cost reduction. The avoidance of hospitalization and shortening length of stay may be associated with a lower risk of hospital acquired conditions (e.g., hospital‐acquired pneumonia, methicillin‐resistant Staphylococcus aureus infection).…”

“…Avoidance of hospitalization may not only reduce costs, it is associated with fewer adverse clinical outcomes. In LRPE patients, longer hospitalization is associated with as much as an 880% greater risk (1.5% vs 13.3%; 95% confidence interval [CI]] = 3.77%–19.94%) of hospital‐acquired conditions . Although few prospective U.S. studies have discharged LRPE patients, the American College of Chest Physicians supports early discharge of these patients with adequate home cirumstances…”

Hjemmebehandling ved lungeembolisme

“…Eksempelvis var det bare 17 av totalt 897 pasienter (1,9 %) i de to nevnte studiene som nådde ett av endepunktene (17,21), og i studien til Den Exter og medarbeidere var det bare 34 pasienter (12 % av biomarkørgruppen) som var innlagt utover 24 timer (17). Samtidig gir hjemmebehandling faerre iatrogene komplikasjoner og betydelig lavere kostnader enn sykehusbehandling av sammenlignbare pasientgrupper (7). Det er således gode grunner for å benytte hjemmebehandling i klinisk praksis, såfremt utvelgelseskriteriene anvendes med omhu og i samsvar med klinisk skjønn.…”

“…Pålitelig risikoberegning har åpnet opp for hjemmebehandling av lungeembolismepasienter med lav risikoprofil, som kan ha både helsemessige og økonomiske fordeler sammenlignet med sykehusbehandling (7,8). Metaanalyser har vist sammenlignbar risiko for tilbakefall av venøs trombose, store blødninger og død ved hjemmebehandling og sykehusbehandling for lungeembolismepasienter med lav risiko (9,10).…”