Cost-effectiveness of managing low-risk pulmonary embolism patients without hospitalization. The low-risk pulmonary embolism prospective management study

Bledsoe, Joseph; Woller, Scott C.; Stevens, Scott M.; Aston, Valerie; Patten, Rich; Allen, Todd L.; Horne, Benjamin D.; Dong, Lydia; Lloyd, James F.; Snow, Greg; Madsen, Troy; Fink, Patrick; Elliott, C. Gregory

doi:10.1016/j.ajem.2020.12.042

Cited by 19 publications

(19 citation statements)

References 18 publications

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“…The presence of right ventricular dysfunction or increased cardiac biomarker levels should discourage treatment out of the hospital. 5,127,[129][130][131][132][133][134][135] The recommendation in AT9 was based on two trials that randomized patients with acute PE to receive LMWH for only 3 days in the hospital 136 or entirely at home 118 compared with being treated with LMWH in the hospital for a longer period, in addition to 15 observational studies, nine of which were prospective, that evaluated treatment of acute PE out of the hospital. 4 At the time of the 1st update, no further randomized trials had been published, although several additional prospective and retrospective observational studies had been completed and included in meta-analyses.…”

Section: Introductionmentioning

confidence: 99%

Antithrombotic Therapy for VTE Disease

Stevens

Woller

Kreuziger

et al. 2021

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Section: Introductionmentioning

confidence: 99%

Antithrombotic Therapy for VTE Disease

Stevens

Woller

Kreuziger

et al. 2021

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643

379

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“…Clinical algorithms, checklists, and prognostic models are being developed and updated to optimize the safety of outpatient management, improve prognostic accuracy for outcome(s), and provide guidance to reduce practice variation. Incorporation of imaging and laboratory assessments for PE-provoked abnlRV have now been incorporated into hybrid clinical algorithms [1,7,[13][14][15][16], and some meta-analyses now support use of one or multiple RV assessment methods [4,17,18]. A consistent definition of PE-provoked abnlRV, however, is lacking [19][20][21][22].…”

Section: Introductionmentioning

confidence: 99%

Development and validation of a prognostic tool: Pulmonary embolism short-term clinical outcomes risk estimation (PE-SCORE)

et al. 2021

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Objective Develop and validate a prognostic model for clinical deterioration or death within days of pulmonary embolism (PE) diagnosis using point-of-care criteria. Methods We used prospective registry data from six emergency departments. The primary composite outcome was death or deterioration (respiratory failure, cardiac arrest, new dysrhythmia, sustained hypotension, and rescue reperfusion intervention) within 5 days. Candidate predictors included laboratory and imaging right ventricle (RV) assessments. The prognostic model was developed from 935 PE patients. Univariable analysis of 138 candidate variables was followed by penalized and standard logistic regression on 26 retained variables, and then tested with a validation database (N = 801). Results Logistic regression yielded a nine-variable model, then simplified to a nine-point tool (PE-SCORE): one point each for abnormal RV by echocardiography, abnormal RV by computed tomography, systolic blood pressure < 100 mmHg, dysrhythmia, suspected/confirmed systemic infection, syncope, medico-social admission reason, abnormal heart rate, and two points for creatinine greater than 2.0 mg/dL. In the development database, 22.4% had the primary outcome. Prognostic accuracy of logistic regression model versus PE-SCORE model: 0.83 (0.80, 0.86) vs. 0.78 (0.75, 0.82) using area under the curve (AUC) and 0.61 (0.57, 0.64) vs. 0.50 (0.39, 0.60) using precision-recall curve (AUCpr). In the validation database, 26.6% had the primary outcome. PE-SCORE had AUC 0.77 (0.73, 0.81) and AUCpr 0.63 (0.43, 0.81). As points increased, outcome proportions increased: a score of zero had 2% outcome, whereas scores of six and above had ≥ 69.6% outcomes. In the validation dataset, PE-SCORE zero had 8% outcome [no deaths], whereas all patients with PE-SCORE of six and above had the primary outcome. Conclusions PE-SCORE model identifies PE patients at low- and high-risk for deterioration and may help guide decisions about early outpatient management versus need for hospital-based monitoring.

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“…Several validated prognostic tools are available to help identify which ED patients are at low risk for short‐term complications, and, as such, may be eligible for discharge home 35 . Among the PE risk stratification tools, the most validated and commonly used are the Hestia clinical decision rule, 17,36,37 the PE Severity Index (PESI) 14,18,38,39 and the simplified PESI (sPESI) 40 . When compared head to head, the Hestia clinical decision rule and sPESI have been shown to be similarly safe and effective, identifying over one third of acute PE patients for outpatient treatment with reassuring outcomes 41,42 .…”

Section: Methodsmentioning

confidence: 99%

“…The outpatient treatment of low‐risk PE was first suggested in the early 2000s 11–13 . Subsequent clinical trials 14–16 and observational studies 17–20 confirmed the safety of this approach, demonstrating that outpatient and inpatient PE treatment were associated with similarly low rates of mortality, recurrent venous thromboembolism (VTE), and bleeding. More than 98% of patients treated as outpatients have an uncomplicated course 21 .…”

Section: Introductionmentioning

confidence: 99%

A clinical decision framework to guide the outpatient treatment of emergency department patients diagnosed with acute pulmonary embolism or deep vein thrombosis: Results from a multidisciplinary consensus panel

et al. 2021

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The outpatient treatment of select emergency department patients with acute pulmonary embolism (PE) or deep vein thrombosis (DVT) has been shown to be safe, cost effective and associated with high patient satisfaction. Despite this, outpatient PE and DVT treatment remains uncommon. To address this, the American College of Emergency Physicians assembled a multidisciplinary team of content experts to provide evidence‐based recommendations and practical advice to help clinicians safely treat patients with low‐risk PE and DVT without hospitalization. The emergency clinician must stratify the patient's risk of clinical decompensation due to their PE or DVT as well as their risk of bleeding due to anticoagulation. The clinician must also select and start an anticoagulant and ensure that the patient has access to the medication in a timely manner. Reliable follow‐up is critical, and the patient must also be educated about signs or symptoms that should prompt a return to the emergency department. To facilitate access to these recommendations, the consensus panel also created 2 web‐based “point‐of‐care tools.”

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Cost-effectiveness of managing low-risk pulmonary embolism patients without hospitalization. The low-risk pulmonary embolism prospective management study

Cited by 19 publications

References 18 publications

Antithrombotic Therapy for VTE Disease

Antithrombotic Therapy for VTE Disease

Development and validation of a prognostic tool: Pulmonary embolism short-term clinical outcomes risk estimation (PE-SCORE)

A clinical decision framework to guide the outpatient treatment of emergency department patients diagnosed with acute pulmonary embolism or deep vein thrombosis: Results from a multidisciplinary consensus panel

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