scholarly journals Assessment of Utilization of Outpatient Based Treatment for Low Risk Patients with Pulmonary Embolism in Two Community Teaching Hospitals

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 5779-5779
Author(s):  
Kavita Agrawal ◽  
Nirav Agrawal ◽  
Harsha Adnani ◽  
Anjali Kakwani
Keyword(s):  
Pulmonary Embolism ◽  
Outpatient Treatment ◽  
Inpatient Treatment ◽  
Conflicts Of Interest ◽  
Oral Anticoagulants ◽  
Low Risk ◽  
Teaching Hospitals ◽  
Outpatient Basis ◽  
Community Hospitals ◽  
Risk Patients

OBJECTIVE: Several randomized controlled trials and meta-analysis has proven safety and efficacy of outpatient based treatment in appropriately selected low-risk patients with pulmonary embolism (PE). Despite the fact that outpatient treatment has been proven safe, prior studies have shown that it is not commonly practiced. Our current multi-center study focuses on identifying practices of outpatient versus inpatient treatment of low risk PE patients in two community hospitals between 2018-2019. METHODS: A retrospective chart review of the patients in two community hospitals with the principal discharge diagnosis of pulmonary embolism aged 18 years or older was conducted. The study period included February 2018 to February 2019. The high risk patients defined as simplified pulmonary embolism severity index (PESI) score of 1 or above were excluded from the study. Low risk patients were defined as with a simplified PESI score of 0. Criteria were established to determine the appropriateness of inpatient admission for low risk patients with PE. The group of low risk patients with thrombocytopenia (platelets less than 70,000/mm3), glomerular filtration rate (GFR) of less than 30 ml/ minute, international normalized ratio (INR) greater than 1.5, pregnancy, active bleeding as documented in the medical records, total bilirubin greater than 3.0 mg/dl, extreme obesity (weight greater than 150 kg), diagnosis of acute PE while on oral anticoagulation, requiring narcotics for chest pain, need for supplemental oxygen , poor social support or presence of concomitant extensive deep vein thrombosis were deemed appropriate for inpatient treatment. The patients without these baseline characteristics were considered appropriate for outpatient treatment. RESULTS: The cohort comprised of 442 patients in two community hospitals. Among these, 172 patients had a simplified PESI score of 1 or above and were excluded from the study. The remaining 270 patients had a simplified PESI score of 0 and were considered low risk. Based on the study criteria, 54% (145 patients out of 270) of the low risk patients were deemed appropriate for outpatient treatment. Out of these, only 16% (23 patients out of 145) were treated at home. The remaining 84% (122 patients out of 145) of the low risk PE patients considered safe for outpatient treatment were actually treated as inpatient. The mean length of hospital stay for this group of patients was 3 days. Anti-coagulation therapy for those treated on outpatient basis was novel oral anticoagulants in 79% (18 patients out of 23) and low molecular weight heparin or warfarin in 21% (5 patients out of 23). CONCLUSION: Our study demonstrates that majority of low risk PE patients deemed appropriate for outpatient based treatment are treated on inpatient basis. This study shows that there is a need to implement interventions to improve practices of outpatient management of appropriately selected low-risk PE patients. Disclosures No relevant conflicts of interest to declare.

Hospitalization or Outpatient Treatment for Acute Pulmonary Embolism - a Retrospective Cohort Study of 439 Consecutive Patients with Community-Aquired Pulmonary Embolism

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 3416-3416
Author(s):  
Sebastian Werth ◽  
Virginia Kamvissi ◽  
Eberhard Kuhlisch ◽  
Jan Beyer-Westendorf
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Outpatient Treatment ◽  
Conflicts Of Interest ◽  
Subjective Assessment ◽  
Early Discharge ◽  
Low Risk ◽  
Hospital Treatment ◽  
Discharge Treatment ◽  
Risk Patients

Abstract Abstract 3416 Introduction: Therapy of pulmonary embolism (PE) today is based on risk stratification scores. Outpatient treatment for selected low-risk patients seems feasible, but data are derived from selected patient cohorts. Little is known about risk factors or clinical outcomes in unselected cohorts. In our hospital, outpatient treatment of low-risk-PE has been standard for nearly ten years. We retrospectively analyzed risk profile and 6-month-outcome of in-hospital or outpatient treatment in patients with community-aquired acute PE (CA-PE). Objectives: To evaluate the proportion of patients with outpatient or early discharge treatment of CA-PE, to evaluate the value of HESTIA score to discriminate between low and high risk patients and to assess 6-month outcome. Methods: Retrospective evaluation of all cases with CA-PE. Inclusion criteria: 1) PE symptoms as reason for hospitalization (exclusion of hospital-aquired PE); 2) symptomatic and confirmed PE (CT or V/Q scan). Evaluation of patient characteristics, hemodynamic and echocardiographic parameters and lab values and group comparisons between outpatient treatment (OT; hospitalized < 24h), early discharge (ED; hospitalized < 72h) and in-hospital treatment (HT) were performed. Result: Between 2000 and 2010, 439 patients were diagnosed with acute CA-PE (table 1). About 25% of patients could be treated as outpatients (n=49; 11.2%) or early discharged (n=63; 14.4%). Patients with in-hospital treatment of PE were significantly older and had more severe PE. Interestingly, the rate of patients with a positive history of VTE was highest in the group of outpatients (45%), followed by the early-discharge group (32%), indicating that these patients are diagnosed at an earlier stage with less severe PE. In contrast, only 25% of patients requiring in-hospital treatment of PE had a positive VTE history. Despite the differences in baseline characteristics, outcomes with regard to recurrent VTE, pulmonary hypertension or mortality were not significantly different between outpatients and early discharge patients. In contrast, outcomes of patients with in-hospital treatment was significantly different with higher mortality (0.0% vs. 3.2% vs. 15.8%). Conclusion: Even before ESC and Hestia scores were implemented, physicians subjective assessment based on hemodynamic, echocardiographic and laboratory parameters clearly discriminated between low, intermediate and high risk PE patients and allowed for outpatient treatment in low-risk PE in 11% of all PE patients. Early discharge was possible in 14% of all patients, despite higher HESTIA scores and a higher rate of elevated troponin levels, initial oxygen requirement or right heart strain in echocardiography. In contrast, patients requiring in-hospital PE treatment were older, had more severe PE and a high 6-month mortality. Despite a positive Hestia score in many patients, about 25% of all community-aquired PE patients can be safely treated as outpatient or early discharge treatment with low 6-month mortality. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Outpatient Treatment in Low-Risk Pulmonary Embolism Patients Receiving Direct Acting Oral Anticoagulants Is Associated With Cost Savings

2020 ◽  
Vol 26 ◽  
pp. 107602962093735
Author(s):  
Raein Ghazvinian ◽  
Johan Elf ◽  
Sofia Löfvendahl ◽  
Jan Holst ◽  
Anders Gottsäter
Keyword(s):  
Pulmonary Embolism ◽  
Outpatient Treatment ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Cost Savings ◽  
Severity Index ◽  
Low Risk ◽  
Potential Cost ◽  
Total Cost ◽  
Outpatient Group

Direct oral anticoagulants (DOAC) are first line treatment for pulmonary embolism (PE). Treatment of acute PE is traditionally hospital based and associated with high costs. The aims of this study were to evaluate potential cost savings with outpatient DOAC treatment compared to inpatient DOAC treatment in patients with low risk PE. A retrospective study in patients with DOAC treated low risk PE (simplified pulmonary severity index [sPESI] ≤ 1) admitted to 8 hospitals during 2013-2015. Health care costs were compared in 223(44%) patients treated as outpatients and 287(56%) treated in hospital. Total cost per patient was 8293 EUR in the inpatient group, and 2176 EUR in the outpatient group (p < 0.001). Total costs for inpatients were higher (p < 0.001) compared to outpatients in both subgroups with sPESI 0 and 1. In multivariate analysis, type of treatment (in- or outpatient, p = < 0.001) and sPESI group (0 or 1, p = < 0.001) were associated with total cost below or above median, whereas age (p = 0.565) and gender (p = 0.177) was not. Adherence to guidelines recommending outpatient treatment with DOAC in patients with low risk PE enables significant savings.

Does the Pulmonary Embolism Severity Index accurately identify low risk patients eligible for outpatient treatment?

2012 ◽  
Vol 129 (6) ◽  
pp. 710-714 ◽  
Author(s):  
Petra M.G. Erkens ◽  
Esteban Gandara ◽  
Philip S. Wells ◽  
Alex Yi-Hao Shen ◽  
Gauruv Bose ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Outpatient Treatment ◽  
Severity Index ◽  
Low Risk ◽  
Risk Patients

scholarly journals Outpatient treatment in low-risk pulmonary embolism patients receiving direct acting oral anticoagulants is associated with cost savings.

2020 ◽  
Author(s):  
Raein Ghazvinian ◽  
Johan Elf ◽  
Anders Gottsäter ◽  
Sofie Löfvendahl ◽  
Jan Holst
Keyword(s):  
Pulmonary Embolism ◽  
Outpatient Treatment ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Cost Savings ◽  
Low Risk ◽  
Potential Cost ◽  
Multicenter Cohort Study ◽  
Total Cost ◽  
Outpatient Group

Abstract Background Direct oral anticoagulants (DOAC) are first line treatment for pulmonary embolism (PE). Treatment of acute PE is traditionally hospital based and associated with high costs, in spite of recent guidelines suggesting outpatient treatment for low-risk patients. The aims of this study were to evaluate potential cost savings with outpatient DOAC treatment of patients with low risk PE compared to DOAC treatment of low risk PE patients in hospital. Methods A retrospective comparatory multicenter cohort study in patients with low risk PE (simplified pulmonary severity index [sPESI]) ≤ 1 admitted to the eight hospitals in Sweden´s southernmost healthcare region during 2013-2015, and treated with DOAC. Local criteria guiding outpatient treatment had been used, and sPESI was calculated retrospectively. Health care costs were analysed in the 223 (44%) patients treated as outpatients and the 287 (56%) treated in hospital. Results Total cost per patient was 7334 EUR in the inpatient group, and 2088 EUR in the outpatient group (p<0.001). In multivariate analysis, type of treatment (in- or outpatient, p=<0.001) and sPESI group (0 or 1, p=<0.001) were significantly associated with total cost below or above median, whereas age (p=0.565) and gender (p=0.177) was not. Total cost for inpatients was higher (p<0.001) compared to outpatients in subgroups with sPESI 0 and 1. Conclusion Better adherence to current guidelines recommending outpatient treatment with DOAC in patients with low risk PE would potentially lead to significant savings in healthcare expenditure.

Lungenembolie

2019 ◽  
Vol 144 (18) ◽  
pp. 1286-1300 ◽  
Author(s):  
Lukas Hobohm ◽  
Mareike Lankeit
Keyword(s):  
Pulmonary Embolism ◽  
Vitamin K ◽  
Clinical Laboratory ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Right Ventricular Dysfunction ◽  
Low Risk ◽  
Hospital Treatment ◽  
Individual Risk ◽  
Risk Patients

AbstractPulmonary embolism (PE) is a life-threatening disease and the third most frequent cardiovascular cause of death after stroke and myocardial infarction. The annual incidence is increasing. The individual risk for PE-related complications and death increases with the number of comorbidities and severity of right ventricular dysfunction. Using clinical, laboratory and imaging parameters, patients with PE can be stratified to four risk classes (high, intermediate-high, intermediate-low and low risk). This risk stratification has concrete therapeutic consequences ranging from out-of-hospital treatment of low-risk patients to reperfusion treatment of (intermediate-) high-risk patients. For haemodynamically unstable patients, a treatment decision should preferable be made in interdisciplinary “Pulmonary Embolism Response Teams” (PERT). Being comparably efficient and due to a preferable safety profile compared to vitamin-K antagonists (VKAs), non-vitamin K-dependent oral anticoagulants (NOACs) are increasingly considered to be the treatment of choice for initial and prolonged anticoagulation of patients with pulmonary embolism. The use of low molecular weight heparins (LMWHs) is recommended for PE patients with cancer; however, recent studies indicate that treatment with factor Xa-inhibitors may be effective and safe (in patients without gastrointestinal cancer). Only prolonged anticoagulation (in reduced dosage) will ensure reduction of VTE recurrence and thus should be considered for all patients with unprovoked events.

scholarly journals Rivaroxaban or Aspirin As Thromboprophylaxis in Multiple Myeloma

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 5068-5068 ◽  
Author(s):  
Gregorio Campos-Cabrera ◽  
Esther Mendez-Garcia ◽  
Salvador Campos-Cabrera ◽  
Jose-Luis Campos-Villagomez ◽  
Virgina Campos-Cabrera
Keyword(s):  
Risk Factor ◽  
Conflicts Of Interest ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Low Risk ◽  
Additional Risk Factor ◽  
Good Efficiency ◽  
Additional Risk ◽  
Risk Patients ◽  
Bleeding Episodes

Abstract Hematological cancer has risk of venous thromboembolism of 28 fold compared to sex and age adjusted incidence in general population (JAMA 2005;293:715-722). This risk increases in patients with MM receiving dexamethasone and immunomodulatory drug. Thus, thromboprophylaxis with aspirin in low risk patients and LMWH or warfarin in high risk patients are recommended (Leukemia 2008;22:414-423). Direct oral anticoagulants are promising due to their convenience and costs-effectiveness in preventing VTE in other settings. They have not been extensively studied in myeloma therapy. From January of 2010 to December of 2017, 105 with MM received thalidomide and dexamethasone based triplet induction therapy, maintenance with thalidomide and creatinine clearance > 30 mL/min. From those, 23 (21.9%) had only an additional risk factor and were randomized 5:1 to receive 100 mg aspirin or 10 mg rivaroxaban until relapse and need another treatment. Doppler ultrasound was performed every six months or as medical indication in all patients and pulmonary CT scan if EP was suspected. Five patients received rivaroxaban, 3 males and 2 females, median age of 67.5 years; additional factors were obesity in 4 and DM in one. Aspirin was received by 18 patients, 10 males an 8 females, median age 66.8 years; additional factors were obesity in 10, DM in 5, erythropoietin in 3. No patient in the Rivaroxaban arm developed thrombosis; bleeding episodes were self-limited to the gums and easy bruising; no major bleeding was detected. One patient in the Aspirin arm, with body mass index of 31.22 kg/m2 as an additional risk factor, developed right iliofemoral DVT without PE; he was changed to rivaroxaban at therapeutic doses for six months with resolution of the DVT and then continue with 10 mg dose; bleeding episodes in all patients were similar to the rivaroxaban arm. In this small group of patients with a low risk factors with an additional one, that could be in an intermediate risk, the use of rivaroxaban showed a good efficiency and security profiles. Either, rivaroxaban or aspirin could be used in this situations and deserve further investigation. Disclosures No relevant conflicts of interest to declare.

Out of Hospital Treatment of Acute Pulmonary Embolism in Patients with a Low NT-ProBNP Level.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 3996-3996
Author(s):  
Mariette J Agterof ◽  
Roger E.G. Schutgens ◽  
Repke J Snijder ◽  
G. Epping ◽  
Henny G Peltenburg ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Emergency Room ◽  
Acute Pulmonary Embolism ◽  
Conflicts Of Interest ◽  
Low Risk ◽  
Hospital Treatment ◽  
Serious Adverse Events ◽  
Risk Patients ◽  
Acute Pe

Abstract Abstract 3996 Poster Board III-932 Background NT-proBNP is emerging to be of great importance in risk assessment of patients with acute pulmonary embolism (PE), by identifying both high and low-risk patients. The aim of the present management study was to investigate the safety of out of hospital treatment of patients with acute PE based on a NT-proBNP < 500 pg/ml. Methods Hemodynamically stable outpatients with objectively diagnosed acute PE and a NT-proBNP level < 500 pg/ml, were considered eligible for participation in this multicenter prospective study. Patients were discharged immediately from the emergency room or within the first 24 hours of admission. The primary objective was the 10-days mortality rate. Secondary objectives were the incidence of re-admission to hospital due to PE or its treatment, the patient's satisfaction during the first ten days of treatment and the incidence of serious adverse events in a 3-month follow-up period. Results Approximately 40 percent of all patients presenting at the emergency room with acute PE fulfilled the inclusion criteria. In total, 152 patients (mean age 53.4 ± 14.3 years; 51% female) with PE were treated as outpatients. No deaths, major bleedings or recurrent venous thromboembolism occurred during the first 10 days or in a follow-up period of 3 months. Seven patients required readmission. Three patients were admitted because of complaints of their PE: two patients with anxiety and pain and one patient with dyspnoea and low oxygen saturation. There were no signs of progression of PE in these 3 patients. Four patients were re-admitted because of an illness unrelated to PE. According to the PSQ18 and anxiety score, patients were satisfied with their out of hospital treatment; they had no progression of anxiety during the first ten days of treatment. Conclusion Out of hospital treatment is safe in a group of low risk patients with non-massive PE, based on NT-proBNP levels < 500 pg/ml. Approximately 40 percent of PE-patients can be treated in an outpatient setting. Patients consider out of hospital treatment as comfortable and have no increase in anxiety scores. Disclosures: No relevant conflicts of interest to declare.

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