Outpatient PE Treatment Safer - Maybe

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There's no place like home
Managing PE as an outpatient may not only be safe, it may be safer than hospitalization.  Authors matched 2 cohorts of patients with stable PE.  The cohort treated at home vs. in the hospital had a lower rate of recurrent VTE, major bleeding, or death at 14 days: 3.3% vs. 13%.  This improvement remained at 3-month follow up.  This is good and bad.  It means that with proper selection, outpatient PE treatment is safe, if not safer, than admission.  But why did the hospitalized patients do so poorly?  Was there a confounder, even with the careful attribute matching in this study?  I wonder.

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Managing PE as an outpatient may not only be safe, it may be safer than hospitalization.  The key is proper patient selection.


Abstract

J Thromb Haemost. 2017 Jan 20. doi: 10.1111/jth.13629. [Epub ahead of print]

Net clinical benefit of hospitalization versus outpatient management of patients with acute pulmonary embolism.

Roy PM1, Corsi DJ2, Carrier M3, Theogene A4, de Wit C3, Dennie C5, Le Gal G3, Delluc A6, Moumneh T1, Rodger M3, Wells P3, Gandara E3.

Author information:

1Emergency Department, CHU Angers; Institut MITOVASC, EA 3860, Université d'Angers, Angers, France.

2Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.

3Department of Medicine, Division of Haematology - Thrombosis Program, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada.

4Medical Study, University of Ottawa, Ottawa, Canada.

5Department of Medical Imaging, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada.

6Department of Internal Medicine, CHU de la Cavale Blanche, Université de Bretagne Occidentale, EA3878 (GETBO), CIC INSERM, 1412, Brest, France.

Abstract

BACKGROUND:

The decision to hospitalize or not patients with acute pulmonary embolism (PE) is controversial. Despite the advantages of close monitoring, hospitalization by itself may lead to in-hospital complications and potentially worsen the prognosis of PE patients.

OBJECTIVES:

To determine the net clinical benefit of hospitalization versus outpatient management of normotensive patients with acute pulmonary embolism (PE).

METHODS:

Retrospective cohort propensity score analysis (radius marching with replacement). Hemodynamically stable PE patients treated as outpatients or inpatients were matched to balance out differences for 28 patient characteristics and known risk factors of adverse events. The primary outcome was the rate of adverse events at 14 days including recurrent venous thromboembolism, major bleeding or death.

RESULTS:

Among 1127 eligible patients, 1081 were included in the matched cohort, 576 treated as inpatients and 505 as outpatients. The 14-day rate of adverse events was 13.0% for inpatients and 3.3% for outpatients: adjusted OR: 5.07 (95%CI: 1.68-15.28). The 3-month rate was 21.7% for inpatients and 6.9% for outpatients: OR 4.90 (95% CI: 2.62-9.17). In the high-risk subgroup (PESI class III-V; n=597), the 14-day rate of adverse events was 16.5% for hospitalized patients vs. 4.5% for outpatients (OR 4.16, 95% CI 1.2-14.35).

CONCLUSION:

Outpatient treatment of hemodynamically stable PE patients seems associated with a lower rate of adverse events than hospitalization and, if confirmed, may be considered as first-line management in patients not requiring specific in-hospital care, regardless of their initial risk stratification, if proper outpatient care can be provided. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

PMID: 28106343 [PubMed - as supplied by publisher]