Pulmonary/original researchCan Selected Patients With Newly Diagnosed Pulmonary Embolism Be Safely Treated Without Hospitalization? A Systematic Review
Introduction
Patients with acute deep venous thrombosis and pulmonary embolism have traditionally been treated initially with parenteral anticoagulation in the hospital. The advent of low-molecular-weight heparin transferred much of early deep venous thrombosis care to an outpatient setting.1, 2, 3, 4 Although a similar site-of-treatment shift for select patients with pulmonary embolism has been recommended by several professional societies,5, 6, 7, 8 outpatient pulmonary embolism management is uncommon. Hindering acceptance of this change in practice is a lack of consensus about how to identify emergency department (ED) patients who are candidates for home treatment, along with concerns about patient safety.9
Emergency physicians provide care for most patients presenting with pulmonary embolism acquired outside the hospital and play a central role in choosing the initial management strategy. We sought to examine the evidence about the safety of exclusive ambulatory management for patients with acute symptomatic pulmonary embolism.
Section snippets
Selection of Participants
We designed our review to answer the following research question: Can selected outpatients with newly diagnosed pulmonary embolism be treated safely and effectively without hospitalization? Previous reviews on overlapping questions exist,10, 11 but our approach differs in 3 ways.
First, our patient population is restricted to those without hospitalization, excepting a period of observation (usually <24 hours) in the ED. We did not examine studies of shortened inpatient stay followed by early
Results
The flow diagram of our search is illustrated in the Figure. From the 2,286 titles and abstracts we screened, we identified 24 prospective studies that included patients with acute symptomatic pulmonary embolism initially treated without hospitalization. After full-text review, we identified 17 studies that met initial exclusion criteria: an atypical outpatient setting or arrangement, viz, a hotel (n=1)23; and objective outcome measures not described or reported for the pulmonary embolism
Limitations
This review is limited by the small number of randomized controlled studies available for inclusion. The observational nature of 7 of the 8 studies subjects the findings to significant risk of bias because of lack of controlling for numerous confounding factors. Nonetheless, we included these data to ensure we had the most complete information on safety, a critical factor in choosing outpatient care. The heterogeneity of patient inclusion/exclusion criteria prevented any formal meta-analysis of
Discussion
Changing common practice is difficult for a condition like acute pulmonary embolism, in which serious complications occur in a limited few.54 Physicians often overestimate the risk of harm with novel treatment strategies or assume hospital-based care is necessarily safer than alternative arrangements. Identifying which subgroups of patients with any illness, acute pulmonary embolism included, can be treated well in a less costly and more comfortable setting is key to enhancing health care
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2021, ChestCitation Excerpt :The recommendation in AT9 was based on two trials that randomized patients with acute PE to receive LMWH for only 3 days in the hospital136 or entirely at home118 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.137–139 The 1st update guidance statement was consistent with AT9 but was modified to state that appropriately selected patients may be treated entirely at home, rather than just be discharged early.
Opinion and practice survey about the use of prognostic models in acute pulmonary embolism
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Outpatient Management of Emergency Department Patients With Acute Pulmonary Embolism: Variation, Patient Characteristics, and Outcomes
2018, Annals of Emergency Medicine
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Supervising editor: Steven M. Green, MD
Author contributions: DRV conceived the study and all authors contributed to its design. DRV and SZ retrieved and summarized the data. DRV drafted the article, and all authors contributed substantively to its critical revision and its final approval. DRV takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Dr. Yealy received federal funding for prior research on pulmonary embolism: 1R01HL085565-01 and 1K12 HL109068-01.
Please see page 652 for the Editor's Capsule Summary of this article.
Publication date: Available online September 1, 2012.