Elsevier

Annals of Emergency Medicine

Volume 60, Issue 5, November 2012, Pages 651-662.e4
Annals of Emergency Medicine

Pulmonary/original research
Can Selected Patients With Newly Diagnosed Pulmonary Embolism Be Safely Treated Without Hospitalization? A Systematic Review

https://doi.org/10.1016/j.annemergmed.2012.05.041Get rights and content

Study objective

Omitting inpatient therapy for emergency department patients with newly diagnosed pulmonary embolism occurs infrequently in the United States. We seek to describe the safety of initial outpatient management of these patients and their demographics, comorbidities, risk stratification, treatment, and outcomes.

Methods

We identified studies from searches of MEDLINE, EMBASE, and other databases from inception through March 22, 2012. We supplemented this with a search of conference proceedings and consultation with experts. We selected prospective studies of adults with acute, symptomatic, objectively confirmed pulmonary embolism who were discharged home without hospitalization. All contributing studies explicitly defined inclusion and exclusion criteria plus objectively confirmed outcome measures: recurrent thromboembolism, major hemorrhage, and mortality. Two investigators independently identified eligible studies and extracted data. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria to assess study quality.

Results

From 2,286 screened titles/abstracts, we selected 8 studies with a total of 777 patients. Seven observational studies were rated low in quality. The one randomized controlled trial was higher in quality, used stricter inclusion criteria, and found that 90-day outcomes for outpatient management were not inferior to inpatient care. Among the 7 studies that reported 90-day outcome measures, the overall incidence of venous thromboembolic–related and hemorrhage-related mortality was very low: 0 of 741 (upper 95% confidence limit 0.62%).

Conclusion

The data on exclusive outpatient management of acute symptomatic pulmonary embolism are limited, but the existing evidence supports the feasibility and safety of this approach in carefully selected low-risk patients.

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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    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.

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