Reducing the hospital burden associated with the treatment of pulmonary embolism

Abstract

Pulmonary embolism (PE) is the most feared clinical presentation of venous thromboembolism (VTE). Patients with PE have traditionally been treated in hospital; however, many are at low risk of adverse outcomes and current guidelines suggest outpatient treatment as an option. Outpatient treatment of PE offers several advantages, including reduced risk of hospital-acquired conditions and potential cost savings. Despite this, patients with low-risk PE are still frequently hospitalized for treatment. This narrative review summarizes current guideline recommendations for the identification of patients with low-risk PE who are potentially suitable for outpatient treatment, using prognostic assessment tools (e.g. the Pulmonary Embolism Severity Index [PESI] and simplified PESI) and clinical exclusion criteria (e.g. Hestia criteria) alone or in combination with additional cardiac assessments. Treatment options are discussed along with recommendations for the follow-up of patients managed in the non-hospital environment. The available data on outpatient treatment of PE are summarized, including details on patient selection, anticoagulant choice, and short-term outcomes in each study. Accumulating evidence suggests that outcomes in patients with low-risk PE treated as outpatients are at least as good as, if not better than, those of patients treated in the hospital. With mounting pressures on health care systems worldwide, increasing the proportion of patients with PE treated as outpatients has the potential to reduce health care burdens associated with VTE.

Keywords: ambulatory care; anticoagulants; pulmonary embolism; risk stratification; venous thromboembolism.

Figure 1

Identification of patients with PE suitable for outpatient treatment and key considerations prior to discharge based on recommendations found in the 2018 BTS guidelines on the outpatient treatment of PE 50. *i.e. no shock or hypotension at presentation. ^†All patients being considered for outpatient management should be reviewed by a senior clinician (e.g. a consultant) prior to discharge on an outpatient pathway. BNP, brain natriuretic peptide; BTS, British Thoracic Society; CT, computed tomography; hs, high‐sensitivity; PE, pulmonary embolism; PESI, Pulmonary Embolism Severity Index; RV, right ventricle; sPESI, simplified Pulmonary Embolism Severity Index.