Outpatient Management of Patients Following Diagnosis of Acute Pulmonary Embolism

Abstract

Objective: While guidelines recommend outpatient management of patients with low-risk pulmonary embolism (PE), little is known about the disposition of patients with PE diagnosed in United States emergency departments (EDs). We sought to determine disposition practices and subsequent health care utilization in patients with acute PE in U.S. EDs.

Methods: This was a retrospective cohort study of adult ED patients with a new diagnosis of acute PE treated at 740 U.S. acute care hospitals from July 1, 2016, through June 30, 2018. The primary outcome was the initial disposition following an ED visit for acute PE. Additional measures included hospital cost and 30-day revisit rate to the ED.

Results: A total of 61,070 cases were included in the overall cohort, of which 4.1% of new cases of PE were discharged from the ED. The median hospital-specific proportion of patients discharged was 3.1% (interquartile range = 0.8%-6.8%). The median odds ratio, representing the importance of the hospital in initial disposition decisions, was 2.21 (95% confidence interval = 2.05 to 2.37), which was greater than any patient-level factor with the exception of concurrent ED diagnosis of hypoxemia/respiratory failure, shock, or hypotension. Within 30 days of discharge, 17.9% of discharged cases had an ED return visit to the ED only and 10.3% of patients were hospitalized. Of the 30-day ED return visits in patients initially managed as outpatients, 1.3% had a bleeding-associated diagnosis.

Conclusion: Despite guidelines promoting outpatient management, few patients are currently discharged home in the United States; however, practice varies widely across hospitals. Return visit rates were high but most did not result in hospitalization.

Figure 1.

Study cohort flow. CPT = Current Procedural Terminology; CTPA = computed tomographic pulmonary angiogram; IVC = inferior vena cava; PE = pulmonary embolism; V/Q = ventilation–perfusion.

Figure 2.

Point estimates represent the proportion of patients with acute PE discharged from the ED for the 568 individual hospitals with at least 20 cases of PE with error bars denoting 95% CIs. PE = pulmonary embolism.