Impact of relative contraindications to home management in emergency department patients with low-risk pulmonary embolism

Kaiser Permanente Clinical Research on Emergency ServicesTreatment (CREST) Network

Research output: Contribution to journalArticle

9 Citations (Scopus)

Abstract

Rationale: Studies of adults presenting to the emergency department (ED) with acute pulmonary embolism (PE) suggest that those who are low risk on the PE Severity Index (classes I and II) can be managed safely without hospitalization. However, the impact of relative contraindications to home management on outcomes has not been described. Objectives: To compare 5-day and 30-day adverse event rates among low-risk ED patients with acute PE without and with outpatient ineligibility criteria. Methods: We conducted a retrospective multicenter cohort study of adults presenting to the ED with acute low-risk PE between 2010 and 2012. We evaluated the association between outpatient treatment eligibility criteria based on a comprehensive list of relative contraindications and 5-day adverse events and 30-day outcomes, including major hemorrhage, recurrent venous thromboembolism, and all-cause mortality. Measurements and Main Results: Of 423 adults with acute low-risk PE, 271 (64.1%) had no relative contraindications to outpatient treatment (outpatient eligible), whereas 152 (35.9%) had at least one contraindication (outpatient ineligible). Relative contraindications were categorized as PE-related factors (n = 112; 26.5%), comorbid illness (n = 42; 9.9%), and psychosocial barriers (n = 19; 4.5%). There were no 5-day events in the outpatient-eligible group (95% upper confidence limit, 1.7%) and two events (1.3%; 95% confidence interval [CI], 0.1-5.0%) in the outpatient-ineligible group (P = 0.13). At 30 days, there were five events (two recurrent venous thromboemboli and three major bleeding events) in the outpatient-eligible group (1.8%; 95% CI, 0.7-4.4%) compared with nine in the ineligible group (5.9%; 95% CI, 2.7-10.9%; P < 0.05). This difference remained significant when controlling for PE severity class. Conclusions: Nearly two-thirds of adults presenting to the ED with low-risk PE were potentially eligible for outpatient therapy. Relative contraindications to outpatient management were associated with an increased frequency of adverse events at 30 days among adults with low-risk PE.

Original languageEnglish (US)
Pages (from-to)666-673
Number of pages8
JournalAnnals of the American Thoracic Society
Volume12
Issue number5
DOIs
StatePublished - May 1 2015

Fingerprint

Pulmonary Embolism
Hospital Emergency Service
Outpatients
Confidence Intervals
Hemorrhage
Venous Thromboembolism
Multicenter Studies
Hospitalization
Cohort Studies
Therapeutics
Mortality

Keywords

  • Ambulatory care
  • Pulmonary embolism
  • Risk assessment

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine

Cite this

Impact of relative contraindications to home management in emergency department patients with low-risk pulmonary embolism. / Kaiser Permanente Clinical Research on Emergency ServicesTreatment (CREST) Network.

In: Annals of the American Thoracic Society, Vol. 12, No. 5, 01.05.2015, p. 666-673.

Research output: Contribution to journalArticle

Kaiser Permanente Clinical Research on Emergency ServicesTreatment (CREST) Network. / Impact of relative contraindications to home management in emergency department patients with low-risk pulmonary embolism. In: Annals of the American Thoracic Society. 2015 ; Vol. 12, No. 5. pp. 666-673.
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abstract = "Rationale: Studies of adults presenting to the emergency department (ED) with acute pulmonary embolism (PE) suggest that those who are low risk on the PE Severity Index (classes I and II) can be managed safely without hospitalization. However, the impact of relative contraindications to home management on outcomes has not been described. Objectives: To compare 5-day and 30-day adverse event rates among low-risk ED patients with acute PE without and with outpatient ineligibility criteria. Methods: We conducted a retrospective multicenter cohort study of adults presenting to the ED with acute low-risk PE between 2010 and 2012. We evaluated the association between outpatient treatment eligibility criteria based on a comprehensive list of relative contraindications and 5-day adverse events and 30-day outcomes, including major hemorrhage, recurrent venous thromboembolism, and all-cause mortality. Measurements and Main Results: Of 423 adults with acute low-risk PE, 271 (64.1{\%}) had no relative contraindications to outpatient treatment (outpatient eligible), whereas 152 (35.9{\%}) had at least one contraindication (outpatient ineligible). Relative contraindications were categorized as PE-related factors (n = 112; 26.5{\%}), comorbid illness (n = 42; 9.9{\%}), and psychosocial barriers (n = 19; 4.5{\%}). There were no 5-day events in the outpatient-eligible group (95{\%} upper confidence limit, 1.7{\%}) and two events (1.3{\%}; 95{\%} confidence interval [CI], 0.1-5.0{\%}) in the outpatient-ineligible group (P = 0.13). At 30 days, there were five events (two recurrent venous thromboemboli and three major bleeding events) in the outpatient-eligible group (1.8{\%}; 95{\%} CI, 0.7-4.4{\%}) compared with nine in the ineligible group (5.9{\%}; 95{\%} CI, 2.7-10.9{\%}; P < 0.05). This difference remained significant when controlling for PE severity class. Conclusions: Nearly two-thirds of adults presenting to the ED with low-risk PE were potentially eligible for outpatient therapy. Relative contraindications to outpatient management were associated with an increased frequency of adverse events at 30 days among adults with low-risk PE.",
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author = "{Kaiser Permanente Clinical Research on Emergency ServicesTreatment (CREST) Network} and Vinson, {David R.} and Drenten, {Carrieann E.} and Jie Huang and Morley, {J. Eileen} and Anderson, {Megan L.} and Reed, {Mary E.} and Daniel Nishijima and Vincent Liu",
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AU - Kaiser Permanente Clinical Research on Emergency ServicesTreatment (CREST) Network

AU - Vinson, David R.

AU - Drenten, Carrieann E.

AU - Huang, Jie

AU - Morley, J. Eileen

AU - Anderson, Megan L.

AU - Reed, Mary E.

AU - Nishijima, Daniel

AU - Liu, Vincent

PY - 2015/5/1

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N2 - Rationale: Studies of adults presenting to the emergency department (ED) with acute pulmonary embolism (PE) suggest that those who are low risk on the PE Severity Index (classes I and II) can be managed safely without hospitalization. However, the impact of relative contraindications to home management on outcomes has not been described. Objectives: To compare 5-day and 30-day adverse event rates among low-risk ED patients with acute PE without and with outpatient ineligibility criteria. Methods: We conducted a retrospective multicenter cohort study of adults presenting to the ED with acute low-risk PE between 2010 and 2012. We evaluated the association between outpatient treatment eligibility criteria based on a comprehensive list of relative contraindications and 5-day adverse events and 30-day outcomes, including major hemorrhage, recurrent venous thromboembolism, and all-cause mortality. Measurements and Main Results: Of 423 adults with acute low-risk PE, 271 (64.1%) had no relative contraindications to outpatient treatment (outpatient eligible), whereas 152 (35.9%) had at least one contraindication (outpatient ineligible). Relative contraindications were categorized as PE-related factors (n = 112; 26.5%), comorbid illness (n = 42; 9.9%), and psychosocial barriers (n = 19; 4.5%). There were no 5-day events in the outpatient-eligible group (95% upper confidence limit, 1.7%) and two events (1.3%; 95% confidence interval [CI], 0.1-5.0%) in the outpatient-ineligible group (P = 0.13). At 30 days, there were five events (two recurrent venous thromboemboli and three major bleeding events) in the outpatient-eligible group (1.8%; 95% CI, 0.7-4.4%) compared with nine in the ineligible group (5.9%; 95% CI, 2.7-10.9%; P < 0.05). This difference remained significant when controlling for PE severity class. Conclusions: Nearly two-thirds of adults presenting to the ED with low-risk PE were potentially eligible for outpatient therapy. Relative contraindications to outpatient management were associated with an increased frequency of adverse events at 30 days among adults with low-risk PE.

AB - Rationale: Studies of adults presenting to the emergency department (ED) with acute pulmonary embolism (PE) suggest that those who are low risk on the PE Severity Index (classes I and II) can be managed safely without hospitalization. However, the impact of relative contraindications to home management on outcomes has not been described. Objectives: To compare 5-day and 30-day adverse event rates among low-risk ED patients with acute PE without and with outpatient ineligibility criteria. Methods: We conducted a retrospective multicenter cohort study of adults presenting to the ED with acute low-risk PE between 2010 and 2012. We evaluated the association between outpatient treatment eligibility criteria based on a comprehensive list of relative contraindications and 5-day adverse events and 30-day outcomes, including major hemorrhage, recurrent venous thromboembolism, and all-cause mortality. Measurements and Main Results: Of 423 adults with acute low-risk PE, 271 (64.1%) had no relative contraindications to outpatient treatment (outpatient eligible), whereas 152 (35.9%) had at least one contraindication (outpatient ineligible). Relative contraindications were categorized as PE-related factors (n = 112; 26.5%), comorbid illness (n = 42; 9.9%), and psychosocial barriers (n = 19; 4.5%). There were no 5-day events in the outpatient-eligible group (95% upper confidence limit, 1.7%) and two events (1.3%; 95% confidence interval [CI], 0.1-5.0%) in the outpatient-ineligible group (P = 0.13). At 30 days, there were five events (two recurrent venous thromboemboli and three major bleeding events) in the outpatient-eligible group (1.8%; 95% CI, 0.7-4.4%) compared with nine in the ineligible group (5.9%; 95% CI, 2.7-10.9%; P < 0.05). This difference remained significant when controlling for PE severity class. Conclusions: Nearly two-thirds of adults presenting to the ED with low-risk PE were potentially eligible for outpatient therapy. Relative contraindications to outpatient management were associated with an increased frequency of adverse events at 30 days among adults with low-risk PE.

KW - Ambulatory care

KW - Pulmonary embolism

KW - Risk assessment

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