Web Tool Identifies Which PE Patients Can Be Treated at Home

Jennifer Garcia

November 12, 2018

An Internet-based support tool may help physicians quickly identify patients with acute pulmonary embolism (PE) who can be safely treated at home, thereby avoiding the need for hospitalization. These findings were published online November 13 in Annals of Internal Medicine.

Researchers led by David R. Vinson, MD, from the Kaiser Permanente Sacramento Medical Center, Sacramento, California, designed a Web-based clinical decision support system (CDSS) to aid emergency department (ED) physicians in identifying patients eligible for outpatient PE care. The CDSS was linked to the electronic health records and included a validated risk-stratification tool, the PE Severity Index, as well as a list of contraindications to outpatient care.

The researchers evaluated use of the CDSS across 21 EDs in northern California between January 1, 2014, and April 30, 2015. At 10 of the sites (intervention sites), there was onsite physician training on PE outpatient management and use of the CDSS as well as ongoing feedback and incentives to encourage enrollment. The remaining 11 sites were considered control sites.

Patients included in the cohort were adults with acute PE who had been diagnosed in the ED or within a 12-hour period prior to ED arrival. PE was identified by CT pulmonary angiography, ventilation-perfusion scan, or compression ultrasonography with associated PE symptoms. Overall, 881 patients were evaluated at the intervention sites, and 822 were evaluated at control sites. Facility and patient characteristics were similar between the two groups.

Using the CDSS, physicians classified patients with PE as low-risk or high-risk to determine whether outpatient care was appropriate. The safety outcome for the study was "5-day return visits for PE-related signs, symptoms, or interventions and 30-day major hemorrhage, recurrent venous thromboembolism, and all-cause mortality."

The researchers found that the home discharge rate increased at the intervention sites without a concurrent increase at the control sites (17.4% pre- and 28.0% postintervention vs 15.1% pre- and 14.5% postintervention, respectively). Further, there was no difference between the groups with respect to 5-day return visits or 30-day major adverse outcomes.

On the basis of these results, the authors calculated that for every 100 patients with PE seen in the ED, use of the CDSS averted 11 hospitalizations, which, assuming a median hospitalization stay of 3.2 days, would result in a savings of approximately $80,000.

"Implementation and structured promotion of a CDSS to aid physicians in site-of-care decision making for ED patients with acute PE safely increased outpatient management," conclude Vinson and colleagues.

The study authors acknowledge that a limitation of the study was the lack of random allocation and that "the limited geographic range and practice setting may have reduced generalizability."

In an accompanying editorial, Paul D. Stein, MD, and Mary J. Hughes, DO, from the Michigan State University College of Osteopathic Medicine, East Lansing, note that difficulty in accurately identifying patients who are eligible for outpatient PE care is likely the reason that so few patients are treated at home.

Use of this computer tool in the ED "enabled physicians to knowledgeably select a larger proportion of patients for home treatment," write the editorialists.

Despite this, Stein and Hughes point out that there are challenges to implementation, including access to outpatient counseling, lack of CDSS promotion and education within hospitals, and variability among physicians regarding candidacy for at-home treatment.

Funding for this study was provided by the Garfield Memorial National Research Fund, the Permanente Medical Group Delivery Science and Physician Researcher Programs, the Kaiser Permanente Innovation Fund for Technology, and the KPNC Community Benefit Program. The authors and the editorialist have disclosed no relevant financial relationships.

Ann Intern Med. Published online November 13, 2018. Abstract, Editorial

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