Outpatient Management of Low-Risk PE: Making This a Sustainable Practice

A short-term initiative to encourage emergency department (ED) staff to treat low-risk patients for acute pulmonary embolism (PE) via outpatient management continued to guide ED clinicians’ decisions 4 years later, suggesting that initiatives for implementing appropriate practice changes may effectively be sustained. This was among study findings recently published in JAMA Network Open.

Previous research has shown that low-risk PE may be safely managed outside of the hospital, thereby lowering health care costs and avoiding the risk and inconvenience of hospitalization for patients, said authors of the current study.  Yet this practice has not been embraced by US physicians, said study authors. “Physician barriers include discomfort with the unfamiliar, aversion to complexity, and concern about medicolegal risks,” they noted.

In 2014, researchers affiliated with Kaiser Permanente and the University of California at Davis initiated an 8-month intervention known as Electronic Support for Pulmonary Embolism Emergency Disposition (eSPEED; ClinicalTrials.gov Identifier: NCT03601676), which aimed to assist ED physicians in surmounting obstacles to outpatient management for low-risk PE patients. The trial provided web-based support and recommendations embedded in the electronic health record, as well as onsite “peer champions,” who acted as educators, advisors, and role models.

During the trial, the use of outpatient care for low-risk PE by ED physicians escalated safely, whereas conventional treatment remained unchanged in physicians who served as controls. At 10 intervention EDs, outpatient care for PE climbed by 59% — from 17.8% of PE patients to 28.3% of patients. At 11 control EDs, no increase in discharge to home was noted; 8.0% of PE patients were sent home during the preintervention period, compared with 7.0% of patients sent home in the postintervention period.

More recently, researchers undertook another study to determine whether the shift to outpatient management of low-risk PE implemented 4 years prior was being sustained at the intervention EDs and whether any shift had occurred among clinicians at control sites in the eSPEED trial. Investigators for this study theorized that the previous improvements would continue and that the gains would extend even to ED physicians who had formerly served as controls.

The investigators conducted a 14-month retrospective cohort trial, named the Sustained Effects (SUS-EFX) Study, beginning in 2019, in 21 EDs within the Kaiser Permanente health care system. In this study, investigators compared the rate of outpatient management of low-risk PE observed in the previous intervention group of ED physicians with that of physicians who had been controls.

A total of 1268 adults visited the ED for PE. Of the total, 229 were excluded due to prior thromboembolic disease, anticoagulation, or brief health plan participation, leaving 1039 eligible patients (N=1039). Study investigators noted that “Patients selected for outpatient care were younger, less commonly arrived by ambulance, had markedly anomalous vital signs or elevated troponin concentrations, and more commonly arrived with pre-ED imaging or were in lower-risk classes than their hospitalized counterparts.”

In all, 156 patients (28.4%) at intervention sites and 122 patients (25.0%) at control sites were managed as outpatients (difference, 3.4; 95% CI, −2.2 to 8.8; P =.21). Moreover, study investigators said that, “When evaluated by risk strata, the intervention EDs outperformed their control counterparts among patients with lower risk: 109 patients (46.2%) vs 81 patients (34.0%; difference, 12.2; 95% CI, 3.4-20.9; P =.007), with no statistically significant differences among patients with higher risk.”

Only 4 outpatients (1.4%) required hospitalization, and 30-day all-cause mortality stood at 4.3%, in line with that of earlier research.

Limitations of the study included incomplete case identification, inability to pin down which interventions led to more outpatient care, and results that may not be valid in other populations or health care sites.

“This cohort study found that prior gains in outpatient management of acute PE among patients in the ED…were associated with increased outpatient management of PE among patients with lower risk 4 years after trial cessation,” the authors explained. “Insights from the SUS-EFX study will inform how we roll out new EHR-embedded decision support for other clinical conditions, now with an eye toward sustainability without continued promotion,” they said.

Reference

Vinson DR, Casey SD, Vuong PL, Huang J, Ballard DW, Reed ME. Sustainability of a clinical decision support intervention for outpatient care for emergency department patients with acute pulmonary embolism. JAMA Netw Open. 2022;5(5):e2212340. doi:10.1001/jamanetworkopen.2022.12340