David R Vinson1,2,3, Erik R Hofmann4,5, Elizabeth J Johnson6, Suresh Rangarajan4,7, Jie Huang8, Dayna J Isaacs9,10, Judy Shan8,11, Karen L Wallace4,12, Adina S Rauchwerger8, Mary E Reed8, Dustin G Mark4,8,13. 1. The Permanente Medical Group, Oakland, CA, USA. drvinson@ucdavis.edu. 2. Kaiser Permanente Division of Research, Oakland, CA, USA. drvinson@ucdavis.edu. 3. Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, 1600 Eureka Road, Roseville, CA, 95661, USA. drvinson@ucdavis.edu. 4. The Permanente Medical Group, Oakland, CA, USA. 5. Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA. 6. Department of Emergency Medicine, UC Davis Health, Sacramento, CA, USA. 7. Department of Adult and Family Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA. 8. Kaiser Permanente Division of Research, Oakland, CA, USA. 9. School of Medicine, University of California, Davis, Sacramento, CA, USA. 10. Internal Medicine Residency Program, University of California Los Angeles, Los Angeles, CA, USA. 11. University of California San Francisco School of Medicine, San Francisco, CA, USA. 12. Department of Radiology, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA. 13. Departments of Emergency and Critical Care Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA.
Abstract
BACKGROUND: The management and outcomes of patients diagnosed with acute pulmonary embolism in primary care have not been characterized. OBJECTIVE: To describe 30-day outcomes stratified by initial site-of-care decisions DESIGN: Multicenter retrospective cohort study PARTICIPANTS: Adults diagnosed with acute pulmonary embolism in primary care in a large, diverse community-based US health system (2013-2019) MAIN MEASURES: The primary outcome was a composite of 30-day serious adverse events (recurrent venous thromboembolism, major bleeding, and all-cause mortality). The secondary outcome was 7-day pulmonary embolism-related hospitalization, either initial or delayed. KEY RESULTS: Among 652 patient encounters (from 646 patients), median age was 64 years; 51.5% were male and 70.7% identified as non-Hispanic white. Overall, 134 cases (20.6%) were sent home from primary care and 518 cases (79.4%) were initially referred to the emergency department (ED) or hospital. Among the referred, 196 (37.8%) were discharged home from the ED without events. Eight patients (1.2%; 95% CI 0.5-2.4%) experienced a 30-day serious adverse event: 4 venous thromboemboli (0.6%), 1 major bleed (0.2%), and 3 deaths (0.5%). Seven of these patients were initially hospitalized, and 1 had been sent home from primary care. All 3 deaths occurred in patients with known metastatic cancer initially referred to the ED, hospitalized, then enrolled in hospice following discharge. Overall, 328 patients (50.3%) were hospitalized within 7 days: 322 at the time of the index diagnosis and 6 following initial outpatient management (4 clinic-only and 2 clinic-plus-ED patients). CONCLUSIONS: Patients diagnosed with acute pulmonary embolism in this primary care setting uncommonly experienced 30-day adverse events, regardless of initial site-of-care decisions. Over 20% were managed comprehensively by primary care. Delayed 7-day pulmonary embolism-related hospitalization was rare among the 51% treated as outpatients. Primary care management of acute pulmonary embolism appears to be safe and could have implications for cost-effectiveness and patient care experience.
BACKGROUND: The management and outcomes of patients diagnosed with acute pulmonary embolism in primary care have not been characterized. OBJECTIVE: To describe 30-day outcomes stratified by initial site-of-care decisions DESIGN: Multicenter retrospective cohort study PARTICIPANTS: Adults diagnosed with acute pulmonary embolism in primary care in a large, diverse community-based US health system (2013-2019) MAIN MEASURES: The primary outcome was a composite of 30-day serious adverse events (recurrent venous thromboembolism, major bleeding, and all-cause mortality). The secondary outcome was 7-day pulmonary embolism-related hospitalization, either initial or delayed. KEY RESULTS: Among 652 patient encounters (from 646 patients), median age was 64 years; 51.5% were male and 70.7% identified as non-Hispanic white. Overall, 134 cases (20.6%) were sent home from primary care and 518 cases (79.4%) were initially referred to the emergency department (ED) or hospital. Among the referred, 196 (37.8%) were discharged home from the ED without events. Eight patients (1.2%; 95% CI 0.5-2.4%) experienced a 30-day serious adverse event: 4 venous thromboemboli (0.6%), 1 major bleed (0.2%), and 3 deaths (0.5%). Seven of these patients were initially hospitalized, and 1 had been sent home from primary care. All 3 deaths occurred in patients with known metastatic cancer initially referred to the ED, hospitalized, then enrolled in hospice following discharge. Overall, 328 patients (50.3%) were hospitalized within 7 days: 322 at the time of the index diagnosis and 6 following initial outpatient management (4 clinic-only and 2 clinic-plus-ED patients). CONCLUSIONS: Patients diagnosed with acute pulmonary embolism in this primary care setting uncommonly experienced 30-day adverse events, regardless of initial site-of-care decisions. Over 20% were managed comprehensively by primary care. Delayed 7-day pulmonary embolism-related hospitalization was rare among the 51% treated as outpatients. Primary care management of acute pulmonary embolism appears to be safe and could have implications for cost-effectiveness and patient care experience.
Authors: David R Vinson; Dustin G Mark; Uli K Chettipally; Jie Huang; Adina S Rauchwerger; Mary E Reed; James S Lin; Mamata V Kene; David H Wang; Dana R Sax; Tamara S Pleshakov; Ian D McLachlan; Cyrus K Yamin; Andrew R Elms; Hilary R Iskin; Ridhima Vemula; Donald M Yealy; Dustin W Ballard Journal: Ann Intern Med Date: 2018-11-13 Impact factor: 25.391
Authors: Dana R Sax; David R Vinson; Cyrus K Yamin; Jie Huang; Troy M Falck; Reena Bhargava; Debra J Amaral; Mary E Reed Journal: Health Aff (Millwood) Date: 2018-12 Impact factor: 6.301
Authors: Aveh Bastani; Erica Su; David H Adler; Christopher Baugh; Jeffrey M Caterino; Carol L Clark; Deborah B Diercks; Judd E Hollander; Susan E Malveau; Bret A Nicks; Daniel K Nishijima; Manish N Shah; Kirk A Stiffler; Alan B Storrow; Scott T Wilber; Annick N Yagapen; Robert E Weiss; Benjamin C Sun Journal: Ann Emerg Med Date: 2018-12-07 Impact factor: 5.721