Trends in home treatment and early discharge of patients with low-risk pulmonary embolism

Abstract

Background Recent guidelines recommend a strategy of home treatment or early discharge in low-risk pulmonary embolism (PE). Contemporary rates of the implementation of this approach in everyday clinical practice are unknown. Objective To determine the proportion of patients with PE who fulfill eligibility criteria for home treatment or early discharge, to investigate in how many of them such a management strategy is actually followed, and to discover differences in early complications between early or later discharge among low-risk patients. Methods Based on the United States Nationwide Emergency Department Sample and Nationwide Readmission Database, we identified low-risk PE patients (absence of hemodynamic instability, cor pulmonale, tachycardia, dyspnea, hypothermia, altered mental status, and fulfillment of the Hestia criteria). We analyzed the proportion of direct or early (<48 hours) discharge and the association with demographic and clinical variables. We also studied the 90-day occurrence of venous thromboembolism recurrence and major bleeding. Results From 2016 to 2020, 641 621 (30.6%) of 2 099 390 PE cases in the Nationwide Emergency Department Sample database were low risk. Among low-risk PE, 31.5% received home treatment compared with 15.4% of those not classified as low risk. Home treatment for low-risk patients showed an increasing trend over time. In the Nationwide Readmission Database, 481 321 (24.7%) of 1 950 708 PE hospitalizations were classified as low risk. An early discharge strategy was followed in 22.6% of all cases, increasing to 45.9% for low-risk PE admissions, with a rising trend observed from 2016. Factors associated with home treatment or early discharge among low-risk patients included age, sex, and absence of comorbidities. Ninety-day incidence of venous thromboembolism recurrence and major bleeding was low among low-risk patients with early discharge (1.3% and 1.5%, respectively). Conclusion There is an increasing adoption of home treatment and early discharge for low-risk PE in routine practice. This approach appears safe, supporting findings from previous trials.