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Unnecessary Hospitalizations for Pulmonary Embolism: Impact on US Health Care Costs

2016; Elsevier BV; Volume: 129; Issue: 9 Linguagem: Inglês

10.1016/j.amjmed.2016.03.041

1555-7162

James E. Dalen, James E. Dalen,

Patient Satisfaction in Healthcare

SEE RELATED ARTICLE, p. 974Each year, more than 350,000 patients are treated for pulmonary embolism in US hospitals.1Centers for Disease Control and Prevention (CDC) Venous thromboembolism in adult hospitalizations – United States, 2007-2009.MMWR Morb Mortal Wkly Rep. 2012; 61: 401-404PubMed Google Scholar SEE RELATED ARTICLE, p. 974 Recent reports indicate that the majority of these patients do not have to be hospitalized: they can be safely treated at home, which will result in a tremendous decrease in our health care costs. One of the first reports that many patients with acute pulmonary embolism can safely be treated at home with subcutaneous injections of low-molecular-weight heparin (LMWH) and oral warfarin appeared in 1998.2Wells P.S. Kovacs M.J. Bormanis J. et al.Expanding eligibility for outpatient treatment of deep venous thrombosis and pulmonary embolism with low molecular-weight heparin.Arch Intern Med. 1998; 158: 1809-1812Crossref PubMed Scopus (302) Google Scholar Since that report, multiple reports have confirmed that low-risk pulmonary embolism patients treated at home have a mortality rate, pulmonary embolism recurrence rate, and an incidence of bleeding complications similar to pulmonary embolism patients who are hospitalized.3Piran S. LeGal G. Wells P.S. et al.Outpatient treatment of symptomatic pulmonary embolism: a systematic review and meta-analysis.Thromb Res. 2013; 132: 515-519Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar, 4Erkins P.M.G. Gandara E. Wells P. Safety of outpatient treatment in acute pulmonary embolism.J Thromb Haemost. 2010; 8: 2412-2417Crossref Scopus (89) Google Scholar The pulmonary embolism patients who can safely be treated at home are low-risk patients who are not in shock, do not require supplemental oxygen or parenteral narcotics for pain, and do not have other conditions that require hospitalization. The percentage of acute pulmonary embolism patients that are low risk has been reported to be more than 50%.2Wells P.S. Kovacs M.J. Bormanis J. et al.Expanding eligibility for outpatient treatment of deep venous thrombosis and pulmonary embolism with low molecular-weight heparin.Arch Intern Med. 1998; 158: 1809-1812Crossref PubMed Scopus (302) Google Scholar, 3Piran S. LeGal G. Wells P.S. et al.Outpatient treatment of symptomatic pulmonary embolism: a systematic review and meta-analysis.Thromb Res. 2013; 132: 515-519Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar, 4Erkins P.M.G. Gandara E. Wells P. Safety of outpatient treatment in acute pulmonary embolism.J Thromb Haemost. 2010; 8: 2412-2417Crossref Scopus (89) Google Scholar The disadvantage of home treatment is that LMWH must be injected. Two new oral anticoagulants (factor Xa inhibitors), rivaroxaban in 2012 and apixaban in 2014, have been approved by the US Food and Drug Administration for treatment of pulmonary embolism without the need for parenteral heparin or LMWH.5Stein P.D. Matta F. Hughes P.G. et al.Home treatment of pulmonary embolism in the era of novel oral anticoagulants.Am J Med. 2016; 129: 974-977Abstract Full Text Full Text PDF Scopus (41) Google Scholar The ability to treat pulmonary embolism with oral anticoagulants alone, without parenteral heparin, simplifies treatment and increases the number of patients who can be treated at home. Stein et al,5Stein P.D. Matta F. Hughes P.G. et al.Home treatment of pulmonary embolism in the era of novel oral anticoagulants.Am J Med. 2016; 129: 974-977Abstract Full Text Full Text PDF Scopus (41) Google Scholar in this issue of The American Journal of Medicine, determined how many patients presenting with pulmonary embolism to the emergency department of 5 different US hospitals in 2013 and 2014 were treated at home. Of 983 patients presenting with pulmonary embolism, 746 (76%) were eligible for home treatment because they were hemodynamically stable and did not require supplemental oxygen. However, only 13 (1.7%) of the 746 eligible patients were treated at home. Ninety-eight percent of these low-risk patients were hospitalized unnecessarily.5Stein P.D. Matta F. Hughes P.G. et al.Home treatment of pulmonary embolism in the era of novel oral anticoagulants.Am J Med. 2016; 129: 974-977Abstract Full Text Full Text PDF Scopus (41) Google Scholar Why were so few patients treated at home? Practice patterns are resistant to change. Hospitalization of patients with acute pulmonary embolism has been the long-standing standard of care. The 2012 American College of Chest Physicians clinical guidelines recommended a 5-day hospitalization for acute pulmonary embolism. They suggested early (2-day) discharge with low-risk pulmonary embolism patients whose home circumstances are adequate.6Kearon C. Akl E.A. Comerato A.J. et al.Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.Chest. 2012; 141: e419s-e494sCrossref PubMed Scopus (2921) Google Scholar This recommendation changed in their 2016 report.7Kearon C. Akl E.A. Ornelas J. et al.Antithrombotic therapy for VTE disease CHEST guideline and expert panel report.Chest. 2016; 149: 315-352Crossref PubMed Scopus (3364) Google Scholar In 2016 they recommended home treatment in low-risk patients if home circumstances are adequate.7Kearon C. Akl E.A. Ornelas J. et al.Antithrombotic therapy for VTE disease CHEST guideline and expert panel report.Chest. 2016; 149: 315-352Crossref PubMed Scopus (3364) Google Scholar The impact of unnecessary hospitalizations of low-risk pulmonary embolism patients on health care costs is enormous. Of the estimated 350,000 patients hospitalized with pulmonary embolism each year, 50% (175,000) are admitted from an emergency department.8Pollack C.V. Schreiber D. Goldhaber S. et al.Clinical Characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department.J Am Coll Cardiol. 2011; 57: 700-706Abstract Full Text Full Text PDF PubMed Scopus (362) Google Scholar More than half (87,500) of these patients could be treated at home. If these 87,500 pulmonary embolism patients were treated at home rather than being admitted for hospital care, at an estimated average cost of $11,500,9Dasta J.F. Pilon D. Mody S.H. et al.Daily hospitalization costs in patients with deep vein thrombosis or pulmonary embolism treated with anticoagulant therapy.Thromb Res. 2015; 135: 303-310Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar it would decrease US health care costs by $1 billion per year. To paraphrase the late Senator Dirksen of Illinois: a billion here, a billion there, and soon we will be talking about real savings! Home Treatment of Pulmonary Embolism in the Era of Novel Oral AnticoagulantsThe American Journal of MedicineVol. 129Issue 9PreviewOutpatient therapy of patients with acute pulmonary embolism has been shown to be safe in carefully selected patients. Problems related to the injection of low-molecular-weight heparin at home can be overcome by use of novel oral anticoagulants. The purpose of this investigation is to assess the prevalence of home treatment in the era of novel oral anticoagulants. Full-Text PDF