An integrated electronic clinical decision support system (CDSS) safely increased outpatient management for low-risk acute pulmonary embolism (PE) patients in a recent study.
The study, published online in Annals of Internal Medicine, sought to determine if the CDSS could safely minimize the number of emergency department (ED) visits in PE patients whose condition could be managed in an outpatient setting.
The controlled pragmatic trial took place between January 2014 and April 2015 and was set at Kaiser Permanent Northern California’s 21 community EDs. After nine months, 10 EDs received a multidimensional technology and education intervention, while the other 11 sites became concurrent controls. The study’s primary outcome was discharge from the ED or a short-term (< 24-hour) ED-based outpatient observation unit to home. Adverse outcomes were PE-related symptoms that resulted in return visits within five days and recurrent venous thromboembolism, major hemorrhage, and all-cause mortality within 30 days.
During the study, 881 eligible PE patients presented at intervention sites and 822 at control sites. Adjusted home discharge increased at intervention sites (17.4% pre- to 28.0% postintervention) but slightly decreased at control sites (15.1% pre- and 14.5% postintervention). CDSS implementation was not correlated with PE-related five-day return visits or in 30-day major adverse outcomes. Researchers observed a difference-in-differences comparison of 11.3 percentage points (95% confidence interval [CI], 3.0 to 19.5 percentage points; P = 0.007).
Paul Stein, MD, and Mary J. Hughes, DO, both of Michigan State University College of Osteopathic Medicine in East Lansing, neither of whom were involved in the study, wrote an accompanying editorial in which they reveal that only about 6% of stable PE patients receive home treatment.
“Home treatment of pulmonary embolism (PE) is much preferred by patients: Most (88%) who received home treatment would choose it again rather than hospitalization,” they wrote. “It is also clearly cost-effective: If all eligible patients with PE seen in U.S. emergency departments were treated at home rather than in the hospital, health care costs would decrease by $1 billion per year. The evidence for safe home treatment of low-risk patients with acute PE is substantial.”
According to Stein, the question “Why?” is multifaceted.
“There are many reasons for this,” he told MedPage Today. “Doctors in the emergency departments may be hurried or they may not be convinced that there will be proper follow-up. There has also been no standard criteria for identifying patients who are good candidates for home treatment.”
The study researchers concluded, “The use of clinical decision support systems to bring validated risk-stratification tools to the ED bedside could help advance this agenda and could be expanded beyond PE to improve care and resource use for other clinical conditions.”
Sources: Annals of Internal Medicine: Increasing Safe Outpatient Management of Emergency Department Patients With Pulmonary Embolism: A Controlled Pragmatic Trial; Mounting Evidence for Safe Home Treatment of Selected Patients With Acute Pulmonary Embolism, Healio