Almost all participants (99%) completed the satisfaction survey, which indicated that 92% of outpatients and 95% of inpatients were satisfied or very satisfied with their care. Hospital readmission rates, ED visits, and visits to primary care physicians were similar, with no significant differences between the 2 groups. The mean time spent in the hospital was 0.5 days (standard deviation [SD], 1.0) for outpatients and 3.9 days (SD, 3.1) for in-patients. Fourteen percent of outpatients and 6% of inpatients received home nursing visits for enoxaparin injection. The total number of home visits was higher among outpatients (348 vs 105). Because both groups had extreme outliers, however, this difference was not statistically significant.
WHAT’S NEW: It’s safe to keep low-risk patients at home
This is the first RCT comparing the safety and effectiveness of outpatient and inpatient treatment of acute, symptomatic PE. Results were statistically comparable, and patients were satisfied being treated at home. Outpatient treatment was less expensive because of the shorter length of stay (0.5 vs 3.9 days) and was associated with the same rates of hospital readmission, ED visits, and visits to primary care physicians. There were more home nursing visits in the outpatient treatment group. But even if you assume a cost of $200 per home visit, the additional cost would be about $282 per individual in the outpatient group—significantly less than the cost of the additional 3.4 days in the hospital for each individual in the inpatient group.
The study also confirmed that the PESI accurately identifies low-risk patients with PE who can be treated in an outpatient setting. Thirty percent of patients who were screened for the OTPE trial met the low-risk eligibility requirement.
CAVEATS: Use of risk assessment tool is essential
The average age of patients in this study was 47 years in the outpatient group and 49 years in the inpatient group. In addition, only 1% to 3% of the patients were diagnosed with cancer. Older patients who have both cancer and PE would be unlikely to qualify for outpatient care.
Physicians applying this practice changer should use the PESI to ensure that outpatient treatment for PE is used only for individuals at low risk.
CHALLENGES TO IMPLEMENTATION: ED coordination, training, and home care won’t be easy
This practice changer may be difficult for family physicians, who might not be included in emergency physicians’ decisions regarding the appropriate treatment for acute PE. In this study, primary care physicians were notified of the randomized treatment plan for their patients, and 17 potential participants were excluded from the trial because of their doctors’ opposition.
Outpatient management should be considered only if arrangements for adequate home nursing care can be made, if needed— and only for patients who are able to follow instructions and self-inject LMWH. Newer anticoagulation medications that are either injected once a day or taken orally might decrease the need for home nursing visits.
Acknowledgement
The PURLs Surveillance System is supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.