Management and Outcomes of Adults Diagnosed with Acute Pulmonary Embolism in Primary Care: Community-Based Retrospective Cohort Study

• Published in: Journal of general internal medicine : JGIM 2022-11, Vol.37 (14), p.3620-3629
• Main Authors: Vinson, David R., Hofmann, Erik R., Johnson, Elizabeth J., Rangarajan, Suresh, Huang, Jie, Isaacs, Dayna J., Shan, Judy, Wallace, Karen L., Rauchwerger, Adina S., Reed, Mary E., Mark, Dustin G.
• Format: Article
• Language: English
• Subjects: Acute Disease; Adult; Adults; Adverse events; Anticoagulants - adverse effects; Cohort analysis; Cohort Studies; Decisions; Embolism; Emergency medical care; Emergency medical services; Fatalities; Female; Health care; Hemorrhage - chemically induced; Hospitalization; Humans; Internal Medicine; Male; Medicine; Medicine & Public Health; Metastases; Middle Aged; Original Research; Patient Discharge; Patients; Primary care; Pulmonary Embolism - chemically induced; Pulmonary Embolism - diagnosis; Pulmonary Embolism - therapy; Pulmonary embolisms; Retrospective Studies; Thromboembolism; Venous Thromboembolism
• ISSN: 0884-8734; 1525-1497; 1525-1497
• DOI: 10.1007/s11606-021-07289-0

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.