Each year, more than 350,000 patients are treated for pulmonary embolism in US hospitals.
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. 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.
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%. 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.
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, 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.
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. This recommendation changed in their 2016 report. In 2016 they recommended home treatment in low-risk patients if home circumstances are adequate.
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. 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, 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!
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-James E. Dalen, MD, MPH, ScD (Hon), James E. Dalen Jr., MA
This article originally appeared in the September 2016 issue of The American Journal of Medicine.
