Comparison of clinical outcomes of venous thromboembolic disease between outpatient and inpatient management

Authors

  • Felipe Aníbal Gregalio Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina. https://orcid.org/0000-0003-3189-2382
  • Camila Juana Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina. https://orcid.org/0000-0003-4023-6563
  • Gian Manattini Palmili Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina. https://orcid.org/0009-0005-8609-999X
  • Bernardo Julio Martínez Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Central de Emergencias de Adultos, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina. https://orcid.org/0000-0002-0270-6520
  • Ignacio Martin Bluro Servicio de Cardiología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina. https://orcid.org/0000-0003-1833-6090
  • Fernando Javier Vázquez Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; CONICET-IMTIB, Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina. https://orcid.org/0000-0003-1480-5101
  • María Florencia Grande Ratti Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Área de Investigación en Medicina Interna, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; CONICET-HIBA, Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina. https://orcid.org/0000-0001-8622-8230

DOI:

https://doi.org/10.47487/apcyccv.v5i1.334

Keywords:

Emergency Service, Hospital, Venous thromboembolism, Pulmonary embolism, Argentina, Ambulatory care

Abstract

Objectives. To compare the occurrence of death, bleeding, and recurrence according to inpatient or outpatient management of venous thromboembolic disease (VTE). Materials and methods. Retrospective cohort that included a consecutive sampling of VTE consultations between 2016 and 2019 diagnosed in the Emergency Center of a private hospital in Argentina. Results. There were 1202 cases, 908 with isolated deep vein thrombosis (DVT), 205 with isolated pulmonary embolism (PE), and 89 cases of combined DVT - PE. 66% were women, with a median age of 77 years; 72% of cases were managed on an outpatient basis (n= 862). Comorbidities associated with hospitalization were obesity (p=0.03), chronic obstructive pulmonary disease (COPD) (p=0.01), heart failure (CHF) (p=0.01), chronic renal failure (CKD) (p=0.01), and cancer (p=0.01). At 90 days, the cumulative incidence of bleeding was 2.6% in inpatient compared to 2.9% in outpatient management (p=0.81); recurrence was 0% versus 0.9% (p=0.07), and mortality was 42.9% versus 18.9%, respectively (p=0.01). The HR for 90-day mortality in hospitalized patients adjusted for confounders (sex, age, type of VTE, obesity, CKD, CHF, COPD, and cancer) was 1.99 (95% CI 1.49-2.64; p=0.01). Conclusions. In this elderly, and predominantly female Argentine population, the 90-day mortality in patients hospitalized for VTE was higher than mortality in patients with outpatient management, without differences in recurrence or major bleeding.

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References

Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016;149(2):315-52. doi: 10.1016/j. chest.2015.11.026.

Long B, Koyfman A. Best Clinical Practice: Controversies in Outpatient Management of Acute Pulmonary Embolism. J Emerg Med. 2017;52(5):668-79. doi: 10.1016/j.jemermed.2016.11.020.

Lutsey PL, Walker RF, MacLehose RF, Norby FL, Evensen LH, Alonso A, et al. Inpatient Versus Outpatient Acute Venous Thromboembolism Management: Trends and Postacute Healthcare Utilization From 2011 to 2018. J Am Heart Assoc. 2021;10(20):e020428. doi: 10.1161/ JAHA.120.020428.

Grande Ratti MF, Duhart MA, Bluro IM, Sberna F, Vazquez FJ. Acute venous thromboembolism in the emergency department: Inpatient versus outpatient management trends from 2016 to 2019. Eur J Intern Med. 2023;116:144-145. doi: 10.1016/j.ejim.2023.07.009.

Roy PM, Moumneh T, Penaloza A, Sanchez O. Outpatient management of pulmonary embolism. Thromb Res. 2017;155:92-100. doi: 10.1016/j. thromres.2017.05.001.

Benchimol JA, Elizondo CM, Giunta DH, Schapira MC, Pollan JA, Barla JD, et al. Survival and functionality in the elderly over 85 years of age with hip fracture. Rev Esp Cir Ortop Traumatol. 2020;64(4):265-71. doi: 10.1016/j.recot.2020.02.001.

Roson M, Benchimol J, Rodota L, Cabrera P, Carabelli GS, Barla JD, et al. [Effect of nutritional status on mortality and functional recovery in older adults with hip fracture]. Acta Ortop Mex. 2020;34(2):96-102. Spanish.

Schapira M, Outumuro MB, Giber F, Pino C, Mattiussi M, Montero-Odasso M, et al. Geriatric co-management and interdisciplinary transitional care reduced hospital readmissions in frail older patients in Argentina: results from a randomized controlled trial. Aging Clin Exp Res. 2022;34(1):85-93. doi: 10.1007/s40520-021-01893-0.

Russo MP, Grande-Ratti MF, Burgos MA, Molaro AA, Bonella MB. Prevalence of diabetes, epidemiological characteristics and vascular complications. Arch Cardiol Mex. 2023;93(1):30-6. doi: 10.24875/ ACM.21000410.

Posadas-Martinez ML, Pagotto VL, Grande Ratti MF, Alfie V, Andresik D, Torres Gomez F, et al. [Mortality and recurrence of venous thromboembolic disease in adult patients: prospective cohort]. Rev Fac Cien Med Univ Nac Cordoba. 2020;77(3):149-54. doi: 10.31053/1853.0605.v77.n3.27135.

Dang A. Real-World Evidence: A Primer. Pharmaceut Med. 2023;37(1):25- 36. doi: 10.1007/s40290-022-00456-6.

Muriel A, Hernández D, Abraira V. Modelos estructurales marginales: una herramienta útil que proporciona evidencia a los estudios observacionales. Nefrología. 2011;2(7 Supl):7-13. doi: 10.3265/ NefrologiaSuplementoExtraordinario.pre2011.Dec.11267.

Vazquez FJ, Posadas-Martínez ML, de Quirós FGB, Giunta DH. Prognosis of patients with suspected pulmonary embolism in Buenos Aires: a prospective cohort study. BMC Pulm Med. 2014;14:200. doi: 10.1186/1471-2466-14-200.

Sandal A, Korkmaz ET, Aksu F, Köksal D, Toros Selçuk Z, Demir AU, et al. Performance of pulmonary embolism severity index in predicting long-term mortality after acute pulmonary embolism. Anatol J Cardiol. 2021;25(8):544-54. doi: 10.5152/AnatolJCardiol.2021.99345.

Polo Friz H, Molteni M, Del Sorbo D, Pasciuti L, Crippa M, Villa G, et al. Mortality at 30 and 90 days in elderly patients with pulmonary embolism: a retrospective cohort study. Intern Emerg Med. 2015;10(4):431-6. doi: 10.1007/s11739-014-1179-z.

Giorgio K, Walker RF, MacLehose RF, Adrianzen-Herrera D, Wang W, Alonso A, et al. Venous thromboembolism mortality and trends in older US adults, 2011-2019. Am J Hematol. 2023;98(9):1364-73. doi: 10.1002/ ajh.26996.

Diaz MH, Ibañez Ledesma LG, Torres Gomez F, Carretero M, Pasquinelli R, Martínez BJ, et al. [Chemotherapy at the end of life is compatible with dignified death and palliative care]. Rev Fac Cien Med Univ Nac Cordoba. 2023;80(2):93-8. doi: 10.31053/1853.0605.v80.n2.37489.

StubblefieldWB,KlineJA.Outpatienttreatmentofemergencydepartment patients diagnosed with venous thromboembolism. Postgrad Med. 2021;133(sup1):11-9. doi: 10.1080/00325481.2021.1916299.

Berghetti L, Danielle MBA, Winter VDB, Petersen AGP, Lorenzini E, Kolankiewicz ACB. Transition of care of patients with chronic diseases and its relation with clinical and sociodemographic characteristics. Rev Lat Am Enfermagem. 2023;31:e4013. doi: 10.1590/1518-8345.6594.4013.

Shepperd S, Iliffe S. Hospital-at-home versus in-patient hospital care. Cochrane Database Syst Rev. 2000;(2):CD000356. doi: 10.1002/14651858. CD000356.

Yoo HH, Nunes-Nogueira VS, Fortes Villas Boas PJ, Broderick C. Outpatient versus inpatient treatment for acute pulmonary embolism. Cochrane Database Syst Rev. 2022;5(5):CD010019. doi: 10.1002/14651858. CD010019.pub4.

Othieno R, Okpo E, Forster R. Home versus in-patient treatment for deep vein thrombosis. Cochrane Database Syst Rev. 2018;1(1):CD003076. doi: 10.1002/14651858.CD003076.pub3.

Kakkos SK, Kirkilesis GI, Tsolakis IA. Editor’s Choice - efficacy and safety of the new oral anticoagulants dabigatran, rivaroxaban, apixaban, and edoxaban in the treatment and secondary prevention of venous thromboembolism: a systematic review and meta-analysis of phase III trials. Eur J Vasc Endovasc Surg. 2014;48(5):565-75. doi: 10.1016/j. ejvs.2014.05.001.

Agnelli G, Buller HR, Cohen A, Curto M, Gallus AS, Johnson M, et al. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med. 2013;369(9):799-808. doi: 10.1056/ NEJMoa1302507.

EINSTEIN Investigators, Bauersachs R, Berkowitz SD, Brenner B, Buller HR, Decousus H, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med. 2010;363(26):2499-510. doi: 10.1056/ NEJMoa1007903.

Schulman S, Kearon C, Kakkar AK, Mismetti P, Schellong S, Eriksson H, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med. 2009;361(24):2342-52. doi: 10.1056/ NEJMoa0906598.

Pintos C, Burgos MA, Pasik NI, Piccioli S, Grande Ratti MF, Russo MP. [Real-world evidence on pharmacological appropriateness in type 2 diabetes mellitus and cardiovascular disease]. Rev Fac Cien Med Univ Nac Cordoba. 2023;80(4):335-51. doi: 10.31053/1853.0605.v80.n4.42272.

Giunta DH, Marquez Fosser S, Boietti BR, Ación L, Pollan JA, Martínez B, et al. Emergency department visits and hospital readmissions in an Argentine health system. Int J Med Inform. 2020;141:104236. doi: 10.1016/j.ijmedinf.2020.104236.

Auerbach AD, Kripalani S, Vasilevskis EE, Sehgal N, Lindenauer PK, Metlay JP, et al. Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients. JAMA Intern Med. 2016;176(4):484-93. doi: 10.1001/jamainternmed.2015.7863.

van Galen LS, Brabrand M, Cooksley T, van de Ven PM, Merten H, So RK, et al. Patients’ and providers’ perceptions of the preventability of hospital readmission: a prospective, observational study in four European countries. BMJ Qual Saf. 2017;26(12):958-69. doi: 10.1136/ bmjqs-2017-006645.

Leung C, Andersen CR, Wilson K, Nortje N, George M, Flowers C, et al. The impact of a multidisciplinary goals-of-care program on unplanned readmission rates at a comprehensive cancer center. Support Care Cancer. 2023;32(1):66. doi: 10.1007/s00520-023-08265-6.

Beyer-Westendorf J. What have we learned from real-world NOAC studies in venous thromboembolism treatment? Thromb Res. 2018;163:83-91. doi: 10.1016/j.thromres.2018.01.034.

Published

2024-02-16

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