7 days ago
You Can Manage Pulmonary Embolism in Primary Care
About 900,000 people are affected by pulmonary embolism (PE) each year in the United States, according to the American Lung Association and about 100,000 people die each year as a result of the disorder.
However, some patients diagnosed with PE may be at low risk for adverse outcomes, and some experts suggest primary care physicians (PCPs) can effectively manage these low-risk patients.
According to some research, it's both possible and feasible. Another potential benefit: Research also suggests that outpatient treatment for low-risk patients could reduce the burden on the healthcare system while reducing costs.
Detailed Assessment to Determine 'Low Risk'
The concept of treating low-risk patients with PE at home is not new.
A 2022 study in the Journal of General Internal Medicine described how 652 patients diagnosed with PE in the primary care setting of a large community-based health system fared. The researchers found a very low incidence of 7-day PE related hospitalization and a low rate of 30-day serious adverse events among the adult patients who were not transferred to the emergency department or hospital.
Also, in August 2022, a panel reviewed the American Society of Hematology (ASH)'s guidelines on managing deep vein thrombosis (DVT) and PE and suggested that home treatment is a possible option. The ASH Clinical Practice Guidelines on Venous Thromboembolism (VTE) stated, 'The panel also made conditional recommendations expressing a preference for home treatment over hospital-based treatment of uncomplicated cases of DVT and PE. Home treatment is suggested when there is a low risk for complications as well as a preference for direct oral anticoagulants for primary treatment of VTE.'
One major component of this option, however, is making sure that a patient is actually at low risk. In fact, the authors of the Journal of General Internal Medicine study also noted that the patients diagnosed with PE in primary care tended to be at low risk, and making that determination is crucial.
Typically, physicians who suspect PE begin with a physical examination of the patient. While the physician's clinical gestalt is important, many also use clinical probability scoring systems such as the Wells criteria to assess factors such as a patient's immobility, clinical symptoms of DVT, a previous DVT or PE, and hemoptysis, or the Geneva scoring system. The diagnosis of PE requires imaging studies such as computed tomographic pulmonary angiography, and lab tests, notably the D-dimer test, to confirm the likelihood of a PE.
The next step is determining if the patient is at low, intermediate, or high risk. That information is crucial to making a decision about how to proceed, whether it's initiating anticoagulation treatment on an outpatient basis and sending the patient home, or it's directing the patient to go directly to the emergency department.
Pulmonologist Gustavo Heresi, MD, Cleveland Clinic, Cleveland, emphasized the importance of risk stratification to determine the likely prognosis for patients once they've been diagnosed with PE. The most commonly used prognostic tool is the Pulmonary Embolism Severity Index (PESI) index, which predicts 30-day mortality in patients with PE, and its simplified version, the sPESI, which uses fewer criteria but produces comparable accuracy results. Physicians can also use the Hestia criteria, Heresi said.
Gustavo Heresi, MD
If a physician determines that a patient is at low risk, then it can be appropriate for a PCP to manage the patient's condition.
'The initial management can be done in the primary care setting,' said Sai Sunkara, MD, a pulmonologist with UI Health in Chicago.
In fact, it's easier now than in the past, given the advances in anticoagulation therapy, such as the use of direct oral anticoagulants.
'Low-risk patients who are stable and minimally at risk, can be treated at home after getting their diagnosis and a treatment plan,' agreed Heresi. But he cautioned that he can't envision the normalization of treating intermediate- or higher-risk patients in a nonemergent setting.
'I don't think that's likely to be conducive to an outpatient treatment management plan,' he said.
Even for low-risk patients, there may be some barriers to outpatient management. According to Geoff Chupp, MD, professor of medicine (pulmonary, critical care, and sleep medicine) at the Yale School of Medicine, New Haven, Connecticut, not every primary care office may have the necessary diagnostic equipment, such as CT machines.
What PCPs Already Do
PCPs already play a key role in caring for patients affected by PE. For example, they may educate patients at elevated risk for DVT because DVT can lead to a PE. Risk factors include cancer, a history of prior thromboembolism, pregnancy, and certain medical conditions, as well as people who have recently undergone surgery or spent time immobilized
'That's generally what we try to do is educate people,' said Lori Solomon, MD, MPH, a family physician and director of the Family Health Center at New York Medical College in Valhalla, New York. 'But sometimes you don't expect people to come in with pulmonary embolisms, so sometimes you just have to be vigilant when people come in and listen to their symptoms and take them seriously.'
Lori Solomon, MD, MPH
Even if the PCP does not take on the initial treatment of a PE, they still play a key role later.
Around the 3-month mark, some patients become less adherent with treatment, said Branden Turner, MD, a family medicine physician with Kaiser Permanente in Los Angeles. 'It's just human nature,' he said. 'The initial fear is gone, but you still need to take your medications.'
He sets up telephone appointments at regular intervals to check in with patients.
However, some patients may not realize when they can discontinue their anticoagulation therapy, and PCPs can take on that role, too, said Solomon.
'It's easy to start a medication, but sometimes people forget to stop it,' she said.
Prioritizing Social Determinants of Health
Before a physician contemplates sending a low-risk patient home on anticoagulant therapy, they need to find out some key pieces of information. For example, Wilson Pace, MD, professor emeritus in family medicine, Anschutz Medical Campus of the University of Colorado, Aurora, Colorado, suggested determining:
What is the patient's living situation? Do they have someone at home who can help them, or do they live alone?
Is it possible to arrange for a home health nurse to check in on the patient at home?
Does the patient have a pulse oximeter and blood pressure monitor to use at home?
Branden Turner, MD
PCPs are already well positioned to have or gather this type of information, said Solomon.
'That is why having a PCP is so important,' she added. 'Treatment plans and follow-up are very dependent on a patient's support system and living conditions.'
Turner agreed. 'This is the crux to me of a good primary care physician: Being able to personalize the care to the patient based on the individual to get the best outcome for them,' he said. 'Health equity in practice. As long as the plan works for the patient and is safe, I'm open to navigate how to achieve the goal.'
