Outpatient versus inpatient treatment for acute pulmonary embolism
Abstract
Background
Pulmonary embolism (PE) is a common life‐threatening cardiovascular condition, with an incidence of 23 to 69 new cases per 100,000 people per year. Outpatient treatment instead of traditional inpatient treatment in selected non‐high‐risk patients with acute PE might provide several advantages, such as reduction of hospitalizations, substantial cost saving and an improvement in health‐related quality of life.
Objectives
To compare the efficacy and safety of outpatient versus inpatient treatment for acute PE for the outcomes of all‐cause and PE‐related mortality; bleeding; and adverse events such as hemodynamic instability, recurrence of PE and patients' satisfaction.
Search methods
The Cochrane Peripheral Vascular Diseases Group Trials Search Co‐ordinator (TSC) searched the Specialised Register (last searched October 2014) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 9). The TSC also searched clinical trials databases. The review authors searched LILACS (last searched November 2014).
Selection criteria
Randomized controlled trials of outpatient versus inpatient treatment in people diagnosed with acute PE.
Data collection and analysis
Two review authors selected relevant trials, assessed methodological quality, and extracted and analyzed data.
Main results
We included one study, involving 339 participants. We ranked the quality of the evidence as low because of the small number of events with imprecision in the confidential interval (CI), the small sample size and it was not possible to verify publication bias. For all outcomes, the CIs were wide and included clinically significant treatment effects in both directions: short‐term mortality (30 days) (RR 0.33, 95% CI 0.01 to 7.98, P = 0.49), long‐term mortality (90 days) (RR 0.98, 95% CI 0.06 to 15.58, P = 0.99), major bleeding at 14 days (RR 4.91, 95% CI 0.24 to 101.57, P = 0.30) and 90 days (RR 6.88, 95% CI 0.36 to 134.14, P = 0.20), recurrent PE within 90 days (RR 2.95, 95% CI 0.12 to 71.85, P = 0.51) and participant satisfaction (RR 0.97, 95% CI 0.92 to 1.03, P = 0.30). PE‐related mortality, minor bleeding, and adverse course such as hemodynamic instability and compliance were not assessed by the single included study.
Authors' conclusions
Current low quality evidence from one published randomized controlled trial did not provide sufficient evidence to assess the efficacy and safety of outpatient versus inpatient treatment for acute PE in overall mortality, bleeding and recurrence of PE adequately. Further well‐conducted research is required before informed practice decisions can be made.
PICOs
Plain language summary
Outpatient versus inpatient treatment for acute pulmonary embolism
Background
Pulmonary embolism (PE) is a common life‐threatening cardiovascular condition, with 23 to 69 new cases per 100,000 people per year. Outpatient treatment instead of traditional inpatient treatment in selected low‐risk patients with acute (sudden‐onset) PE might provide several advantages such as reduction of hospital admissions, substantial costs saving and improvement in health‐related quality of life. This systematic review aimed to evaluate the risks and benefits of outpatient versus inpatient treatment for acute PE.
Study characteristics
We searched scientific databases for clinical trials of adults (aged over 18 years) allocated to home management (outpatient) or hospital management (inpatient) of acute PE. The evidence is current to October 2014.
Key results
We found one study, involving 339 participants. We are uncertain as to whether, compared with inpatient treatment, outpatient treatment has an important effect on number of deaths, bleeding and recurrence of PE and patient satisfaction because the results were imprecise and the included study did not report side effects such as hemodynamic instability (where drugs or procedures are needed to maintain a stable blood pressure), minor bleeding and compliance (how well people follow medical advice).
Quality of the evidence
The evidence of the included study was of low quality because there was imprecision in the results due to the small number of events, there was a small number of people in the study and it was not possible to verify publication bias as reports of studies where no effect was shown might not be published. Therefore, further well‐conducted randomized controlled trials (where people are allocated at random to one of two or more treatments groups, one of which is a control treatment) are required before informed practice decisions can be made.
