title: Impact of relative contraindications to home management in emergency department patients with low-risk pulmonary embolism.
abstract: BACKGROUND
  Studies of adults presenting to the emergency department (ED) with acute pulmonary embolism (PE) suggest that those who are low risk on the PE Severity Index (classes I and II) can be managed safely without hospitalization. However, the impact of relative contraindications to home management on outcomes has not been described.
  
  
  OBJECTIVE
  To compare 5-day and 30-day adverse event rates among low-risk ED patients with acute PE without and with outpatient ineligibility criteria.
  
  
  METHODS
  We conducted a retrospective multicenter cohort study of adults presenting to the ED with acute low-risk PE between 2010 and 2012. We evaluated the association between outpatient treatment eligibility criteria based on a comprehensive list of relative contraindications and 5-day adverse events and 30-day outcomes, including major hemorrhage, recurrent venous thromboembolism, and all-cause mortality.
  
  
  RESULTS
  Of 423 adults with acute low-risk PE, 271 (64.1%) had no relative contraindications to outpatient treatment (outpatient eligible), whereas 152 (35.9%) had at least one contraindication (outpatient ineligible). Relative contraindications were categorized as PE-related factors (n = 112; 26.5%), comorbid illness (n = 42; 9.9%), and psychosocial barriers (n = 19; 4.5%). There were no 5-day events in the outpatient-eligible group (95% upper confidence limit, 1.7%) and two events (1.3%; 95% confidence interval [CI], 0.1-5.0%) in the outpatient-ineligible group (P = 0.13). At 30 days, there were five events (two recurrent venous thromboemboli and three major bleeding events) in the outpatient-eligible group (1.8%; 95% CI, 0.7-4.4%) compared with nine in the ineligible group (5.9%; 95% CI, 2.7-10.9%; P < 0.05). This difference remained significant when controlling for PE severity class.
  
  
  CONCLUSIONS
  Nearly two-thirds of adults presenting to the ED with low-risk PE were potentially eligible for outpatient therapy. Relative contraindications to outpatient management were associated with an increased frequency of adverse events at 30 days among adults with low-risk PE.
authors.affiliation: 1 Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California.
authors.forename: David R
authors.initials: DR
authors.lastname: Vinson
authors.forename: Carrieann E
authors.initials: CE
authors.lastname: Drenten
authors.forename: Jie
authors.initials: J
authors.lastname: Huang
authors.forename: J Eileen
authors.initials: JE
authors.lastname: Morley
authors.forename: Megan L
authors.initials: ML
authors.lastname: Anderson
authors.forename: Mary E
authors.initials: ME
authors.lastname: Reed
authors.forename: Daniel K
authors.initials: DK
authors.lastname: Nishijima
authors.forename: Vincent
authors.initials: V
authors.lastname: Liu
mesh_terms: D000328:Adult; D000553:Ambulatory Care / Q000379:methods*; D002140:California / Q000453:epidemiology; D019468:Disease Management; D004636:Emergency Service, Hospital; D005260:Female; D005500:Follow-Up Studies; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011655:Pulmonary Embolism / Q000401:mortality / Q000628:therapy*; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends
keywords: ambulatory care; pulmonary embolism; risk assessment