title: Practice patterns and complication rates of thrombolysis for pulmonary embolism.
abstract: Practice patterns, bleeding complication rates, and outcomes of thrombolytic use for pulmonary embolism (PE) outside of clinical trials are not well characterized. Retrospective cohort study of patients with PE, using an enhanced administrative database of approximately 20 % of hospitalizations in the United States, 2008-2011. We used hierarchical logistic regression to identify patient- and hospital-level factors associated with thrombolytic use and quantified between-hospital variation in thrombolysis. We calculated rates of hemorrhagic complications and mortality in patients receiving thrombolytics stratified by vasopressor use. We identified 91,860 hospitalizations for PE; thrombolytics were utilized in 13.2 % (578/4363) who received vasopressors and 1.6 % (1320/82,997) who did not receive vasopressors. Patients who received thrombolytics were younger, more likely white, with private insurance, fewer comorbidities and more acute organ failures. Hospitals varied widely in thrombolysis rates for PE (0-100 % of patients on vasopressors, 0-12.5 % not on vasopressors) with 17 % of variation unexplained by patient or hospital characteristics. Bleeding complication rates for patients receiving thrombolytics versus no thrombolytics, respectively, were: ICH (0.8 vs. 0.08 %, p < 0.01), major bleeding (13 vs. 3 %, p < 0.01), and major bleeding with transfusion (2.5 vs. 0.05 %, p < 0.01). Among patients given vasopressors, thrombolytics were not associated with hospital mortality (thrombolysis 41 % vs. no thrombolysis 35 % mortality; adjusted OR 0.97, 95 % CI 0.93-1.01, p = 0.15). There is wide variation in thrombolytic use for PE in the US. Patient characteristics and complications associated with real-world thrombolytic use were similar to published randomized trials.
authors.affiliation: Pulmonary and Critical Care Medicine, Providence Medford Medical Center, 1111 Crater Lake Ave, Medford, OR, 97504, USA. alienanorexia@gmail.com.|Department of Medicine, Pulmonary Center and the Section of Pulmonary and Critical Care Medicine, Boston University School of Medicine, Boston, MA, USA. alienanorexia@gmail.com.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Bradford
authors.affiliation: Center for Quality of Care Research and Division of General Internal Medicine, Baystate Medical Center, Springfield, MA, USA.|Department of Medicine, Tufts University School of Medicine, Boston, MA, USA.
authors.forename: Peter K
authors.initials: PK
authors.lastname: Lindenauer
authors.affiliation: Department of Medicine, Pulmonary Center and the Section of Pulmonary and Critical Care Medicine, Boston University School of Medicine, Boston, MA, USA.
authors.forename: Allan J
authors.initials: AJ
authors.lastname: Walkey
mesh_terms: D000368:Aged; D015331:Cohort Studies; D005260:Female; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use; D006470:Hemorrhage / Q000139:chemically induced; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D011655:Pulmonary Embolism / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D012189:Retrospective Studies; D015912:Thrombolytic Therapy / Q000009:adverse effects* / Q000379:methods*; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
chemical_list: D005343:Fibrinolytic Agents; D014662:Vasoconstrictor Agents
keywords: Comparative effectiveness research; Patient outcome assessment; Pulmonary embolism; Therapeutic thrombolysis; Thrombolytic therapy