title: Outcomes related to variation in hospital pulmonary embolus observation stay utilization.
abstract: OBJECTIVE
  To characterize hospital variation in use of observation stays to manage pulmonary embolism (PE) and its association with subsequent outcomes.
  
  
  METHODS
  We performed a cross-sectional study of hospitals reporting ≥75 PE encounters (emergency department, observation stay or inpatient admission) using Premier data from 11/2012-3/2015. We included hospital encounters for adults with a primary diagnosis of PE (415.1x), ≥1 diagnostic test claim for PE on day 0-2 and evidence of PE treatment. Hospitals were divided into tertiles (Ts) based on the proportion of all PE encounters managed as an observation stay. The association between observation stay utilization and the proportion of PE encounters resulting in in-hospital death or re-admission within the same or subsequent 2-months were compared across Ts using a generalized estimating equation adjusted for individual encounter disease severity.
  
  
  RESULTS
  Observation PE management increased over the study period (1.9%-5.4%; Pearson's r = 0.88, p < 0.001). Of all hospitals reporting ≥1 PE encounter, 255 had ≥75 encounters (representing a total of 38,172 PE encounters) and were included in the analysis. Individual hospital observation use for PE management varied from 0%-33.9%. Mean hospital rates of PE observation stay by T were T1 = 0.1%, T2 = 2.2% and T3 = 7.9%. Hospitals that used observation stays most frequently (T3) were more likely in the South or Mid-west (p < 0.001), to be a teaching hospital (p = 0.03) and less likely to serve an urban population (p = 0.02). Hospitals in T3 (n = 11,780 encounters) were not associated with a statistically significant increased risk of in-hospital death (2.3% vs. 2.1%-2.6%) or all-cause (4.7% vs. 5.1%-5.4%), venous thromboembolism-(1.4% vs. 1.8%-2.0%) or major bleeding (0.3% vs. 0.2-0.3%)-related re-admission in the same or subsequent 2-months compared to T1 (n = 12,940 encounters) and T2 (n = 13,452 encounters).
  
  
  CONCLUSIONS
  PE management via observation stays has increased over recent years. Hospitals more frequently utilizing observation stays may not experience increased negative outcomes, such as re-admission.
authors.affiliation: a Department of Pharmacy Practice , University of Connecticut School of Pharmacy , Storrs , CT , USA.
authors.forename: Craig I
authors.initials: CI
authors.lastname: Coleman
authors.affiliation: b Department of Emergency Medicine , Baylor College of Medicine , Houston , TX , USA.
authors.forename: W Frank
authors.initials: WF
authors.lastname: Peacock
authors.affiliation: a Department of Pharmacy Practice , University of Connecticut School of Pharmacy , Storrs , CT , USA.
authors.forename: Erin R
authors.initials: ER
authors.lastname: Weeda
authors.affiliation: c Department of Health Economics and Outcomes Research , Janssen Scientific Affairs, LLC , Raritan , NJ , USA.
authors.forename: Veronica
authors.initials: V
authors.lastname: Ashton
authors.affiliation: d Department of Emergency Medicine , University of Cincinnati , Cincinnati , OH , USA.
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Fermann
mesh_terms: D003430:Cross-Sectional Studies; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D006470:Hemorrhage / Q000209:etiology; D006742:Hospital Bed Capacity; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D019370:Observation; D010343:Patient Admission / Q000706:statistics & numerical data; D010359:Patient Readmission / Q000706:statistics & numerical data*; D011655:Pulmonary Embolism / Q000150:complications* / Q000175:diagnosis*; D012111:Residence Characteristics; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D054556:Venous Thromboembolism / Q000209:etiology
keywords: Pulmonary embolism; major bleeding; observation stay; physicians’; practice patterns; venous thromboembolism