ShareThisParticipating in an international study comparing outpatient to inpatient treatment for certain low-risk cases of pulmonary embolism, a man had been randomly selected to receive his care while admitted to a hospital. But when he found out there was a group of people undergoing treatment at home, he "absolutely afterward insisted on being released early" to do the same, said Donald Yealy, chairman of the department of emergency medicine at the University of Pittsburgh School of Medicine and senior author of the two-continent study published recently by The Lancet.
A pulmonary embolism is a blockage in an artery of the lung, usually caused when a blood clot grows in a vein deep in a leg and then breaks off and travels. About 30 percent of patients with undiagnosed and untreated pulmonary embolism die, according to the National Institutes of Health. Diagnosed, it is frequently treated with anticoagulants. Other treatments include thrombolytic, or clot dissolvers, and surgery.
The man in the study did well after going home, Yealy said.
So did the overwhelming majority of the 171 participating outpatients, with statistical results virtually matching those of the 168 inpatients, prompting the authors to conclude outpatient care "can safely and effectively be used in place of inpatient care."
The outpatients spent a mean of 3.4 days fewer in the hospital; they also reported in a survey that "they enjoyed having the same care (as inpatients) but in a setting they were comfortable in," Yealy said.
Outpatient care has been recommended for most stable, low-risk patients with acute pulmonary embolism by doctor associations like the American College of Physicians, he said, but the study noted that most treatment is inpatient-based. The reason: "Physicians are naturally risk-averse. They don't want harm for their patients, and in the U.S. until there was clear evidence (it) was just as effective, people may have avoided that," Yealy said.
He believes that results of the Outpatient Treatment of Pulmonary Embolism, or OTPE, trial will persuade more physicians to prescribe outpatient treatment for qualified patients. The change, however, will take time, Yealy said.
The OPTE trial enrolled patients at 19 emergency departments in Switzerland, France, Belgium and the United States. They were qualified by a medical index that rates "how likely you are to have a difficult or bad outcome with your blood clot in your lung," Yealy said.
Along with being randomized, the study was "open-label," meaning both patients and doctors knew which therapy was being used. It also was a "non-inferiority" trial, meaning the researchers were not trying to prove one method or the other was superior, but, rather, trying to prove the methods were equivalent choices.
The outpatients received training from a study nurse on how to give themselves enoxaparin shots twice a day and were scheduled to be discharged within 24 hours of when they were randomized. If self-injection was impossible, the nurse either taught a caregiver how to do it or arranged a visiting nurse.
The inpatients were admitted to the hospital and received the same enoxaparin regimen.
Yealy stressed that the study does not advocate one type of care over the other. "What we're trying to say is one size of treatment doesn't fit all," he said. "People would want their doctor to pick the treatment that fits their needs and risks."
(Contact Pohla Smith at psmith(at)post-gazette.com. For more stories visit scrippsnews.com)
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