https://immattersacp.org/weekly/archives/2018/11/13/4.htm

Web-based decision support tool may help determine safety of outpatient PE management

The tool was added to the patient care workflow in the ED after the diagnosis of pulmonary embolism (PE) was confirmed but before site-of-care decision making was completed.


An internet-based electronic clinical decision support tool may be able to increase rates of safe outpatient management of pulmonary embolism (PE), a new study found.

Researchers at Kaiser Permanente Northern California performed a controlled pragmatic trial at 21 community EDs to examine the effect of an integrated electronic clinical decision support system used for risk stratification and decision making in patients presenting with acute PE. The study period lasted 16 months, from January 2014 to April 2015. At month 9, 10 intervention sites received a technology and education intervention while the other 11 sites acted as concurrent controls. Intervention sites also had study champions who provided in-person education about the tool to ED and hospitalist physicians and continued to promote the tool throughout the study.

The clinical decision support system was added to the patient care workflow after the diagnosis of PE was confirmed but before site-of-care decision making was completed. The system reviewed eligibility criteria and listed, defined, and automatically populated the components of the PE Severity Index (PESI), which the treating physician then edited as needed. After the PESI score was calculated, the system provided the physician with the patient's risk class and tailored estimates of 30-day all-cause mortality, based on the literature. For low-risk patients, defined as classes I and II, the system said that “outpatient management is often possible.” For higher-risk patients, defined as classes III to V, the system noted that “inpatient care is often indicated.” The PESI was supplemented with an evidence-based list of relative contraindications to PE management.

The study's primary outcome was outpatient management immediately from the ED or after a short-term stay in an ED-based outpatient observation unit. Adverse outcomes, including return visits for PE-related symptoms within five days and recurrent venous thromboembolism, major hemorrhage, and all-cause mortality within 30 days, were also evaluated. The researchers used a differences-in-differences approach to compare preintervention and postintervention changes at the intervention and control sites while adjusting for demographic and clinical characteristics. Study results were published online Nov. 13 by Annals of Internal Medicine.

There were 881 eligible patients with PE at intervention sites (421 in the preintervention period, 460 in the postintervention period) and 822 at control sites (410 in the preintervention period, 412 in the postintervention period). Patients at the intervention sites were slightly younger, were more likely to be African-American, and had less chronic lung disease and heart failure and lower PESI scores. Rates of adjusted home discharge increased significantly at the intervention sites (17.4% preintervention to 28.0% postintervention) but not the control sites (15.1% preintervention and 14.5% postintervention), a difference-in-difference comparison of 11.3 percentage points (95% CI, 3.0 to 19.5 percentage points; P=0.007). Rates of PE-related return visits at five days and major adverse outcomes at 30 days did not appear to increase with implementation of the clinical decision support system.

Site allocation was not randomized, and it is difficult to know which elements of the system most contributed to outpatient management, the authors said. They also pointed out that although the patient populations at the included medical centers were diverse, the geographic area and the practice setting were limited, possibly also limiting generalizability. However, they concluded that implementation and structured promotion of a clinical decision support system can help physicians make site-of-care decisions about PE management without increasing return visits within five days or major adverse outcomes at 30 days.

“Identifying the most appropriate venue of care for patients with acute medical conditions is a key priority for transforming U.S. health care,” the authors wrote. “The use of [clinical decision support systems] to bring validated risk-stratification tools to the ED bedside could help advance this agenda and could be expanded beyond PE to improve care and resource use for other clinical conditions.”

An accompanying editorial mentioned potential challenges in implementation of the tool, including that the health system provided fast, close follow-up after discharge that may not be available at all centers and that patients treated at home may not have time for the extensive education required regarding PE. They also noted that the intervention sites had champions of the intervention who promoted use of the clinical decision support system and that uptake might not have been as high otherwise.

However, patients with PE overwhelmingly prefer to be treated at home, and the article shows that home treatment can be safe in appropriately selected patients, the editorialists said. “The investigators are to be congratulated for showing the effectiveness of this computer tool that, when intensively promoted, enabled physicians to knowledgeably select a larger proportion of patients for home treatment,” they wrote.