CRD summary

This review concluded that subgroups of stable patients may be safely treated at home for pulmonary embolism with a well-defined management programme, but the quality of this evidence was inadequate and further research was warranted. There were several methodological weaknesses in the included studies and some potential for bias in the review, but the authors’ conclusions seem suitably cautious.

Authors' objectives

To assess the safety of outpatient treatment and early discharge of symptomatic pulmonary embolism.

Searching

PubMed and EMBASE were searched up to January 2008 for publications without language restrictions. Search terms were reported. Reference lists of retrieved articles were manually searched. Primary authors were contacted for full manuscripts where necessary.

Study selection

Randomised controlled studies (RCTs), observational studies and case reports that initially administered antithrombotic treatment partially (early discharge) or totally at home in patients with symptomatic pulmonary embolism were eligible for inclusion. Outcomes of interest were short-term (first week or until low-molecular weight heparin was administered) and long-term (≥3 months) all-cause mortality, death from pulmonary embolism or major haemorrhage, recurrent venous thromboembolism and major bleeding.

Included studies were conducted between 2000 and 2007. Where reported, mean age of patients ranged from 54.6 to 66.4 years. Some studies included only cancer patients. Treatment included administration of dalteparin and warfarin, unfractionated heparin followed by dalteparin and warfarin, nadroparin-phenprocoumon, fondaparinus-vitamin K antagonist, tinzaparin-warfarin, tinzaparin/nadroparin-warfarin, low-molecular weight heparin alone or with warfarin and enoxaparin/nadroparin-warfarin. Patients, home care nurses or a family member administered low-molecular weight heparin. Patients were telephoned regularly or were supervised inside or outside the home setting, or had a 24 hours emergency contact number. Exclusion criteria differed between studies.

Two reviewers selected studies for inclusion. Disagreements were resolved through discussion or referral to a third reviewer.

Assessment of study quality

The quality of RCTs was assessed according to the Jadad scale. Observational cohorts were assessed on the following criteria: study type (prospective or retrospective), patient selection, use of a control group, short- and long-term (≥3 months) follow-up data and loss to follow up (<5%, 5& to 20%, >20%). Each item received a score of one. Studies that scored 5 were categorised as high quality, scores of 4 indicated medium quality and studies that scored 3 or less were defined as low quality.

It appeared that one reviewer conducted the quality assessment and this was checked by a second reviewer.

Data extraction

One reviewer extracted data on incidence rates (number and percentage) in the short and long term. A second reviewer checked the data extraction.

Methods of synthesis

Data were reported as a narrative synthesis and presented in tables.

Results of the review

Eleven studies (n=938 calculated from the table, range 21 to 158) were included in the analysis: seven prospective cohort and four retrospective reviews (case note, database-based or record-based). Three studies included control groups (patients treated entirely in hospital, n=121). None of the studies were categorised as high quality, one was of medium quality and the other 10 studies were of low quality. Four studies recruited participants consecutively. Three studies included a control group. Follow-up duration ranged from one to two weeks and 13 months. Loss to follow-up ranged between zero and 2%.

No patient died in the short term (first seven to 10 days), seven patients had recurrent venous thromboembolism and two experienced major bleeding (six studies). In the long term, between two and 12 patients died from all-cause mortality (range from zero to 43.5%, all in cancer patients). One patient died from pulmonary embolism or major bleeding in the intervention group; no patients died in the control group. In the long term, between zero and seven patients (1.4% to 9.3%) in the intervention group had recurrent venous thromboembolism and seven patients had major bleeding. Between one and three patients (3.2% to 9.3%) in the control groups experienced venous thromboembolism; none experienced major bleeding.

Authors' conclusions

Evidence suggested that certain subgroups of stable patients with normal blood pressure and no requirement for oxygen therapy may be safely treated at home with a well-defined management programme, but the quality of this evidence was insufficient to permit conclusions to be drawn about safety of outpatient treatment of pulmonary embolism. Further research was warranted.

CRD commentary

The review question and inclusion criteria were clearly defined. The literature search included two electronic databases and one other appropriate source without language restrictions. As only full publications were included, potentially relevant studies may have been missed. Publication bias was not formally assessed. Study quality was assessed with appropriate criteria, but study quality was low. Each stage of the review process was undertaken in duplicate to reduce potential for reviewer error and bias. Given the differences in interventions and study methodology, a narrative synthesis was appropriate. The authors acknowledged the poor quality of the included studies and the differences among patients and study methodology. There were several methodological weaknesses with the included studies, and some potential for bias in the review, but the authors’ conclusions seem suitably cautious.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.

Research: The authors stated that further research was warranted for a better short-term prognostic risk stratification of the subgroup of patients with pulmonary embolism in whom outpatient treatment may be safe.

Funding

Not stated.

Bibliographic details

Squizzato A, Galli M, Dentali F, Ageno W. Outpatient treatment and early discharge of symptomatic pulmonary embolism: a systematic review. European Respiratory Journal 2009; 33(5): 1148-1155. [PubMed: 19407049]

Original Paper URL

http://erj.ersjournals.com/content/33/5/1148.abstract

Indexing Status

Subject indexing assigned by NLM

MeSH

Acute Disease; Anticoagulants /therapeutic use; Humans; Length of Stay; Outpatients; Patient Discharge; Patient Selection; Pulmonary Embolism /drug therapy /mortality; Recurrence; Risk Assessment; Safety

AccessionNumber

12009107615

Database entry date

10/11/2010

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.