Talya Bordin-Wosk, MD

Background: Despite multiple guidelines that support outpatient management of acute PE in the appropriate patient population, the rate of hospital admission for patients eligible for outpatient management remains high. One explanation is that physicians may have difficulty identifying which patients meet discharge criteria.

Study design: Controlled pragmatic trial.

Setting: Kaiser Permanente Northern California (KPNC).

Synopsis: A total of 21 KPNC EDs participated in this 16-month study of 1,703 patients; 11 EDs served as control sites and 10 as intervention sites. At month 9, ED physician study champions at intervention sites provided in-person training on outpatient PE management, the validated PE severity index (PESI), and the electronic CDSS. The CDSS was designed to use evidence-based guidelines to assist physicians in identifying patients eligible for outpatient care or short-term (less than 24-hour) observation in the ED. The CDSS was incorporated into the electronic medical record navigator used by ED physicians and not only calculated the PESI score, but also provided the patient’s risk class and 30-day all-cause mortality estimate. Adverse outcomes were defined as 5-day return visits for PE-related symptoms, recurrent VTE, major hemorrhage, and all-cause 30-day mortality. Results demonstrated an increase in home discharge at intervention sites (17.4% pre to 28% post) without an increase in adverse outcomes.

Bottom line: Use of an electronic CDSS to identify patients appropriate for home management of acute PE decreased admission rates without increasing adverse outcomes.

Citation: Vinson DR et al. Increasing safe outpatient management of emergency department patients with pulmonary embolism: a controlled pragmatic trial. Ann Int Med. 2018;169(12):855-65.

Dr. Bordin-Wosk is an assistant clinical professor in the division of hospital medicine at the University of California, San Diego.

Background: Despite multiple guidelines that support outpatient management of acute PE in the appropriate patient population, the rate of hospital admission for patients eligible for outpatient management remains high. One explanation is that physicians may have difficulty identifying which patients meet discharge criteria.

Study design: Controlled pragmatic trial.

Setting: Kaiser Permanente Northern California (KPNC).

Synopsis: A total of 21 KPNC EDs participated in this 16-month study of 1,703 patients; 11 EDs served as control sites and 10 as intervention sites. At month 9, ED physician study champions at intervention sites provided in-person training on outpatient PE management, the validated PE severity index (PESI), and the electronic CDSS. The CDSS was designed to use evidence-based guidelines to assist physicians in identifying patients eligible for outpatient care or short-term (less than 24-hour) observation in the ED. The CDSS was incorporated into the electronic medical record navigator used by ED physicians and not only calculated the PESI score, but also provided the patient’s risk class and 30-day all-cause mortality estimate. Adverse outcomes were defined as 5-day return visits for PE-related symptoms, recurrent VTE, major hemorrhage, and all-cause 30-day mortality. Results demonstrated an increase in home discharge at intervention sites (17.4% pre to 28% post) without an increase in adverse outcomes.

Bottom line: Use of an electronic CDSS to identify patients appropriate for home management of acute PE decreased admission rates without increasing adverse outcomes.

Citation: Vinson DR et al. Increasing safe outpatient management of emergency department patients with pulmonary embolism: a controlled pragmatic trial. Ann Int Med. 2018;169(12):855-65.

Dr. Bordin-Wosk is an assistant clinical professor in the division of hospital medicine at the University of California, San Diego.

Background: Despite multiple guidelines that support outpatient management of acute PE in the appropriate patient population, the rate of hospital admission for patients eligible for outpatient management remains high. One explanation is that physicians may have difficulty identifying which patients meet discharge criteria.

Study design: Controlled pragmatic trial.

Setting: Kaiser Permanente Northern California (KPNC).

Synopsis: A total of 21 KPNC EDs participated in this 16-month study of 1,703 patients; 11 EDs served as control sites and 10 as intervention sites. At month 9, ED physician study champions at intervention sites provided in-person training on outpatient PE management, the validated PE severity index (PESI), and the electronic CDSS. The CDSS was designed to use evidence-based guidelines to assist physicians in identifying patients eligible for outpatient care or short-term (less than 24-hour) observation in the ED. The CDSS was incorporated into the electronic medical record navigator used by ED physicians and not only calculated the PESI score, but also provided the patient’s risk class and 30-day all-cause mortality estimate. Adverse outcomes were defined as 5-day return visits for PE-related symptoms, recurrent VTE, major hemorrhage, and all-cause 30-day mortality. Results demonstrated an increase in home discharge at intervention sites (17.4% pre to 28% post) without an increase in adverse outcomes.

Bottom line: Use of an electronic CDSS to identify patients appropriate for home management of acute PE decreased admission rates without increasing adverse outcomes.

Citation: Vinson DR et al. Increasing safe outpatient management of emergency department patients with pulmonary embolism: a controlled pragmatic trial. Ann Int Med. 2018;169(12):855-65.

Dr. Bordin-Wosk is an assistant clinical professor in the division of hospital medicine at the University of California, San Diego.

Background: A critical juncture in the American Heart Association/American College of Cardiology 2014 perioperative guidelines relies on clinicians categorizing patients undergoing noncardiac surgery as either low risk (less than 1%) or elevated risk (greater than or equal to 1%) for a MACE. The purpose of this study is to determine whether there is variability between the three risk calculators endorsed by the ACC/AHA guidelines as prediction tools to make this risk stratification.

Study design: Retrospective observational study.

Setting: National Surgical Quality Improvement Program database.

Synopsis: The NSQIP database was used to identify 10,000 patients who had undergone noncardiac surgery. The risk of MACE for each patient was then calculated using the Revised Cardiac Risk Index, the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator, and the National Surgical Quality Improvement Program Myocardial Infarction or Cardiac Arrest calculator. Data were analyzed using the intraclass correlation coefficient and kappa analysis. Results demonstrated that 29% of the time the three calculators disagreed on which patients were classified as low risk. This suggests that, when following the ACC/AHA perioperative guidelines, a recommendation for further preoperative cardiac testing may depend on which risk prediction tool is used to calculate the risk of MACE.

Bottom line: Nearly one-third of the time, the three risk calculators recommended in the ACC/AHA 2014 perioperative guidelines do not agree on which patients are classified as low risk; this may affect clinical decision making for some patients.

Citation: Glance LG et al. Impact of the choice of risk model for identifying low-risk patients using the 2014 American College of Cardiology/American Heart Association perioperative guidelines. Anesthesiology. 2018;129(5):889-900.

Dr. Bordin-Wosk is an assistant clinical professor in the division of hospital medicine at the University of California, San Diego.

Background: A critical juncture in the American Heart Association/American College of Cardiology 2014 perioperative guidelines relies on clinicians categorizing patients undergoing noncardiac surgery as either low risk (less than 1%) or elevated risk (greater than or equal to 1%) for a MACE. The purpose of this study is to determine whether there is variability between the three risk calculators endorsed by the ACC/AHA guidelines as prediction tools to make this risk stratification.

Study design: Retrospective observational study.

Setting: National Surgical Quality Improvement Program database.

Synopsis: The NSQIP database was used to identify 10,000 patients who had undergone noncardiac surgery. The risk of MACE for each patient was then calculated using the Revised Cardiac Risk Index, the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator, and the National Surgical Quality Improvement Program Myocardial Infarction or Cardiac Arrest calculator. Data were analyzed using the intraclass correlation coefficient and kappa analysis. Results demonstrated that 29% of the time the three calculators disagreed on which patients were classified as low risk. This suggests that, when following the ACC/AHA perioperative guidelines, a recommendation for further preoperative cardiac testing may depend on which risk prediction tool is used to calculate the risk of MACE.

Bottom line: Nearly one-third of the time, the three risk calculators recommended in the ACC/AHA 2014 perioperative guidelines do not agree on which patients are classified as low risk; this may affect clinical decision making for some patients.

Citation: Glance LG et al. Impact of the choice of risk model for identifying low-risk patients using the 2014 American College of Cardiology/American Heart Association perioperative guidelines. Anesthesiology. 2018;129(5):889-900.

Dr. Bordin-Wosk is an assistant clinical professor in the division of hospital medicine at the University of California, San Diego.

Background: A critical juncture in the American Heart Association/American College of Cardiology 2014 perioperative guidelines relies on clinicians categorizing patients undergoing noncardiac surgery as either low risk (less than 1%) or elevated risk (greater than or equal to 1%) for a MACE. The purpose of this study is to determine whether there is variability between the three risk calculators endorsed by the ACC/AHA guidelines as prediction tools to make this risk stratification.

Study design: Retrospective observational study.

Setting: National Surgical Quality Improvement Program database.

Synopsis: The NSQIP database was used to identify 10,000 patients who had undergone noncardiac surgery. The risk of MACE for each patient was then calculated using the Revised Cardiac Risk Index, the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator, and the National Surgical Quality Improvement Program Myocardial Infarction or Cardiac Arrest calculator. Data were analyzed using the intraclass correlation coefficient and kappa analysis. Results demonstrated that 29% of the time the three calculators disagreed on which patients were classified as low risk. This suggests that, when following the ACC/AHA perioperative guidelines, a recommendation for further preoperative cardiac testing may depend on which risk prediction tool is used to calculate the risk of MACE.

Bottom line: Nearly one-third of the time, the three risk calculators recommended in the ACC/AHA 2014 perioperative guidelines do not agree on which patients are classified as low risk; this may affect clinical decision making for some patients.

Citation: Glance LG et al. Impact of the choice of risk model for identifying low-risk patients using the 2014 American College of Cardiology/American Heart Association perioperative guidelines. Anesthesiology. 2018;129(5):889-900.

Dr. Bordin-Wosk is an assistant clinical professor in the division of hospital medicine at the University of California, San Diego.