Trends in Initial Anticoagulation Among US Patients Hospitalized With Acute Pulmonary Embolism 2011-2020 - 18/06/24

Doi : 10.1016/j.annemergmed.2024.05.009

Lauren M. Westafer, DO, MS ^a,^b,^⁎ , Thomas Presti, MD ^c, Meng-Shiou Shieh, PhD ^b, Penelope S. Pekow, PhD ^b,^d, Geoffrey D. Barnes, MD, MSc ^e, Alok Kapoor, MD, MSc ^f,^g, Peter K. Lindenauer, MD, MSc ^b,^f,^h
^a Department of Emergency Medicine, University of Massachusetts Chan Medical School - Baystate, Springfield, MA
^b Department of Healthcare Delivery and Population Science University of Massachusetts Chan Medical School - Baystate, Springfield, MA
^c Division of Pulmonary and Critical Care, Baystate Medical Center, Springfield, MA
^d School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA
^e Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
^f Department of Population and Quantitative Health Science, University of Massachusetts Medical School, Worcester, MA
^g Department of Medicine, Division of Hospital Medicine, University of Massachusetts Chan Medical School, Worcester, MA
^h Division of Hospital Medicine, Baystate Medical Center, Springfield, MA

^∗Corresponding Author.

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Abstract

Study objective

Guidelines recommend low-molecular-weight heparin (LMWH) and direct oral anticoagulants (DOACs) rather than unfractionated heparin (UFH) for treatment of acute pulmonary embolism (PE) given their efficacy and reduced risk of bleeding. Using data from a large consortium of US hospitals, we examined trends in initial anticoagulation among hospitalized patients diagnosed with acute PE.

Methods

We conducted a retrospective study of inpatient and observation cases between January 1, 2011, and December 31, 2020, among individuals aged more than or equal to 18 years treated at acute care hospitals contributing data to the Premier Healthcare Database. Included cases received a diagnosis of acute PE, underwent imaging for PE, and received anticoagulation at the time of admission. The primary outcome was the initial anticoagulant selected for treatment.

Results

Among 299,016 cases at 1,045 hospitals, similar proportions received initial treatment with UFH (47.4%) and LMWH (47.9%). Between 2011 and 2020, the proportion of patients initially treated with UFH increased from 41.9% to 56.3%. Over this period, use of LMWH as the initial anticoagulant was reduced from 58.1% in 2011 to 37.3% in 2020. The proportion of cases admitted to the ICU, treated with mechanical ventilation or vasopressors, and inpatient mortality were stable. Factors most strongly associated with receipt of UFH were admission to the ICU (odds ratio [OR] 6.90; 95% confidence interval [CI] 6.31 to 7.54) or step-down unit (OR 2.30; 95% CI 2.16 to 2.45), receipt of thrombolysis (OR 4.25; 95% CI 3.09 to 5.84) or vasopressors (OR 1.83; 95% CI 1.32 to 2.54), and chronic renal disease (OR 1.67; 95% CI 1.54 to 1.81).

Conclusions

Despite recommendations that LMWH and DOACs be considered first-line for most patients with acute PE, use of UFH is common and increasing. Further research is needed to elucidate factors associated with persistent use of UFH and opportunities for deimplementation of low-value care.

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Plan

Introduction

Background

Importance

Goals of This Investigation

Materials and Methods

Study Design and Setting

Selection of Participants

Characteristics of Study Subjects

Trends in Anticoagulant Use

Predictors of UFH Use

Secondary Outcomes

Limitations

Discussion

	Please see page XX for the Editor’s Capsule Summary of this article.
	Supervising editor: Steven M. Green, MD. Specific detailed information about possible conflict of interest for individual editors is available at editors.
	Author contributions: LMW, PKL, and TP conceived the study. LMW, PKL, TP, MS, and PP designed the study. MS and PP conducted the analysis. LMW drafted the manuscript, and all authors contributed substantially to its revision. LMW takes responsibility for the paper as a whole.
	Data sharing statement: Partial or complete data sets and the data dictionary are available from publication on request to Dr. Westafer at email lauren.westafer@baystatehealth.org to investigators who provide an institutional review board letter of approval.
	All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Funding and support: By Annals’ policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). The project described was supported by the National Heart, Lung and Blood Institute through grant number 5K23H155895 (LMW). PKL is supported by K24 HL132008: Research and Mentoring in Comparative Effectiveness and Implementation Science. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. AK reports receiving independent grants from Pfizer and Bristol Myers Squibb. All other authors report no conflicts of interest.
	Presentation information: Presented at the Society for Academic Emergency Medicine conference May 2024 in Phoenix, AZ.