Introduction: In routine clinical practice, in most countries, patients with pulmonary embolism (PE) are hospitalized a few days for clinical surveillance and to start anticoagulant treatment. Clinical trials and guidelines suggest that patients with stable PE could safely be treated as outpatients. This shift in management may increase general practitioner (GP) role in PE early management. However, GP opinion and suggestion regarding PE home treatment has never been assessed.
Methods: Phone survey conducted in France among a random sample of 360 GP working in 6 regions representative of national access to French healthcare system namely, Brittany, Centre, Ile de France (Paris), Languedoc-Roussillon, Nord Pas de Calais, Provence Alpes Côte d'Azur. Primary objective was to assess GP' acceptability to PE home treatment. Secondary objectives included GP' preferences in terms of PE outpatient pathway, their current exposure to and management of PE as well as their personal experience with PE initial outpatient management.
Results: During two pre-specified campaigns of recruitment (March-June 2015 and June-August 2017), 564 GP were contacted in order to reach study expected sample size (participation rate: 64%, 180 GP recruited during in each campaign).
Most GP (95%) stated that they manage suspicion of PE less than once every 6 months.
Current PE patient pathway is presented in Figure 1. 21% of GP (n=76) have already managed at least one patient with acute PE in the outpatient setting and 87% of GP (n=312) were favorable to home treatment of stable PE. This latter rate was similar during the 2 campaigns of recruitment. GP practicing alone were less likely to accept outpatient management of PE than those who worked in collaboration with other physicians: OR=0.3 [0.1 - 0.9]. Main reasons for their refusal were perceived seriousness of disease (90% of cases) and bleeding risk (60%).
Figure 2 summarizes GP' suggestions and agreement regarding PE outpatient pathway. As per GP', conditions for discharge from emergency room (ER) department should include a medical report immediately available at time of patient's discharge (100% of GP agreed with), absence of social and medical facility isolation of the patient (99% of GP agreed with) patient's (99% of GP agreed with) and GP's (74% of GP agreed with) consents and a phone call to GP (74% of GP agreed with) to communicate initial treatment (56% of GP agreed with) and to provide the phone number of the hospitalist on call (56% of GP agreed with). After patient's discharge, 86% (n=309) of GP felt that outpatient pathway should be collaborative with a thrombosis specialist and should include follow-up visits with a thrombosis specialist at one week (89%, n=290), 3-6 months (80%) and when anticoagulant treatment is stopped (97%). A similar proportion of GP wanted PE patients to be managed either exclusively by themselves (8%, n=27) or by a thrombosis specialist (7%, n=24). 61% (n=219) of GP felt that direct oral anticoagulants (DOAC) should facilitate development of PE home treatment (16 did not, p<0.05) and that this should improve patient's quality of life.
Conclusion: The vast majority of GP are favorable to stable PE home treatment if a formal outpatient pathway is established. DOAC are perceived as another key for the success of the development of PE home treatment.
Galanaud:BMS Pfizer: Consultancy; Servier: Consultancy; Sanofi: Consultancy; Aspen: Consultancy; Bayer: Research Funding.
Asterisk with author names denotes non-ASH members.