Hospital volume and outcomes for acute pulmonary embolism: multinational population based cohort study

Abstract

Objectives: To evaluate the association between experience in the management of acute pulmonary embolism, reflected by hospital case volume, and mortality.

Design: Multinational population based cohort study using data from the Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) registry between 1 January 2001 and 31 August 2018.

Setting: 353 hospitals in 16 countries.

Participants: 39 257 consecutive patients with confirmed diagnosis of acute symptomatic pulmonary embolism.

Main outcome measure: Pulmonary embolism related mortality within 30 days after diagnosis of the condition.

Results: Patients with acute symptomatic pulmonary embolism admitted to high volume hospitals (>40 pulmonary embolisms per year) had a higher burden of comorbidities. A significant inverse association was seen between annual hospital volume and pulmonary embolism related mortality. Admission to hospitals in the highest quarter (that is, >40 pulmonary embolisms per year) was associated with a 44% reduction in the adjusted odds of pulmonary embolism related mortality at 30 days compared with admission to hospitals in the lowest quarter (<15 pulmonary embolisms per year; adjusted risk 1.3% v 2.3%; adjusted odds ratio 0.56 (95% confidence interval 0.33 to 0.95); P=0.03). Results were consistent in all sensitivity analyses. All cause mortality at 30 days was not significantly reduced between the two quarters (adjusted odds ratio 0.78 (0.50 to 1.22); P=0.28). Survivors showed little change in the odds of recurrent venous thromboembolism (odds ratio 0.76 (0.49 to 1.19)) or major bleeding (1.07 (0.77 to 1.47)) between the low and high volume hospitals.

Conclusions: In patients with acute symptomatic pulmonary embolism, admission to high volume hospitals was associated with significant reductions in adjusted pulmonary embolism related mortality at 30 days. These findings could have implications for management strategies.

Trial registration: ClinicalTrials.gov NCT02832245.

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; DJ has served as an adviser or consultant for Bayer HealthCare Pharmaceuticals, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Leo Pharma, Pfizer, Rovi, and Sanofi; served as a speaker or a member of a speakers’ bureau for Bayer HealthCare Pharmaceuticals, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Leo Pharma, Rovi, and Sanofi; and received grants for clinical research from Daiichi Sankyo, Sanofi, and Rovi; BB was supported by the National Heart, Lung, and Blood Institute, National Institutes of Health (grant T32 HL007854; the content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health) and reports serving as a consulting expert (on behalf of the plaintiff) for a litigation related to inferior vena caval filters; LJ-P has served as an adviser or consultant for Actelion Pharmaceuticals, Bayer HealthCare Pharmaceuticals, Leo Pharma, Menarini, Pfizer, and Rovi; in the past three years, RDY has received research funding from Bayer HealthCare Pharmaceuticals, Bristol-Myers Squibb, Pfizer, and Portola, and has served as a consultant for Bayer HealthCare, Bristol-Myers Squibb, Glaxo-Smithkline, Janssen, Johnson and Johnson, Ortho Pharmaceuticals, Organon, Pfizer, Portola, Sanofi, and Scios; MM has served as an adviser or consultant for Bayer HealthCare Pharmaceuticals, Daiichi Sankyo, Leo Pharma, and Sanofi; served as a speaker or a member of a speakers’ bureau for Bayer HealthCare Pharmaceuticals, Daiichi Sankyo, Leo Pharma, and Sanofi; and received grants for clinical research from Sanofi and Bayer; the other authors declare no other relationships or activities that could appear to have influenced the submitted work.

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Figures

Fig 1

STROBE study cohort flow diagram

Fig 2

Relation between hospital volume and pulmonary embolism related mortality. Data are adjusted odds ratios (95% confidence intervals)