Pulmonary embolism home treatment: What GP want?

BACKGROUND: In routine clinical practice, in most countries, patients with pulmonary embolism (PE) are hospitalized for clinical surveillance and to start anticoagulant treatment. Clinical trials and guidelines suggest that patients with stable PE can be safely treated as outpatients. This shift in management may increase general practitioners' (GP) role in PE early management. However, GP opinion regarding PE home treatment has never been assessed. METHODS: Survey conducted in France among a random sample of 360 GP (564 contacted to reach targeted sample size) working in regions representative of national access to French healthcare system. Main objectives were to assess i) GP' acceptability to PE home treatment ii) GP' preferred outpatient pathway. RESULTS: 87% of GP were favorable to home treatment of stable PE if the medical report is immediately available when the patient is discharged from ER (100%), in the absence of social and medical facility isolation of the patient (99%) and if the patient (99%) and GP (76%) consented. Outpatient pathways should be collaborative, between GP and a thrombosis specialist, and should include specialized follow-up visits at one week (80%), 3-6 months (80%) and when anticoagulant treatment is stopped (97%). 61% of GP felt that direct oral anticoagulants (DOAC) should facilitate PE home treatment, which should improve patient's quality of life. CONCLUSION: The vast majority of interviewed GP are favorable to home treatment of stable PE if a formal outpatient pathway is established. DOAC are perceived as another key for the success of the development of PE home treatment.

Practice variation in the management of distal deep vein thrombosis in primary vs. secondary cares: A clinical practice survey.

INTRODUCTION: Distal deep-vein thromboses (iDDVT) are infra-popliteal DVTs. They are as frequent but less serious than proximal DVT. Their management is debated. METHODS: Clinical practice survey among a random selection of 111 general practitioners (GP) and 56 vascular medicine physicians (VMP) working in Languedoc-Roussillon (France) to assess and compare iDDVTs management by GP and VMP. RESULTS: In case of DVT, GP manage their patients alone in 35% of cases. In case of collaborative management, VMP initiate and stop anticoagulants (>74% of cases) whereas GP monitor anticoagulation (>76% of cases). With iDDVT, there was no difference between GP and VMP in terms of use (94% vs. 92%) and intensity of anticoagulation (full dose: 99%vs.100%). Duration of anticoagulation differed: GP modulated less frequently duration of anticoagulation in presence of a transient risk factor (58% vs. 90%, p<0.05) or according to the deep-calf or muscular location of iDDVT (6% vs. 36%, p<0.05) and treated more frequently iDDVT as long as proximal DVT (49% vs. 13%, p<0.05). When comparing GP, there was no significant difference in terms of therapeutic management between those who used to manage DVT alone and those who used to manage in collaboration with a thrombosis expert. CONCLUSION: Treatment of iDDVT differed between GP and VMP. Half of GP don't modulate treatment according to anatomical location or to the provoked/unprovoked character of DVT. Given the low frequency of exposure to DVT in general practice, systematic referral to a thrombosis expert rather than continuous medical formation program seems appropriate to improve management.