0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letters |

Trends in In-Hospital Deaths Among Hospitalizations With Pulmonary Embolism FREE

James Tsai, MD, MPH; Scott D. Grosse, PhD; Althea M. Grant, PhD; W. Craig Hooper, PhD; Hani K. Atrash, MD, MPH
[+] Author Affiliations

Author Affiliations: Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia.


Arch Intern Med. 2012;172(12):960-961. doi:10.1001/archinternmed.2012.198.
Text Size: A A A
Published online

Pulmonary embolism (PE) is a potentially life-threatening condition that typically occurs when a thrombus from deep veins in the leg, pelvis, arms, or heart embolizes to the lungs.1,2 Recent data linked PE to approximately 247 000 hospitalizations in the United States in 2006.3 To our knowledge, the case-fatality rate and estimated number of in-hospital deaths among a national representative example of hospitalizations that encompass first-listed and any-listed PE diagnoses in the United States are limited. Therefore, we report nationally representative estimates of in-hospital deaths (ie, annual number and case-fatality rate) among hospitalizations with a PE diagnosis (ie, first-listed and any-listed) in the United States by analyzing data from the 2001-2008 National Hospital Discharge Survey (NHDS).4

The NHDS is conducted annually by the National Center for Health Statistics, Centers for Disease Control and Prevention, Atlanta, Georgia, to collect demographic and medical information on a sample of hospitalizations from a national probability selection of hospitals in the 50 states and the District of Columbia.4 All survey procedures involving human subjects and confidentiality were reviewed and approved by the Research Ethics Review Board of the National Center for Health Statistics. The NHDS assigns each sampled hospitalization a maximum of 7 diagnostic codes based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Pulmonary embolism was identified using ICD-9-CM codes 415.1x, 634.6x, 635.6x, 636.6x, 637.6x, 638.6, and 673.2x. The first-listed code is a principal diagnosis. We limited our analysis to a sample of nonnewborn hospitalizations with a first-listed (n = 8990) or an any-listed (n = 14 721) PE diagnosis.

To assess in-hospital deaths with a first-listed or an any-listed PE diagnosis during the study period and to ensure adequate subgroup size, we calculated the annual number of deaths and case-fatality rates for the following 2-year periods: 2001-2002, 2003-2004, 2005-2006, and 2007-2008. We performed orthogonal polynomial contrasts to test linear trends in the proportions of case fatality across these periods. We accessed the data via the Research Data Center and used SPSS 19 Complex Samples for Survey Analysis (IBM Corp) and Stata 11 (StataCorp LP) to perform the data management and analyses to account for complex sample survey design.5,6

Among hospitalizations in the United States during 2001-2002, 2003-2004, 2005-2006, and 2007-2008, the estimated annual number of in-hospital deaths were 5870, 5140, 5440, and 3600, respectively, for first-listed PE and 17 920, 14 870, 17 600, and 18 560, respectively, for any-listed PE (Figure). The case-fatality rates (ie, number of deaths per 100 hospitalizations) declined linearly across the 4 defined study periods (P < .05 for linear trend); they were 5.9%, 4.2%, 3.8%, and 2.4%, respectively, for first-listed PE and 11.4%, 7.8%, 7.8%, and 7.1%, respectively, for any-listed PE (Figure).

Place holder to copy figure label and caption
Graphic Jump Location

Figure. Estimated annual number of in-hospital deaths with a diagnosis of pulmonary embolism (PE) (A) and estimated case-fatality rates (B) among hospitalizations with a PE diagnosis during the periods 2001-2002, 2003-2004, 2005-2006, and 2007-2008, National Hospital Discharge Survey, United States.

Because of the scope of this article, we report several overall estimates of in-hospital deaths with a first-listed and an any-listed PE diagnosis in the United States during 2001-2008 that were not available previously. The annual number of deaths ranged from 3600 to 5870 and from 14 870 to 18 560 among hospitalizations with a first-listed PE diagnosis and an any-listed PE diagnosis, respectively. Despite the decline in the overall case-fatality rate of hospitalizations with a PE diagnosis, we did not find a corresponding reduction in the numbers of in-hospital deaths, especially among those with a first-listed PE diagnosis. Although the exact reasons for the decline in case-fatality rates were unknown and may warrant further investigation, the decrease may be multifaceted and could be attributable to a combination of an increased number of PE diagnoses resulting from improved diagnostic techniques together with more effective treatment and fewer complications.7,8

Regardless of an overall decline in the case-fatality rate in hospitalizations related to PE during the study period, the annual number of in-hospital deaths remains relatively stable, especially for any-listed PE. As the US population is aging, reducing the number of in-hospital deaths from PE and improving patients' quality of life are important clinical and public health goals and pose a formidable challenge for the health care systems. The decline in the case-fatality rate stabilized during the periods of 2005-2006 and 2007-2008 in hospitalizations with any-listed PE. Therefore, our results provide support for identifying and implementing effective preventive strategies among hospitalized patients.

Our research has some limitations. Although we evaluated in-hospital deaths with a diagnosis of PE, PE cases may be underreported because (1) asymptomatic patients with PE and other comorbid conditions might be undiagnosed and (2) a misdiagnosed PE or a PE diagnosis was not made before death occurred. Nonetheless, our study represents an important effort to characterize PE-related mortality burden in US hospitals.

In conclusion, the estimated annual number of in-hospital deaths among hospitalizations with a diagnosis of PE remained relatively stable during 2001-2008, despite the decline in the case-fatality rates for the same period. Therefore, PE remains an important clinical and public health concern in the United States.

Correspondence: Dr Tsai, Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Rd, Mail Stop E-64, Atlanta, GA 30333 (jxt9@cdc.gov).

Published Online: April 2, 2012. doi:10.1001/archinternmed.2012.198

Author Contributions:Study concept and design: Tsai, Grant, and Atrash. Acquisition of data: Tsai. Analysis and interpretation of data: Tsai, Grosse, Hooper, and Atrash. Drafting of the manuscript: Tsai and Atrash. Critical revision of the manuscript for important intellectual content: Tsai, Grosse, Grant, Hooper, and Atrash. Statistical analysis: Tsai and Grosse. Administrative, technical, and material support: Grant. Study supervision: Grant and Atrash.

Financial Disclosure: None reported.

Disclaimer: The findings and conclusions in this Research Letter are those of the authors and do not necessarily represent the views of the Research Data Center, the National Center for Health Statistics, or the Centers for Disease Control and Prevention.

Additional Contributions: Stephanie Robinson, MPH, of the Research Data Center, National Center for Health Statistics, Centers for Disease Control and Prevention, coordinated the review of our research proposal and provided administrative and technical support for accessing the data.

Tapson VF. Acute pulmonary embolism.  N Engl J Med. 2008;358(10):1037-1052
PubMed   |  Link to Article
Agnelli G, Becattini C. Acute pulmonary embolism.  N Engl J Med. 2010;363(3):266-274
PubMed   |  Link to Article
Stein PD, Matta F. Epidemiology and incidence: the scope of the problem and risk factors for development of venous thromboembolism.  Clin Chest Med. 2010;31(4):611-628
PubMed   |  Link to Article
 National Hospital Discharge Survey (NHDS). Centers for Disease Control and Prevention Web site. http://www.cdc.gov/nchs/index.htm. Accessed August 8, 2011
 NCHS Research Data Center (RDC). Centers for Disease Control and Prevention Web site. http://www.cdc.gov/rdc/. Accessed August 8, 2011
Brogan D. Software for sample survey data, misuse of standard packages. In: Armitage P, Colton T, eds. Encyclopedia of Biostatistics. 2nd ed. New York, NY: John Wiley & Sons Inc; 2005:5057-5064
Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis.  Arch Intern Med. 2011;171(9):831-837
PubMed   |  Link to Article
Tapson VF. Acute pulmonary embolism: comment on “time trends in pulmonary embolism in the United States.”  Arch Intern Med. 2011;171(9):837-839
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure. Estimated annual number of in-hospital deaths with a diagnosis of pulmonary embolism (PE) (A) and estimated case-fatality rates (B) among hospitalizations with a PE diagnosis during the periods 2001-2002, 2003-2004, 2005-2006, and 2007-2008, National Hospital Discharge Survey, United States.

Tables

References

Tapson VF. Acute pulmonary embolism.  N Engl J Med. 2008;358(10):1037-1052
PubMed   |  Link to Article
Agnelli G, Becattini C. Acute pulmonary embolism.  N Engl J Med. 2010;363(3):266-274
PubMed   |  Link to Article
Stein PD, Matta F. Epidemiology and incidence: the scope of the problem and risk factors for development of venous thromboembolism.  Clin Chest Med. 2010;31(4):611-628
PubMed   |  Link to Article
 National Hospital Discharge Survey (NHDS). Centers for Disease Control and Prevention Web site. http://www.cdc.gov/nchs/index.htm. Accessed August 8, 2011
 NCHS Research Data Center (RDC). Centers for Disease Control and Prevention Web site. http://www.cdc.gov/rdc/. Accessed August 8, 2011
Brogan D. Software for sample survey data, misuse of standard packages. In: Armitage P, Colton T, eds. Encyclopedia of Biostatistics. 2nd ed. New York, NY: John Wiley & Sons Inc; 2005:5057-5064
Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis.  Arch Intern Med. 2011;171(9):831-837
PubMed   |  Link to Article
Tapson VF. Acute pulmonary embolism: comment on “time trends in pulmonary embolism in the United States.”  Arch Intern Med. 2011;171(9):837-839
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 11

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com

Users' Guides to the Medical Literature
Thromboembolism or Acute Pulmonary Embolism

Users' Guides to the Medical Literature
Table 9.2-3 Refuted Evidence From Observational Studiesa