Achieving equitable care in pulmonary embolism: exploring the potential of pulmonary embolism response teams

TO THE EDITOR:

Pulmonary embolism (PE) is the third leading cause of cardiovascular mortality.¹ Race-related health disparities in venous thromboembolism incidence and mortality have been well documented.² Studies have shown that Black patients are disproportionately affected by venous thromboembolism, with a reported 50% higher annual age-standardized mortality from PE than their White counterparts.³ The disparity may be partly explained by the higher prevalence of high-risk PE in Black individuals.² Increasing evidence suggests that pulmonary embolism response teams (PERTs) may lead to improved patient outcomes and reduced health care expenditures.^4,5 Recent data from the Nationwide Inpatient Sample demonstrated increased mortality and reduced access to advanced PE therapies in non-White individuals compared with White individuals.⁶ However, there is limited evidence on whether PERT involvement overcomes racial disparities. We sought to assess the association of race with outcomes in patients with acute PE managed with PERT.

We conducted a retrospective analysis of all patients for whom PERT was activated in a tertiary hospital (Cleveland Clinic, Cleveland, OH) between 4 January 2020 and 18 September 2023. We compared baseline characteristics, PE-related characteristics (including presence of hypoxia or hypotension and 2019 European Society of Cardiology risk of early death in PE), treatment modality (including use of thrombolysis, catheter-directed therapy, and vasopressors) and outcomes (including 30-day PE-related mortality, length of stay, and the occurrence of a major bleed within 90 days) between patients who self-identified as Black individuals and all other racial groups. All patients included in this analysis who were treated with catheter-directed therapy were treated with catheter-directed large bore mechanical aspiration.

A total of 366 patients were included in this analysis (115 Black patients and 251 patients from other racial groups). A comparison of demographic characteristics, PE-related characteristics, and outcomes can be seen in Table 1. There was no significant difference in age, body mass index, gender, and history of chronic lung disease. Black patients had higher rates of smoking (22.8% vs 11.6%; P = .01) and heart failure (22.5% vs 12.3%; P = .02). Notably, Black patients had lower rates of cancer history (18.6% vs 33.8%; P = .008), perhaps diluting the mortality outcomes, with cancer being a risk factor for increased mortality. There was no significant difference in PE severity among the cohorts (P = .45). With regard to outcomes, there was no difference in length of stay (13.8 vs 14.3 days; P = .78). However, there was a numerically higher, but not statistically significant, increase in the rate of major bleeding in the Black population (9.2% vs 4.3%; P = .11) and 30-day PE-related mortality (8.3% vs 4.3%; P = .15). The unadjusted hazard ratio for PE-related mortality by 30 days was 1.92 (P = .15; 95% confidence interval, 0.78-4.73). After adjusting for age, body mass index, gender, European Society of Cardiology (ESC) classification, and use of catheter-related thrombectomy and systemic thrombolysis, the hazard ratio was 1.31 (P = .63; 95% confidence interval, 0.43-3.93).

Our study demonstrated that there was a numerically higher, but not statistically significant, rate of high-risk PE in the Black population. There was no statistically significant difference in the rates of advanced PE treatment provided, the duration of admission, or major bleeding events. Additionally, there was no statistically significant difference in mortality rates after adjusting for covariates deemed to be relevant. Rehman et al, in a cohort of 290 patients, and Dronamraju et al, in a cohort of 425 patients, have recently shown a lack of mortality difference between Black and White patients in centers with PERTs.^7,8 Our study is consistent with these data in demonstrating no significant difference in mortality between races in the PERT era.^7,8 

This study does have its limitations. Although this study was conducted in a large, tertiary care center, it was still a single-center study. Therefore, these findings may not be generalizable to the broader population. Of the 29 patients who died at 30 days, 3 Black patients (27.2%) and 2 White patients (9.5%) were of unspecified risk class, complicating the assessment of those at the greatest mortality risk. Given the retrospective and observational nature of this study, it is impossible to account for unknown confounders that may play a role in outcomes. Additionally, we may not have enough power to detect statistically significant differences between the 2 groups. An additional limitation of this work is that the analysis was restricted to patients for whom a PERT was activated, and thus, we were unable to determine potential differences regarding PERT activation according to race. The time of the analysis included all major waves of COVID-19, which affected PE epidemiology and practice patterns in hospitals. Lastly, our analysis did not include a comparison with a pre–PERT era control group. Regardless, our center's experience adds to the growing body of evidence suggesting the potential of PERT-based care in reducing racial disparities and improving PE outcomes.

Institutional review board approval was obtained for this study under institutional guidelines.

Contribution: L.T. and L.V.S. designed the project; and L.V.S., A.R., P.C., F.A., G.J.B., and L.T. wrote, revised, and finalized the manuscript.

Conflict-of-interest disclosure: The authors declare no competing financial interests.

Correspondence: Leben Tefera, Vascular Medicine, Cleveland Clinic, 9500 Euclid Ave, Building J3-5, Cleveland, OH 44195; email: teferal@ccf.org.