Evidence of improvement: A two-decade decline in pulmonary embolism procedural mortality

Given the severity of pulmonary embolisms (PEs), investigating mortality trends is important to evaluate health care system progress. The primary objective of this study was to investigate the trend in US PE-related procedural mortality over the past two decades. The secondary objective was to investigate the variation in trends across major treatment modalities.

We performed a longitudinal retrospective multicenter cohort analysis of PE-related mortality using the National Inpatient Sample, from 1998 to 2021. Our analytic sample included adult individuals diagnosed with PE and treated with catheter-directed thrombolysis, catheter-directed embolectomy (data available since 2015), surgical embolectomy, or medical management. The exposure was the year of hospital admission. The primary outcome variable was inpatient, all-cause mortality.

The analysis sample included 1,338,332 admissions treated medically and 14,153 admissions treated procedurally. Of the procedure group, 59% received catheter-directed thrombolysis (n = 8363), 24% catheter-directed embolectomy (n = 3453), and 17% surgical embolectomy (n = 2337). Percent mortality for patients undergoing procedural treatment for PE decreased from 33.3% in 1998 to 6.0% in 2021 (Kendall's tau = -0.79; P < .001). Predictors of mortality included advancing age, increasing comorbidity burden, female sex, and race. Percent mortality for patients undergoing catheter-directed thrombolysis decreased from 14.3% in 1998 to 5.7% in 2021 (Kendall's tau = -0.58; P < .001), for patients undergoing catheter-directed embolectomy from 20.8% in 2015 to 6.0% in 2021 (Kendall's tau = -0.90; P < .01), and for patients undergoing surgical embolectomy from 37.1% in 1998 to 10.0% in 2021 (Kendall's tau = -0.67; P < .001). Adjusted mortality odds for the full procedural cohort fell 10% yearly (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.89-0.91). When stratified by treatment, the adjusted mortality odds dropped 7.0% (OR, 0.93; 95% CI, 0.90-0.96) for catheter-directed thrombolysis and 5.0% (OR, 0.95; 95% CI, 0.93-0.97) for surgical embolectomy. The adjusted change in mortality odds for catheter-directed embolectomy was not significant (OR, 0.96; 95% CI, 0.81-1.15). Percent mortality for patients undergoing medical management decreased from 12.0% in 1998 to 9.9% in 2021, with a nadir of 5.9% in 2012 (Kendall's tau = -0.62; P < .001). The adjusted mortality odds for the medical management group increased 1.0% yearly (OR, 1.01; 95% CI, 1.01-1.02).

PE-related mortality has decreased significantly among patients treated procedurally and those treated with catheter-directed thrombolysis and surgical embolectomy over the past two decades. These findings suggest that management and patient selection for procedural treatment of moderate to severe PEs may be improving over time.