PERT Data Emerge, Though the Exact Strategy Isn’t a Done Deal

HOLLYWOOD, FL—Pulmonary embolism response teams (PERTs) harness resources across specialties to expedite treatment, but does this coordinated effort improve outcomes? Now data are starting to trickle in that suggest the concept is having an impact, though exactly which elements are most instrumental is still unknown.

For Akhilesh Sista, MD (NYU Langone School of Medicine, New York, NY), who shared some of these favorable numbers during a debate at the 2020 International Symposium on Endovascular Therapy (ISET), the answer to whether this strategy works is a definitive “yes.”

He did, however, acknowledge that “PERTs probably increase the procedures you do, but that may not be a bad thing,” since some data suggest that more-advanced care is tied to better outcomes in PE patients.

We’re starting to circle around some ideas that maybe PERTs are not just this nice concept but might be changing outcomes. Akhilesh Sista

Keith M. Sterling, MD (Inova Alexandria Hospital, VA), assigned to the other side of the debate, didn’t try to debunk the popular multidisciplinary strategy. The PERT concept is like “mom and apple pie: you can’t talk bad about it. No PERT teams? It’s un-American,” he joked, pointing out that 2019 European guidelines encourage PERTs while the US guideline-writers have stayed mum.

The idea is appealing, Sterling agreed. “It’s clean, it’s efficient.” And thanks to the PERT Consortium, there is “a lot of marketing: podcasts, symposiums, flyers—they even control the internet. When I did my literature review for [today asking] ‘What are the problems with being a PERT?’ everything that came up is ‘Why you need to have a PERT,’” Sterling said as the ISET audience chuckled.

But PERTs aren’t one-size-fits-all, he cautioned, and may not provide benefits beyond a more-generic coordinated approach. Sterling proposed an alternative: the “pulmonary embolism response process,” memorably abbreviated as PERP.

Pro-PERT Data Emerge

For his part, Sista stressed that PERTs should play a role in PE care. A key part of the concept is that “PERTs immediately alert all important parties to a patient in need,” he stressed.

More broadly, though, PERTs “increase awareness and education at a local level,” Sista noted. He cited a 2018 paper from Vascular Medicine to illustrate his point: physicians surveyed at the University of Rochester 1 year after their PERT’s debut—not just those on the team but across the institution—reported being more confident in identification and management of high-risk PE, their knowledge of indications for systemic thrombolysis, and their ability to choose anticoagulants, among other things.

“That general awareness can only be good for the care of PE patients,” he stated.

Other research, done at the Cleveland Clinic and published last year in the American Journal of Cardiology, suggests that “PERTs increase efficiency and [reduce] time to heparin,” Sista noted. “The number one standard of care for pulmonary embolism remains anticoagulation.” Speed was especially improved in “intermediate- and high-risk patients who are most at risk for clinical deterioration,” added Sista.

He pointed out that PERTs do seem to be having an impact on treatment patterns. A 2019 paper from the Journal of Thrombosis and Thrombolysis looked at changes between the period before and after PERT implementation at Massachusetts General Hospital. Patients with PE treated in from 2012 to 2016 were more likely than those treated from 2006 to 2012 to receive any advanced therapy (19.3% vs 9.0%; P = 0.002) or catheter-directed therapy in particular (13.6% vs 0.5%; P < 0.0001).

“We are starting to see that this advanced-therapy approach—especially in patients who need it the most, if we can identify the patients who need it the most—may change outcomes,” Sista emphasized. Contemporary data on massive and submassive PE published in the American Journal of Medicine in late 2018, for instance, show that advanced therapy within 7 days independently predicts mortality at 90 days (HR 0.39; 95% CI 0.20-0.76).

“After the awareness that PERT brought, maybe we don’t have to have a patient in the ICU for 5 or 6 days after we’ve stabilized them,” Sista noted.

Numbers from the National University Hospital in Singapore support the idea that applying the PERT approach can shorten ICU stays. Patients with massive PE in the study who were eligible for reperfusion were more likely to receive it and the gap between diagnosis and treatment times decreased. Bleeding and overall survival to discharge did not change. In other words, being able to risk stratify which lower-risk patients can be released earlier without sacrificing safety may make up for the added costs of more-intensive care in those who require it, researchers suggest in Heart, Lung and Circulation.

Painting an even better picture, the aforementioned study from the Cleveland Clinic found that “PERT-era patients” were less likely to experience major or clinically relevant nonmajor bleeding or to die within 30 days. As Sista noted at ISET, “We’re starting to circle around some ideas that maybe PERTs are not just this nice concept but might be changing outcomes.”

Not All Is Perfect With PERTs

Before proposing the PERP model, Sterling made his case that PERTs are not the only path. He asserted that it’s worth asking whether PERTs are required to provide quality, evidence-based, state-of-the-art care and to be able to triage PE patients appropriately.

“I don’t think you have to have a PERT to do this. I think all physicians need to practice at the top of their game,” he said.

Furthermore, he asked, do PERTs complicate clinical decision-making? The sheer number of potential team members can span from specialists in emergency medicine, pulmonary/critical care, cardiology, radiology, vascular medicine, internal medicine, cardiothoracic surgery, and hematology, among other fields, to hospitalists, pharmacists, nurses, and administrators. “At these larger centers where you hear a lot about PERTS, they have residents and fellows at their disposal from every service,” Sterling stressed. “A lot of hospitals don’t have that.”

In the real world, evidence from numerous studies shows that PERT team members and patient populations are quite varied, as are the preferred treatments, with differences even at the same center between day and night, he said.

Outcomes pre- and post-PERT haven’t changed all that much despite greater use of advanced therapy, Sterling countered, citing the same Journal of Thrombosis and Thrombolysis paper as did Sista.

With the PERT model, there are “other issues to deal with,” he added. “It’s more call for different specialties, there’s no remuneration [or] credit for doing this, [and] you now have turf wars. One service or department always seems to dominate who’s calling the real shots.” When inadequate data and strong opinions combine, Sterling continued, there can be “therapeutic nihilism and basically stagnation.”

PERP, to get around these challenges, places the emphasis on the process rather than the team. “You just need to have your hospital or your environment do what needs to be done to take care of PE patients. It’s more inclusive of both the small and large hospitals,” he said. Not every service has to be included, just the individuals directly involved in decision-making, such as emergency-department physicians, hospitalists, intensivists, and endovascular specialists. Ensuring that these people are consistently available can help streamline treatment, disposition, and follow-up, he said.

Even without a PERT, it’s still possible to provide “very-high-quality, state-of-the art care,” Sterling concluded. “Consider developing a [process] just as you would for any other disease or condition that you treat.”