Abstract Introduction High-risk pulmonary embolism (PE) is associated with acute right-ventricular failure and high in-hospital mortality, often prompting the use of aggressive reperfusion or interventional therapies. While these advanced strategies improve hemodynamics, their economic impact and post-discharge trajectory remain underexplored. Understanding whether higher upfront expenditures translate into fewer downstream hospitalizations and costs is critical for optimizing PE care pathways. Methods We conducted a retrospective cohort study using the 2022 Nationwide Readmissions Database (NRD) to identify adult hospitalizations with high-risk pulmonary embolism (PE), defined by cardiogenic shock, cardiac arrest, or the need for vasopressors, extracorporeal membrane oxygenation (ECMO), or mechanical ventilation at admission. Patients receiving advanced therapy—including systemic thrombolysis, catheter-directed thrombolysis or thrombectomy, surgical embolectomy, or ultrasound-assisted thrombolysis—were compared with those managed conservatively. Multivariate logistic and linear regressions assessed in-hospital mortality, discharge disposition, readmissions (30- and 180-day), and associated costs, adjusting for demographics, comorbidities, and hospital factors. Results Among 8, 383 hospitalizations with high-risk PE, 2, 959 (35. 3%) received advanced therapy. These patients were younger (mean 61. 7 vs 64. 7 years, p = 0. 003) and more often male (56% vs 52%, p 0. 001). Unadjusted mortality was slightly higher with advanced therapy (6. 1% vs 5. 0%, p = 0. 033), but after adjustment, advanced therapy was not independently associated with mortality (aOR 0. 95, 95% CI 0. 76-1. 20, p = 0. 68). Advanced-therapy patients experienced shorter hospital stays (7. 1 vs 7. 9 days; β = -0. 9, p = 0. 001) and were more frequently discharged home (68. 3% vs 63. 2%; aOR 0. 90, p = 0. 048), although they required more VV-ECMO use (0. 9% vs 0. 3%; aOR 2. 55, p = 0. 009) with similar CRRT use (0. 8% vs 0. 8%; p = 0. 64). Economic outcomes revealed a front-loaded cost pattern. The mean index hospitalization charge was nearly twice as high for advanced therapy (184, 000 vs 96, 000; β = +71, 000, p 0. 001), mainly due to ECMO, IMV, and care in teaching hospitals. Conversely, readmission costs over 180 days were significantly lower for advanced-therapy patients (25, 000 vs 32, 000; β = -7, 000, p 0. 05), reflecting fewer 30-day (4. 6% vs 5. 9%; aOR 0. 80, p = 0. 041) and 180-day readmissions (16. 7% vs 20. 1%; aOR 0. 79, p = 0. 001). Conclusion Our study showed that in high-risk PE, advanced reperfusion and interventional therapy significantly raise initial hospitalization costs but are linked to shorter stays, better discharge outcomes, and fewer costly readmissions over six months. These results support a “spend-early-to-save-later” strategy and emphasize the need for prospective, multicenter cost-effectiveness research to identify which patients benefit both clinically and financially from early aggressive treatment This abstract is funded by: None
Khan et al. (Fri,) studied this question.