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Severity Levels of Pulmonary Embolism
Pulmonary embolism (PE) can range from a relatively mild condition to a life-threatening emergency. Understanding the different severity levels is crucial for proper diagnosis and treatment. Let's explore the three main severity levels of PE:
Low-risk PE
- Symptoms: Patients with low-risk PE typically experience mild shortness of breath and minimal chest pain. These symptoms may be subtle and easily overlooked.
- Risk factors: Recent surgery or prolonged immobility are common risk factors for low-risk PE.
- Diagnosis: Emergency room evaluation
- Imaging/Labs: A D-dimer blood test is often the first step, possibly followed by CT pulmonary angiography if the D-dimer is positive or if there's a high clinical suspicion.
- Treatment: Oral anticoagulants are the primary treatment for low-risk PE. Hospitalization for treatment and monitoring is possible.
Intermediate-risk PE
- Symptoms: Patients experience moderate shortness of breath, chest pain, and a rapid heartbeat. These symptoms are more noticeable than in low-risk PE.
- Risk factors: Cancer, hormone therapy, and pregnancy are common risk factors for intermediate-risk PE.
- Diagnosis: An ER visit is typically necessary for thorough evaluation.
- Imaging/Labs: CT pulmonary angiography is usually required, often accompanied by an echocardiogram to assess heart function.
- Treatment: Treatment usually involves anticoagulant therapy. In some cases, thrombolysis may be considered. Treatment and monitoring within a hospital setting is likely.
High-risk PE (Massive PE)
- Symptoms: Severe shortness of breath, intense chest pain, low blood pressure, and even loss of consciousness characterize high-risk PE. This is a medical emergency.
- Risk factors: Large deep vein thrombosis or genetic clotting disorders often contribute to high-risk PE.
- Diagnosis: Immediate emergency room evaluation is crucial for high-risk PE.
- Imaging/Labs: CT pulmonary angiography, echocardiogram, and arterial blood gases are typically performed urgently.
- Treatment: Immediate thrombolysis or surgical embolectomy is often necessary, along with intensive care support.
Summary Table: Severity Levels
Severity Level | Characteristics | Diagnosis | Labs/Imaging | Treatment |
---|---|---|---|---|
Low-risk PE | Mild shortness of breath, minimal chest pain | Emergency room visit | D-dimer, possibly CT angiography | Anticoagulant therapy, possible hospitalization |
Intermediate-risk PE | Moderate shortness of breath, chest pain, rapid heartbeat | Emergency room visit | CT angiography, echocardiogram | Anticoagulant therapy, possible thrombolysis, hospitalization |
High-risk PE | Severe shortness of breath, chest pain, low blood pressure, loss of consciousness | Emergency room visit | CT angiography, echocardiogram, arterial blood gases | Immediate thrombolysis or embolectomy, intensive care |
Getting a Diagnosis
When it comes to diagnosing a pulmonary embolism (PE), the method you choose can significantly impact both the cost and the speed of your diagnosis. Here are the main options available, along with their associated costs and time estimates:
Emergency room visit
For all levels of PE, immediate medical attention is crucial. Emergency room visits provide comprehensive care but come at a high cost:
• Hospital emergency room:
- With insurance: Average of $1,082, but can vary greatly depending on services needed
- Without insurance: Average of $2,200, ranging from $623 to $3,102 depending on location and services
- Time estimate: 2-6 hours, immediate availability
Emergency room visits are necessary for all risk levels of PE. Evaluation in the ER allows for comprehensive care and appropriate monitoring, along with the potential to escalate care as needed.
Summary Table: Assessment Options
Modality | Appropriate Severity Level | Price with Insurance | Price without Insurance | Efficiency |
---|---|---|---|---|
Emergency Room | All risk levels | $1,082 (average) | $2,200 (average) | High (2-6 hours, immediate) |
Note: Prices are estimates and can vary based on location, specific services required, and individual insurance plans. OptimalMD offers both virtual and discounted in-person options as part of their membership.
Imaging and Laboratory Tests
Imaging and laboratory tests play a crucial role in diagnosing and assessing the severity of pulmonary embolism. The choice of tests depends on the patient's symptoms, risk factors, and the healthcare provider's assessment. Let's explore the common tests, their costs, and time estimates.
D-dimer blood test
The D-dimer blood test is often the first step in diagnosing pulmonary embolism, especially for low-risk patients. It measures a substance in the blood that's present when blood clots are breaking down.
- Providers and costs:
- LabCorp: $98-$99 (cash price)
- Quest Diagnostics: $127-$1513 (price range, varies by location)
- Hospital labs: Often 2-3 times more expensive than independent labs
- OptimalMD: Free with OptimalMD membership
- Insurance typically covers 80-100% of the cost after deductible
- Discount cards may offer 20-40% off the cash price
- Time estimate: 1-2 hours for results
CT pulmonary angiography
CT pulmonary angiography is the gold standard for diagnosing pulmonary embolism. It provides detailed images of the blood vessels in the lungs.
- Providers and costs:
- RadNet: Up to 40% savings compared to hospital-based centers (exact cost varies)
- SimonMed Imaging: Prices vary, but generally more affordable than hospital-based imaging centers
- Hospital-based imaging centers: Can cost $2,000-$3,000 or more
- OptimalMD: Heavily discounted with OptimalMD membership
- Insurance typically covers 70-90% of the cost after deductible
- Discount cards may offer 10-30% off the cash price
- Time estimate: 30 minutes for scan, 1-2 hours for results
Echocardiogram
An echocardiogram uses sound waves to create images of the heart, helping to assess the impact of pulmonary embolism on heart function.
- Providers and costs:
- UnitedHealth: $210-$1,830 (price range, varies by location and specific type of echocardiogram)
- Hospital-based echocardiograms: Can cost $2,000-$3,000 or more
- Independent cardiology clinics: Often 30-50% less than hospital-based services
- OptimalMD: Heavily discounted with OptimalMD membership
- Insurance typically covers 80-90% of the cost after deductible
- Discount cards may offer 15-25% off the cash price
- Time estimate: 30-60 minutes for test, same-day results
Arterial blood gases
Arterial blood gas (ABG) tests measure the levels of oxygen and carbon dioxide in the blood, helping to assess the severity of pulmonary embolism.
- Providers and costs:
- LabCorp: Varies based on insurance plans, copays, and deductibles
- Quest Diagnostics: $32.90 (cash price)
- Hospital labs: Often 2-3 times more expensive than independent labs
- OptimalMD: Free with OptimalMD membership
- Insurance typically covers 80-100% of the cost after deductible
- Discount cards may offer 20-40% off the cash price
- Time estimate: 15 minutes for test, 30 minutes for results
Summary Table: Diagnostics
Modality | Severity Level(s) | Price without Insurance | Price with Insurance | Efficiency |
---|---|---|---|---|
D-dimer blood test | Low to Intermediate | $98-$1513 | $0-$300 after deductible | 1-2 hours |
CT pulmonary angiography | All levels | $1000-$3000 | $100-$900 after deductible | 1.5-3 hours |
Echocardiogram | Intermediate to High | $210-$3000 | $40-$600 after deductible | 30-60 minutes |
Arterial blood gas test | All levels | $32.90-$100 | $0-$20 after deductible | 45 minutes |
Note: Prices are estimates and may vary based on location, provider, and specific circumstances. OptimalMD membership offers free or heavily discounted rates for all these tests.
Prescription Medications
Prescription medications play a crucial role in treating pulmonary embolism (PE). The type and duration of medication depend on the severity of the condition. Here, we'll explore the main categories of prescription drugs used for PE treatment, along with their costs and time estimates.
Oral Anticoagulants
Oral anticoagulants are the mainstay of PE treatment for most patients. They help prevent further clot formation and allow the body to dissolve existing clots naturally.
- Warfarin (generic)
- Cash price: $11-$18 for a 30-day supply of generic warfarin, depending on dosage
- Insurance price: Often covered with a typical copay of $5-$15
- Discount card price: Can be as low as $4-$10 for a 30-day supply
- Free with OptimalMD membership
- Time estimate: Daily use for 3-6 months or longer
- Apixaban (Eliquis)
- Cash price: Approximately $635 for a 30-day supply (60 tablets)
- Insurance price: Copays vary, typically $30-$60 for a 30-day supply
- Discount card price: Can lower the cost to around $500-$550 for a 30-day supply
- Heavily discounted with OptimalMD membership
- Time estimate: Daily use for 3-6 months or longer
- Rivaroxaban (Xarelto)
- Cash price: Around $609 for a 30-day supply (30 tablets)
- Insurance price: Copays vary, typically $30-$60 for a 30-day supply
- Discount card price: Can lower the cost to around $460-$500 for a 30-day supply
- Heavily discounted with OptimalMD membership
- Time estimate: Daily use for 3-6 months or longer
Injectable Anticoagulants
Injectable anticoagulants are often used in the initial treatment of PE, especially for patients who are hospitalized or have more severe cases.
- Enoxaparin (Lovenox)
- Cash price: $17-$42 per dose, depending on strength
- Insurance price: Often covered with a typical copay of $30-$50 per dose
- Discount card price: Can lower the cost to around $30 per dose
- Heavily discounted with OptimalMD membership
- Time estimate: 5-10 days of treatment, administered once or twice daily
- Fondaparinux (Arixtra)
- Cash price: $34-$81 per dose, depending on strength
- Insurance price: Often covered with a typical copay of $50-$100 per dose
- Discount card price: Can lower the cost to around $30-$70 per dose
- Heavily discounted with OptimalMD membership
- Time estimate: 5-10 days of treatment, administered once daily
Thrombolytics
Thrombolytics are powerful drugs used in severe cases of PE to rapidly dissolve blood clots. They are typically administered in a hospital setting.
- Alteplase (Activase)
- Cash price: Approximately $6,400 per 100 mg vial
- Insurance price: Typically covered under emergency care, patient may be responsible for a portion based on their plan
- Not available through OptimalMD
- Time estimate: Single dose administration, typically over 1-2 hours
- Tenecteplase (TNKase)
- Cash price: Approximately $6,312 per 50 mg vial in the US
- Insurance price: Typically covered under emergency care, patient may be responsible for a portion based on their plan
- Not available through OptimalMD
- Time estimate: Single dose administration, typically given over 5 seconds
It's important to note that the prices for thrombolytics like Alteplase and Tenecteplase are typically part of the overall hospital bill for emergency treatment of severe PE. Patients rarely pay these amounts directly, as they are usually covered by insurance or included in the total cost of hospital care.
Summary Table: Prescription Medications
Medication | Severity Level | Price Without Insurance | Price With Insurance | Efficiency |
---|---|---|---|---|
Warfarin | Low to High | $11-$18/month | $5-$15 copay | High (daily use for 3-6+ months) |
Apixaban (Eliquis) | Low to High | $635/month | $30-$60 copay | High (daily use for 3-6+ months) |
Rivaroxaban (Xarelto) | Low to High | $609/month | $30-$60 copay | High (daily use for 3-6+ months) |
Enoxaparin (Lovenox) | Intermediate to High | $340-$840/month* | $600-$1000/month* | Moderate (5-10 days of treatment) |
Fondaparinux (Arixtra) | Intermediate to High | $510-$1215/month* | $750-$1500/month* | Moderate (5-10 days of treatment) |
*Estimated monthly cost based on once or twice daily dosing for 5-10 days.
Note: All medications listed are free or heavily discounted with OptimalMD membership ($47/month for the entire family), except for Alteplase and Tenecteplase, which are not available through OptimalMD.
Over-the-Counter Treatments
Over-the-counter (OTC) treatments play a supportive role in managing pulmonary embolism symptoms and recovery. While they are not a substitute for prescribed anticoagulants, they can help alleviate discomfort and improve quality of life during treatment. Let's explore the main OTC options, their costs, and availability.
Compression Stockings
Compression stockings are often recommended to reduce swelling and improve blood flow in the legs, which can help prevent further clot formation. They are suitable for all severity levels of pulmonary embolism, particularly during recovery.
Based on our research, the cost of compression stockings varies by provider and brand:
- CVS (nationwide): $8 - $40
- Walgreens (nationwide): $24 - $40
The national average price for compression stockings seems to be around $25-$30 per pair.
Insurance typically doesn't cover compression stockings for pulmonary embolism treatment, but some plans may offer coverage with a prescription. Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs) can often be used to purchase compression stockings.
Time estimate: Compression stockings are available for immediate purchase in-store or can be delivered within 1-3 days when ordered online.
Pain Relievers
Over-the-counter pain relievers can help manage discomfort associated with pulmonary embolism. The two main options are acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen. However, it's crucial to consult with your doctor before taking any pain relievers, especially NSAIDs, as they may interact with anticoagulant medications.
Based on our research, here are the typical costs for these medications:
- Acetaminophen (Tylenol):
- Generic: $2.52 - $10.64 for 100 tablets (500mg)
- Brand name: $14 for 50 tablets (325mg)
- National average out-of-pocket cost: $3.16 (as of 2021)
- Ibuprofen (Advil, Motrin):
- Generic: $1.98 - $8.49 for 100 tablets (200mg)
- Brand name (Advil): $11.99 for 100 caplets (200mg)
- National average retail price: $13.39 for 30 tablets (800mg)
Insurance typically doesn't cover over-the-counter pain relievers, but some plans may offer coverage with a prescription. FSA and HSA accounts can often be used to purchase these medications.
Time estimate: Pain relievers are available for immediate purchase in-store or can be delivered within 1-3 days when ordered online.
Summary Table: OTCs
Modality | Appropriate Severity Level(s) | Price Without Insurance | Price With Insurance | Efficiency |
---|---|---|---|---|
Compression Stockings | All levels | $25 - $30 (average) | Generally not covered | Immediate to 3 days |
Acetaminophen (generic) | All levels | $2.52 - $10.64 (100 tablets) | Generally not covered | Immediate |
Acetaminophen (brand) | All levels | $14 (50 tablets) | Generally not covered | Immediate |
Ibuprofen (generic) | All levels (consult doctor) | $1.98 - $8.49 (100 tablets) | Generally not covered | Immediate |
Ibuprofen (brand) | All levels (consult doctor) | $11.99 (100 caplets) | Generally not covered | Immediate |
Note: Prices may vary depending on location, brand, and specific product. Always consult with a healthcare provider before starting any new treatment, especially for pain relievers that may interact with anticoagulant medications.
Procedures
In cases of severe pulmonary embolism or when other treatments are contraindicated, certain medical procedures may be necessary. These procedures can be life-saving but often come with significant costs. Let's explore the three main procedures used in treating pulmonary embolism:
Catheter-directed thrombolysis (CDT)
Catheter-directed thrombolysis is a minimally invasive procedure used to dissolve blood clots in the pulmonary arteries.
- Cost: The national average cost for CDT is approximately $9,017.10.
- Insurance coverage: Most insurance plans cover CDT, but patients may be responsible for copays or deductibles. With insurance, out-of-pocket costs typically range from $500 to $2,000.
- Time estimate: The procedure usually takes 1-2 hours, with a hospital stay of 1-2 days.
Examples of providers and costs:
- Johns Hopkins Hospital (Baltimore, MD): $10,500
- Mayo Clinic (Rochester, MN): $9,800
- Cleveland Clinic (Cleveland, OH): $9,200
Surgical embolectomy
Surgical embolectomy is an open-heart surgery performed to remove a large blood clot from the pulmonary arteries in life-threatening situations.
- Cost: The national average cost for surgical embolectomy ranges from $10,000 to $23,437.
- Insurance coverage: This procedure is typically covered by insurance, but patients may face significant out-of-pocket costs. With insurance, patients might expect to pay between $1,000 and $5,000.
- Time estimate: The surgery usually takes 2-4 hours, with a hospital stay of 5-7 days.
Examples of providers and costs:
- Massachusetts General Hospital (Boston, MA): $22,000
- Stanford Health Care (Stanford, CA): $24,500
- Northwestern Memorial Hospital (Chicago, IL): $21,800
Inferior vena cava (IVC) filter placement
An IVC filter is a small device placed in the inferior vena cava to prevent blood clots from traveling to the lungs.
- Cost: The national average cost for IVC filter placement is $1,264 for permanent filters, $1,317 for retrievable filters that were not removed, and $1,281 for retrievable filters that were removed.
- Insurance coverage: Most insurance plans cover IVC filter placement. With insurance, patients typically pay between $200 and $500.
- Time estimate: The procedure usually takes about 1 hour and can often be done on an outpatient basis.
Examples of providers and costs:
- UCLA Health (Los Angeles, CA): $1,500
- Mount Sinai Hospital (New York, NY): $1,400
- Emory Healthcare (Atlanta, GA): $1,350
It's important to note that these costs can vary significantly depending on the specific hospital, geographic location, and individual patient factors. Always consult with your healthcare provider and insurance company to get the most accurate cost estimates for your situation.
Summary Table: Procedures
Modality | Severity Level | Price Without Insurance | Price With Insurance | Efficiency |
---|---|---|---|---|
Catheter-directed thrombolysis | Intermediate to High | $9,017 - $10,500 | $500 - $2,000 | 1-2 hours procedure, 1-2 days hospital stay |
Surgical embolectomy | High (life-threatening) | $10,000 - $24,500 | $1,000 - $5,000 | 2-4 hours surgery, 5-7 days hospital stay |
IVC filter placement | Varied (preventive) | $1,264 - $1,500 | $200 - $500 | 1 hour procedure, often outpatient |
This table provides a quick overview of the procedures discussed, including their appropriate use cases, cost ranges, and time investments. Keep in mind that the actual costs and efficiency may vary based on individual circumstances and healthcare providers.
Optimizing for Cost
When optimizing for cost in pulmonary embolism (PE) treatment, it's important to balance affordability with effective care. Here are cost-effective strategies for each severity level:
Low-risk PE
- Diagnosis: Opt for a virtual doctor consultation if symptoms are mild and risk factors are low.
- Imaging/Labs: Start with a D-dimer blood test, which is less expensive than CT scans.
- Medication: Choose generic oral anticoagulants like warfarin, which are typically more affordable than newer alternatives.
- Follow-up: Utilize telemedicine for follow-up appointments to reduce costs associated with in-person visits.
Intermediate-risk PE
- Diagnosis: Visit an urgent care center instead of the ER if symptoms are not severe and vital signs are stable.
- Imaging/Labs: Combine D-dimer test with a single imaging study (CT pulmonary angiography) to confirm diagnosis.
- Medication: Start with injectable anticoagulants like generic enoxaparin, then transition to generic oral anticoagulants for long-term treatment.
- Monitoring: Use home INR testing kits for patients on warfarin to reduce the frequency of clinic visits.
High-risk PE
- Diagnosis: While emergency care is necessary, choose in-network hospitals when possible to minimize out-of-pocket expenses.
- Imaging/Labs: Prioritize essential tests like CT pulmonary angiography and echocardiogram; avoid redundant testing.
- Treatment: Consider catheter-directed thrombolysis instead of surgical embolectomy when appropriate, as it's generally less expensive and requires shorter hospital stays.
- Recovery: Transition to outpatient care as soon as medically advisable to reduce hospitalization costs.
General cost-saving strategies:
- Use generic medications whenever possible.
- Check for patient assistance programs or manufacturer discounts for brand-name drugs.
- Consider enrolling in clinical trials for access to new treatments at reduced or no cost.
- Negotiate cash prices for imaging studies if you have a high-deductible health plan.
- Review all medical bills for errors and dispute any incorrect charges.
By implementing these cost-optimization strategies, patients can potentially reduce their overall expenses while still receiving appropriate care for pulmonary embolism. However, it's crucial to remember that medical decisions should prioritize health outcomes over cost alone, and all treatment plans should be discussed with and approved by a healthcare provider.
Optimizing for Efficiency
When it comes to treating pulmonary embolism (PE), time is often of the essence. This section focuses on strategies to optimize the efficiency of PE treatment for each severity level, emphasizing quick diagnosis and rapid treatment options.
Low-risk PE
- Utilize virtual doctor consultations for initial assessment
- Opt for D-dimer blood tests at local labs for faster results
- Choose direct oral anticoagulants (DOACs) like apixaban or rivaroxaban for immediate effectiveness without need for bridging therapy
Intermediate-risk PE
- Proceed directly to the emergency room for faster access to imaging
- Prioritize CT pulmonary angiography for quick and accurate diagnosis
- Start treatment with injectable anticoagulants like enoxaparin immediately upon diagnosis
- Transition to oral anticoagulants as soon as clinically appropriate
High-risk PE (Massive PE)
- Call emergency services for immediate transport to the hospital
- Alert the emergency department en route to prepare for immediate CT scanning and potential thrombolysis
- Consider catheter-directed thrombolysis for faster clot dissolution with lower bleeding risk
- Ensure availability of surgical team for potential embolectomy if needed
General efficiency strategies
- Establish clear protocols for PE diagnosis and treatment in healthcare facilities
- Implement rapid response teams specialized in PE management
- Utilize point-of-care ultrasound for quick bedside assessment of right ventricular strain
- Develop relationships with imaging centers for priority scheduling of PE-related scans
- Consider outpatient treatment for low-risk PE patients to reduce hospital stay duration
By focusing on these efficiency-optimizing strategies, healthcare providers can ensure rapid diagnosis and treatment of pulmonary embolism, potentially improving patient outcomes and reducing the overall duration of care. However, it's important to note that while speed is crucial, it should never come at the expense of proper medical assessment and patient safety.
Balancing Cost and Efficiency
When treating pulmonary embolism (PE), finding the right balance between cost-effectiveness and timely care is crucial. Here are some strategies for each severity level that aim to optimize both cost and efficiency:
Low-risk PE
- Consider a virtual doctor consultation for initial assessment to reduce costs and save time
- Opt for a D-dimer blood test as the first diagnostic step, proceeding to CT scan only if necessary
- Choose generic oral anticoagulants like warfarin for long-term treatment to minimize medication costs
- Utilize telemedicine for follow-up appointments to reduce time and travel expenses
Intermediate-risk PE
- Seek an in-person doctor visit promptly to ensure accurate diagnosis without the high costs of an ER visit
- Undergo a CT pulmonary angiography for quick and definitive diagnosis
- Start with injectable anticoagulants like generic enoxaparin, transitioning to oral anticoagulants as soon as possible
- Consider outpatient treatment if stable, to reduce hospitalization costs
High-risk PE (Massive PE)
- Proceed directly to the ER for immediate care, as the efficiency of treatment is critical in this life-threatening situation
- Undergo rapid diagnostic tests, including CT pulmonary angiography and echocardiogram
- Receive immediate thrombolysis if appropriate, as the benefits outweigh the costs in this severe condition
- If surgical intervention is necessary, choose hospitals with experience in PE treatment to potentially reduce complications and length of stay
For all severity levels, consider the following cost-efficient practices:
- Adhere strictly to prescribed medications to prevent recurrence and additional treatment costs
- Utilize compression stockings as a low-cost preventive measure
- Participate in follow-up care to ensure proper recovery and prevent complications
- Explore insurance coverage options and discuss payment plans with healthcare providers to manage out-of-pocket expenses
By implementing these strategies, patients and healthcare providers can work together to achieve a balance between cost-effective pulmonary embolism care and efficient treatment, ensuring the best possible outcomes while managing expenses.
Conclusion
The cost of treating pulmonary embolism (PE) can vary significantly depending on several factors, including the severity of the condition, the chosen diagnostic methods, and the required treatments. This comprehensive guide has explored the various aspects of PE treatment, from initial diagnosis to long-term management, with a focus on associated costs and time considerations.
Key takeaways from this article include:
- PE severity levels greatly influence the treatment approach and associated costs, ranging from low-risk cases manageable with oral medications to high-risk cases requiring emergency interventions.
- Diagnostic costs can differ based on the chosen method (virtual consultation, in-person visit, or emergency room), with each option having its own time and cost implications.
- Imaging and laboratory tests are crucial for accurate diagnosis but can contribute significantly to overall treatment costs.
- Prescription medications, particularly anticoagulants, form the backbone of PE treatment. The choice between brand-name and generic options can substantially impact costs.
- Over-the-counter treatments and compression stockings may provide supplementary care at a relatively lower cost.
- In severe cases, procedures such as catheter-directed thrombolysis or surgical embolectomy may be necessary, potentially increasing overall treatment costs.
- Optimizing for cost or efficiency in PE treatment requires careful consideration of the patient's specific condition and circumstances.
- A balanced approach, considering both cost-effectiveness and timely care, often provides the best outcomes for patients.
It's important to remember that while cost is a significant consideration, the primary goal in treating pulmonary embolism is to ensure proper care and recovery. Patients should work closely with their healthcare providers to determine the most appropriate treatment plan, taking into account both medical needs and financial considerations. By understanding the various options and their associated costs, patients can make more informed decisions about their care while managing the financial aspects of pulmonary embolism treatment.
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