BMJ 2001;322:1212-1213 ( 19 May )

Papers

Eligibility for home treatment of deep vein thrombosis: prospective study

Editorial by Eikelboom and Baker

Thomas Schwarz, clinical research fellow, Benjamin Schmidt, clinical research fellow, Ulrike Höhlein, medical student, Jan Beyer, clinical research fellow, Hans-Egbert Schröder, professor, Sebastian M Schellong, consultant. 

Department of Internal Medicine, Division of Vascular Medicine, University Hospital "Carl Gustav Carus", D-01307 Dresden, Germany

Correspondence to: T Schwarz [log in to unmask]

Low molecular weight heparin is safe and effective for the treatment of deep vein thrombosis.1 We have recently shown in a randomised study that immobilisation is not necessary.2 The results challenge the traditional notion that these patients must be treated in hospital. For selected patients, outpatient treatment has been shown to be safe and effective. 3 4 We determined the proportion of patients who still require admission to hospital and why.


 

  Methods and results

Between 1 November 1998 and 15 August 1999 all patients presenting to the vascular diagnostics unit of the University Hospital Dresden, Germany, as outpatients with acute deep vein thrombosis in the leg were prospectively evaluated regarding eligibilty for home treatment. We defined acute deep vein thrombosis as non-compressible deep veins on ultrasonography (UM9 HDI, linear array 4-7 MHz, ATL, Bothell, Washington, DC) and symptoms that had been present for less than two weeks. Written informed consent was obtained from all patients.

On the day of diagnosis patients were started on oral anticoagulation with phenprocoumon (adjusted to a target international normalised ratio of 2-3) and the low molecular weight heparin nadroparin (90 IU/kg body weight twice daily) until a therapeutic ratio was achieved. All patients received class II compression stockings. At presentation, the decision regarding hospital admission was based on medical reasons, home care situation, patients' and general practitioners' rejection of outpatient treatment, and hospital service logistics. The 95% confidence intervals were calculated according to the Wilson procedure.

We assessed recurrent venous thromboembolism (verified by sonography, ventilation-perfusion scan, or pulmonary angiography), major bleeding, and death at clinical follow up of patients treated at home. Assessments were at three and six days and two, four, and 12 weeks after initiation of treatment. The study was approved by the local ethics committee.

A total of 117 consecutive outpatients (48 men, 69 women) were diagnosed as having acute deep vein thrombosis. Of these, 92 received home treatment---that is, they were not admitted at all. The median (range) age was 62.0 (19-95) years. Three patients were admitted to hospital for medical reasons; 11 because of the home care situation; and 11 for reasons of hospital service logistics (table). At the 12 week follow up of the 92 patients, eight had died (six from cancer and two from chronic heart failure; three had recurrent thrombosis; and four had developed minor bleeding. No clinical pulmonary embolism or major bleeding occurred. Safety and efficacy figures are similar to those previously published.5


                              
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Reasons for admission to hospital in 117 consecutive outpatients with deep vein thrombosis




 

  Comment

Most outpatients presenting with acute deep vein thrombosis do not need to be admitted to hospital. The proportion who do require admission depends mainly on factors to do with infrastructure rather than medical reasons. In our study, only 3% of patients were admitted for medical reasons, and in 9% admission was because medication and international normalised ratio could not be monitored. Even these patients could have been treated as outpatients if adequate professional care had been available at home. No serious complications were noted in patients treated in an outpatient setting. Another 9% of our patients presented in the emergency room and were already being treated for deep vein thrombosis suspected on clinical grounds alone. They were admitted until ultrasound examination could be performed.

 

  Acknowledgments

We thank Roswitha Frommhold of the nursing staff for excellent patient care and Harry R Büller, Amsterdam, for his helpful criticism.

Contributors: TS and SMS had the original idea for the study, recruited a large number of patients, created the trial database, analysed the data, and wrote the paper. BS conducted statistical analysis and recruited patients. UH advised on data collection and analysed the data. JB recruited patients for the study. HES revised the final version of the manuscript and is the guarantor of the paper. All authors approved the final version of the paper.

 

  Footnotes

Funding: Sanofi-synthelabo, Berlin, and medi-Bayreuth, Bayreuth.

Competing interests: None declared.


 

  References


1.

Dolovich LR, Ginsberg JS, Douketis JD, Holbrook AM, Cheah G. A meta-analysis comparing low-molecular-weight heparins with unfractionated heparin in the treatment of venous thromboembolism. Arch Int Med 2000; 160: 181-188[Medline].

2.

Schellong SM, Schwarz T, Kropp J, Prescher Y, Beuthien B, Daniel WG. Bed rest in deep vein thrombosis and the incidence of pulmonary embolism. Thromb Haemost 1999; 82(suppl): 127-129[Medline].

3.

Koopman MM, Prandoni P, Piovella F, Ockelford PA, Brandjes DPM, van der Meer J, et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. N Engl J Med 1996; 334: 682-687[Medline].

4.

Levine M, Gent M, Hirsh J, Leclerc J, Anderson D, Weitz J, et al. A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med 1996; 334: 677-681[Medline].

5.

Lensing WA, Prandoni P, Prins MH, Büller HR. Deep-vein thrombosis. Lancet 1999; 353: 479-485[Medline].

(Accepted 16 January 2001)

©

 

Edward E. Rylander, M.D.

Diplomat American Board of Family Practice.

Diplomat American Board of Palliative Medicine.