Cochrane for Clinicians

Putting Evidence into Practice

Deep Venous Thrombosis: Home vs. Inpatient Treatment

 

Am Fam Physician. 2018 Dec 1;98(11):642-644.

Author disclosure: No relevant financial affiliations.

Clinical Question

Is home therapy for deep venous thrombosis (DVT) superior to in-hospital treatment in reducing recurrent venous thromboembolism (VTE)?

Evidence-Based Answer

Patients treated at home with low-molecular-weight heparin (LMWH) have lower rates of recurrent VTE than those treated in a hospital (number needed to treat [NNT] = 23; 95% confidence interval [CI], 22 to 96). There were no clear differences in the occurrence of minor or major bleeding or death. Individual studies showed some improvement in quality-of-life measures with home therapy. Costs were lower for home treatment of VTE, with a savings of 3% to 64% over three to six months of therapy.1 (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

DVT affects up to 900,000 U.S. adults (one to two per 1,000) annually. VTE refers to both DVT and pulmonary embolism (PE), and is estimated to cause 60,000 to 100,000 deaths in the United States per year.2 Although historically VTE was initially managed in the inpatient setting with unfractionated heparin and warfarin, immediate home management with LMWH and/or oral anticoagulants has recently become a more common practice. The authors of this review compared the rate of recurrence, bleeding, and death in patients treated with inpatient protocols vs. exclusively outpatient protocols, while also examining the costs associated with treatment in the two settings.

This Cochrane review included seven trials with 1,839 patients from countries outside the United States.1 The primary outcomes were recurrence of VTE, venous gangrene, minor or major bleeding, or death over three to 12 months of follow-up. Secondary outcomes included patient satisfaction, quality of life, and cost. Only a portion (between 23% and 49%) of patients in the included studies randomized to home VTE therapy were treated exclusively at home. Treatment of VTE (six trials; n = 1,708) at home resulted in lower rates of recurrence compared

Author disclosure: No relevant financial affiliations.

References

show all references

1. Othieno R, Okpo E, Forster R. Home versus in-patient treatment for deep vein thrombosis. Cochrane Database Syst Rev. 2018;(1):CD003076....

2. Centers for Disease Control and Prevention. Venous thromboembolism (blood clots). Data & statistics. https://www.cdc.gov/ncbddd/dvt/data.html. Accessed April 30, 2018.

3. Koopman M, Prandoni P, Piovella F, et al.; the Tasman Study Group. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home [published correction appears in N Engl J Med. 1997;337(17):1251]. N Engl J Med. 1996;334(11):682–687.

4. Levine M, Gent M, Hirsh 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(11):677–681.

5. Kearon C, Akl E, Ornelas J, et al. Antithrombotic therapy for VTE disease. CHEST guideline and expert panel report [published correction appears in Chest. 2016;150(4):988]. Chest. 2016;149(2):315–352.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, Assistant Medical Editor.

A collection of Cochrane for Clinicians published in AFP is available at https://www.aafp.org/afp/cochrane.

 

 

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