Is home therapy for deep venous thrombosis (DVT) superior to in-hospital treatment in reducing recurrent venous thromboembolism (VTE)?
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.)
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 with inpatient treatment (NNT = 23; 95% CI, 22 to 96).
No differences were noted in the rates of minor or major bleeding or death. Quality of life was addressed in three studies, but the results were inconsistent; one study found no difference in quality of life between those treated at home or as inpatients, a second found an improved quality of life for those treated at home that did not persist to the 12th week of follow-up, and the third found only a small improvement in social function in those treated at home. Four studies reported on cost-effectiveness, and although the results of these could not be pooled, they demonstrated that inpatient VTE care cost more than home therapy. Home care savings over inpatient therapy varied from 3% to 64% in the studies, largely because of savings associated with direct hospitalization costs.
The authors rated the overall evidence as low to very low quality. Many patients in the home treatment group were initially hospitalized, and protocols to blind reviewers and randomize treatment allocation were not accomplished or not described in most of these studies. There was significant variation in exclusion criteria, such as whether PE was suspected or whether patients had received prior treatment for a thromboembolic event, which limits the applicability of this review's findings to the general population.3,4 Further, the studies included in this review were conducted outside the United States, limiting generalizability to the domestic population.
Current American College of Chest Physicians guidelines on VTE treatment recommend home therapy for acute lower-extremity DVT and low-risk PE (i.e., clinically stable with good cardiopulmonary reserve) in appropriately selected patients. This includes those who feel well enough to be treated at home and who have well-maintained living conditions, strong support from family or friends, telephone access, and the ability to return to the hospital if deterioration occurs.5
Editor's Note: Dr. Saguil is a Contributing Editor for AFP. In addition, the number needed to treat and confidence intervals reported in this Cochrane for Clinicians were calculated by the authors based on raw data provided in the original Cochrane review.
The practice recommendations in this activity are available at http://www.cochrane.org/CD003076.
The views expressed in this article are the authors' and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. government.