Home versus in-patient treatment for deep vein thrombosis

Abstract

Deep vein thrombosis (DVT) occurs when a blood clot blocks blood flow through a vein. This can happen after surgery, trauma, or when a person has been immobile. Clots can dislodge and block blood flow to the lungs, causing death. Heparin is a blood-thinning drug used in the first 3-5 days of DVT treatment. Low molecular weight heparins (LMWH) allow people with DVT to receive their initial treatment at home instead of in hospital. To collate randomised controlled trials (RCTs) comparing home (LMWH) versus hospital (LMWH or UH) treatment for DVT, and to compare the safety, efficacy, acceptability and cost implications of home versus hospital treatment. We searched the Cochrane Peripheral Vascular Diseases Group trials register (inception to May 2007) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (last searched Issue 2, 2007) which includes searches of MEDLINE (January 1966 onwards) and EMBASE (January 1980 onwards). We also handsearched non-listed journals and contacted researchers in the field. RCTs of home versus hospital treatment for DVT in which DVT was clinically confirmed and treated with either LMWH or UH. One reviewer selected the material for inclusion and another reviewed the literature and selection of trials. Two reviewers independently extracted data. Outcomes included PE, recurrent DVT, gangrene, heparin complications, and death. Six RCTs involving 1708 participants with comparable treatment arms were included. All six had fundamental problems including high exclusion rates, partial hospital treatment of many in the LMWH arms, and comparison of UH in hospital with LMWH at home. The trials showed that patients treated at home with LMWH are less likely to have recurrence of venous thromboembolism (VTE) compared to hospital treatment with UH or LMWH (fixed effect relative risk (FE RR) 0.61; 95% confidence interval (CI) 0.42 to 0.90). Home treated patients also had lower mortality (FE RR 0.72; 95% CI 0.45 to 1.15) and fewer major bleeding (FE RR 0.67; 95% CI 0.33 to 1.36), but were more likely to have minor bleeding than those in hospital (FE RR 1.29; 95% CI 0.94 to 1.78) though these were not statistically significant. The limited evidence suggests that home management is cost effective and preferred by patients. Further large trials comparing these treatments are unlikely to occur. Therefore, home treatment is likely to become the norm; further research will be directed to resolving practical issues.