Home versus in-patient treatment for deep vein thrombosis.

Abstract

Deep vein thrombosis (DVT) affects 1-2/1,000 of the adult population per annum in western societies. It may be associated with pulmonary embolism (PE) which carries a 10% fatality rate. Sufferers may develop post-thrombotic syndrome with swelling of the leg, secondary varicose veins and ulceration. In the initial stages of treatment for DVT patients are traditionally admitted to hospital for intravenous treatment with unfractionated heparin (UH) for three to five days. The dose of UH required to provide a therapeutic level of anticoagulation is unpredictable, so the blood must be closely monitored. Fractionated, or low molecular weight heparin (LMWH), is given subcutaneously once daily and requires no monitoring, so can be given in hospital or at home. To collate all randomised controlled trials (RCTs) comparing a home treatment regime (LMWH) with hospital treatment (LMWH or UH) for the initial phase of treatment for DVT, and to compare the safety, efficacy, patient acceptability and cost implications of home versus in-patient treatment. All published reports of home treatment were traced through MEDLINE, and EMBASE (up to and including December 2000) using the search strategy described by the Cochrane Peripheral Vascular Diseases Group. Additional searches included the Cochrane CCTR/CENTRAL database, handsearching non-listed journals, and personal communication with researchers. 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 (IGS): the other (AAM) reviewed the literature and selection of trials. Outcomes included PE, recurrent DVT, gangrene, heparin complications, and death. Only two major RCTs with comparable treatment arms were found. Both 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 home treatment was no more liable to complications than hospital treatment. Initial results from a smaller RCT comparing LMWH treatment in both home and hospital arms came to the same conclusion. The limited evidence suggests that home management is cost effective, and likely to be preferred by patients. Further large trials comparing these treatments are unlikely to be held. Therefore, home treatment is likely to become the norm, and further research will be directed to resolving practical issues.