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Clinical Decisionmaking

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Some patients with deep venous thrombosis can be treated safely at home

A certain group of patients suffering from lower extremity deep venous thrombosis (DVT), that is, blood clot in a deep vein of a leg, can be treated safely at home, concludes a study support in part by the Agency for Health Care Policy and Research (National Research Service Award F32 HS00124). These are patients who are not at high risk for bleeding or recurrent clotting, and who do not have pulmonary embolism, limited cardiopulmonary reserve, or another illness that requires hospitalization.

Using these criteria, none of the patients in this study who were treated at home developed complications. They were treated with subcutaneous injections of low-molecular-weight heparin (LMWH)—an anticoagulant—instead of the unfractionated intravenous (IV) heparin, which is the traditional treatment for hospitalized patients with DVT.

The benefit of home treatment includes infrequent and safer subcutaneous dosing, without the need for repeated blood tests to monitor partial thromboplastin time (blood coagulation time), which is required to avoid internal bleeding with IV heparin, explains Roger D. Yusen, M.D., of Washington University School of Medicine. Dr. Yusen and his colleagues developed the criteria for outpatient treatment eligibility. They retrospectively applied the criteria to 195 hospitalized patients at one hospital who were newly diagnosed with proximal lower extremity DVT to determine the proportion of patients eligible for outpatient therapy.

Nine percent of patients were classified as eligible and 9 percent as possibly eligible for outpatient therapy. None of these patients developed complications. Of the 82 percent of patients classified as ineligible, 8 percent died or developed serious complications. Thus, the eligibility criteria had a sensitivity of 100 percent and a negative predictive value of 100 percent for predicting serious complications. These findings suggest that objective criteria may be used to select patients for proximal lower extremity DVT home therapy.

More details are in "Criteria for outpatient management of proximal lower extremity deep venous thrombosis," by Dr. Yusen, Brennan M. Haraden, M.D., Brian F. Gage, M.D., M.Sc., and others, in the April 1999 Chest 115, pp. 972-979.

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