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Communications to the Editor |

Outpatient Treatment of Deep Venous Thrombosis Outpatient Treatment of Deep Venous Thrombosis FREE TO VIEW

Teresa L. Carman, MD; Bernardo B. Fernandez, MD
Author and Funding Information

Affiliations: Cleveland Clinic Florida, Ft. Lauderdale, FL ,  Washington University School of Medicine, St. Louis, MO

Correspondence to: Bernardo B. Fernandez, Jr., MD, Vascular Medicine, Cleveland Clinic Florida, 3000 W Cypress Creek Rd, Ft. Lauderdale, FL 33309-1710



Chest. 1999;116(5):1492-1493. doi:10.1378/chest.116.5.1492-a
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To the Editor:

We read with interest the recent article by Yusen et al (April 1999)1on the retrospective application of inclusion/exclusion criteria for the outpatient treatment of patients with proximal deep venous thrombosis (DVT). When we implemented a clinical pathway for treating patients with DVT, primarily as outpatients, we performed an investigation similar to that of Dr. Yusen and his colleagues. Our results differ significantly. Our retrospective review of patients admitted to our hospital between August 1997 and 1998 indicated that 24 of 75 patients (32%) treated for DVT (all sites inclusive) met the criteria for outpatient treatment. This rate is consistent with the rates given in previously published trials24 and is considerably lower than that in Wells et al,5 who treated 83% of their patients using outpatient therapy. Our exclusion criteria differ from those of Yusen et al1 in that we do not have an upper limit to the age of the patient we are willing to treat and that we consider end-stage renal disease and pregnancy to be contraindications to outpatient therapy.

Since implementing our pathway, we have treated 13 patients as outpatients (following a limited admission for teaching and initiation of therapy). This group comprises approximately 50% of the patients admitted to our hospital for DVT thus far. The majority of our patients are elderly, with an average age for our treated patients of 69 years (range, 38 to 98 years). Our patients have not experienced any major bleeding episodes. One patient suffered a pulmonary embolism while still in the hospital and was treated with IV unfractionated heparin and placement of an inferior vena cava filter. To date, 9 of 13 patients have been assisted with home health care following discharge, primarily for prothrombin time management and injection assistance. With the addition of home health care, most patients are“ accessible” for follow-up, and we often use home health care to help follow our elderly patients after discharge.

We feel that the estimate made by Yusen et al1 is very conservative with respect to the number of patients that may be successfully managed using outpatient therapy. The 100% sensitivity of their protocol for prediction of a negative outcome is commendable; however, the positive predictive value of 8% and the specificity of 20% are extremely low and omit a considerable number of patients who would do quite well with outpatient therapy.

Yusen, RD, Haraden, BM, Gage, BF, et al (1999) Criteria for outpatient management of proximal lower extremity deep venous thrombosis.Chest115,972-979. [CrossRef]
 
Koopman, M, Prandoni, P, Piovella, F, et al Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home.N Engl J Med1996;334,682-687. [CrossRef]
 
Levine, M, Gent, M, Hirsch, 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 Med1996;334,677-681. [CrossRef]
 
Columbus Investigators.. Low-molecular-weight heparin in the treatment of patients with venous thromboembolism.N Engl J Med1997;337,657-662. [CrossRef]
 
Wells, PS, Kovacs, MJ, Bormanis, J, et al Expanding eligibility for outpatient treatment of deep venous thrombosis and pulmonary embolism with low-molecular-weight heparin.Arch Intern Med1998;158,1809-1812. [CrossRef]
 

Outpatient Treatment of Deep Venous Thrombosis

To the Editor:

We appreciate the comments made by Dr. Judson. The purpose of our study (April 1999)1 was to evaluate the criteria for outpatient management of acute proximal lower extremity deep venous thrombosis (DVT). We attempted to assess the outcomes of patients undergoing “usual” care for DVT. One third of our cohort of patients had the diagnosis of DVT made in the outpatient setting, and two thirds of these outpatients were considered potentially eligible for outpatient DVT therapy.

Of the combined cohort of outpatients and inpatients, 9% were classified as eligible and 9% were classified as possibly eligible for outpatient DVT therapy. During initial hospital-based therapy (heparin is converted to warfarin), no major complications occurred in these two groups. Of the 82% of patients not considered eligible for outpatient therapy, serious complications (recurrent thromboembolism, major bleeding, or death) occurred during initial therapy in 8%. These adverse outcomes were not associated with anticoagulation treatment intensity outside of the therapeutic window. Therefore, our eligibility criteria had a sensitivity of 100% and a negative predictive value of 100% for predicting serious complications. We have applied and further prospectively validated our outpatient DVT treatment criteria in 50 consecutive patients who have undergone initial outpatient DVT therapy with low-molecular-weight heparin. In these patients, serious complications have not occurred during the initial DVT treatment period.

We thank Drs. Carman and Fernandez for sharing their experience regarding outpatient DVT treatment. Though we are pleased to see that their patients did not have a significant rate of major bleeding, the literature suggests that elderly patients receiving anticoagulants are at higher risk for hemorrhage than younger patients.23 Further research on bleeding risks in the elderly will shed more light on this issue.

Regarding outpatient treatment of acute DVT, we are not surprised to see the existence of heterogeneity of criteria and of patient eligibility.45 We agree that our criteria are quite conservative. When starting an outpatient DVT treatment program, health-care providers may wish to use conservative criteria. In addition, health-care providers and patients need to determine an acceptable level of risk that would accompany home therapy. We recommend that health-care providers do the following: (1) adapt and develop criteria to fit their local environment and patient population; (2) assess patient outcomes; and (3) revise criteria to improve outcomes. Continued discussion about the appropriateness of medical treatment regimens and the setting for their administration hopefully will lead to further research and improved patient outcomes.

References
Yusen, R, Haraden, B, Gage, B, et al Criteria for outpatient management of proximal lower extremity deep venous thrombosis.Chest1999;115,972-979. [CrossRef]
 
Landefeld, S, Beyth, R Anticoagulant-related bleeding: clinical epidemiology, prediction and prevention.Am J Med1993;95,315-328. [CrossRef]
 
Kuijer, P, Hutten, B, Prins, M, et al Prediction of the risk of bleeding during anticoagulant treatment for venous thromboembolism.Arch Intern Med1999;159,457-460. [CrossRef]
 
Koopman, M, Prandoni, P, Piovella, F, et al Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home.N Engl J Med1996;334,682-687. [CrossRef]
 
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 Med1996;334,677-681. [CrossRef]
 

Figures

Tables

References

Yusen, RD, Haraden, BM, Gage, BF, et al (1999) Criteria for outpatient management of proximal lower extremity deep venous thrombosis.Chest115,972-979. [CrossRef]
 
Koopman, M, Prandoni, P, Piovella, F, et al Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home.N Engl J Med1996;334,682-687. [CrossRef]
 
Levine, M, Gent, M, Hirsch, 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 Med1996;334,677-681. [CrossRef]
 
Columbus Investigators.. Low-molecular-weight heparin in the treatment of patients with venous thromboembolism.N Engl J Med1997;337,657-662. [CrossRef]
 
Wells, PS, Kovacs, MJ, Bormanis, J, et al Expanding eligibility for outpatient treatment of deep venous thrombosis and pulmonary embolism with low-molecular-weight heparin.Arch Intern Med1998;158,1809-1812. [CrossRef]
 
Yusen, R, Haraden, B, Gage, B, et al Criteria for outpatient management of proximal lower extremity deep venous thrombosis.Chest1999;115,972-979. [CrossRef]
 
Landefeld, S, Beyth, R Anticoagulant-related bleeding: clinical epidemiology, prediction and prevention.Am J Med1993;95,315-328. [CrossRef]
 
Kuijer, P, Hutten, B, Prins, M, et al Prediction of the risk of bleeding during anticoagulant treatment for venous thromboembolism.Arch Intern Med1999;159,457-460. [CrossRef]
 
Koopman, M, Prandoni, P, Piovella, F, et al Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home.N Engl J Med1996;334,682-687. [CrossRef]
 
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 Med1996;334,677-681. [CrossRef]
 
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