Home versus in-patient treatment for deep vein thrombosis

Richard Othieno (Corresponding Author), Mayada Abu Affan, Emmanuel Okpo

Research output: Contribution to journalArticle

42 Citations (Scopus)

Abstract

BACKGROUND: 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.

OBJECTIVES: 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.

SEARCH STRATEGY: 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.

SELECTION CRITERIA: RCTs of home versus hospital treatment for DVT in which DVT was clinically confirmed and treated with either LMWH or UH.

DATA COLLECTION AND ANALYSIS: 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.

MAIN RESULTS: 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.

AUTHORS' CONCLUSIONS: 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.

Original languageEnglish
Article numberCD003076
JournalCochrane Database of Systematic Reviews
Issue number3
Early online date18 Jul 2007
DOIs
Publication statusPublished - 2007

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Venous Thrombosis
Low Molecular Weight Heparin
Confidence Intervals
Therapeutics
Randomized Controlled Trials
Heparin
Hemorrhage
Costs and Cost Analysis
Gangrene
Peripheral Vascular Diseases
Venous Thromboembolism
MEDLINE
Libraries
Veins
Thrombosis
Research Personnel
Safety
Recurrence
Lung
Mortality

Keywords

  • Fibrinolytic Agents
  • Heparin
  • Heparin, Low-Molecular-Weight
  • Home Care Services
  • Hospitalization
  • Humans
  • Randomized Controlled Trials as Topic
  • Secondary Prevention
  • Thrombolytic Therapy
  • Venous Thrombosis

Cite this

Home versus in-patient treatment for deep vein thrombosis. / Othieno, Richard (Corresponding Author); Abu Affan, Mayada ; Okpo, Emmanuel.

In: Cochrane Database of Systematic Reviews, No. 3, CD003076, 2007.

Research output: Contribution to journalArticle

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abstract = "BACKGROUND: 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.OBJECTIVES: 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.SEARCH STRATEGY: 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.SELECTION CRITERIA: RCTs of home versus hospital treatment for DVT in which DVT was clinically confirmed and treated with either LMWH or UH.DATA COLLECTION AND ANALYSIS: 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.MAIN RESULTS: 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.AUTHORS' CONCLUSIONS: 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.",
keywords = "Fibrinolytic Agents, Heparin, Heparin, Low-Molecular-Weight, Home Care Services, Hospitalization, Humans, Randomized Controlled Trials as Topic, Secondary Prevention, Thrombolytic Therapy, Venous Thrombosis",
author = "Richard Othieno and {Abu Affan}, Mayada and Emmanuel Okpo",
note = "Acknowledgements We extend our acknowledgement to Ivor Schraibman, Elizabeth Royle, and Alan Milne for authoring the original draft of this review. We would like to thank the Cochrane Peripheral Vascular Disease Group for their assistance with updating this review. We would also like to thank the Cochrane Consumer Network for providing an updated Plain Language Summary.",
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T1 - Home versus in-patient treatment for deep vein thrombosis

AU - Othieno, Richard

AU - Abu Affan, Mayada

AU - Okpo, Emmanuel

N1 - Acknowledgements We extend our acknowledgement to Ivor Schraibman, Elizabeth Royle, and Alan Milne for authoring the original draft of this review. We would like to thank the Cochrane Peripheral Vascular Disease Group for their assistance with updating this review. We would also like to thank the Cochrane Consumer Network for providing an updated Plain Language Summary.

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N2 - BACKGROUND: 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.OBJECTIVES: 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.SEARCH STRATEGY: 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.SELECTION CRITERIA: RCTs of home versus hospital treatment for DVT in which DVT was clinically confirmed and treated with either LMWH or UH.DATA COLLECTION AND ANALYSIS: 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.MAIN RESULTS: 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.AUTHORS' CONCLUSIONS: 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.

AB - BACKGROUND: 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.OBJECTIVES: 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.SEARCH STRATEGY: 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.SELECTION CRITERIA: RCTs of home versus hospital treatment for DVT in which DVT was clinically confirmed and treated with either LMWH or UH.DATA COLLECTION AND ANALYSIS: 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.MAIN RESULTS: 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.AUTHORS' CONCLUSIONS: 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.

KW - Fibrinolytic Agents

KW - Heparin

KW - Heparin, Low-Molecular-Weight

KW - Home Care Services

KW - Hospitalization

KW - Humans

KW - Randomized Controlled Trials as Topic

KW - Secondary Prevention

KW - Thrombolytic Therapy

KW - Venous Thrombosis

U2 - 10.1002/14651858.CD003076.pub2

DO - 10.1002/14651858.CD003076.pub2

M3 - Article

JO - Cochrane Database of Systematic Reviews

JF - Cochrane Database of Systematic Reviews

SN - 1469-493X

IS - 3

M1 - CD003076

ER -