Our study’s possibly eligible group, whose members each had one relative contraindication to outpatient therapy, had no in-hospital complications. When developing the a priori criteria, we decided to keep the possibly eligible group separate from the eligible group based on a lack of data related to potential outpatient and LMWH therapy in patients with certain characteristics. For example, there have been limited data published regarding use of LMWH in pregnant patients. Also, dialysis therapy is considered a relative contraindication because LMWH is cleared primarily via the kidneys, and appropriate dosing may be difficult. In addition, there is an increased risk of hemorrhage in patients with renal failure. The geographic criterion was developed because of potential difficulties with follow-up in remote areas. As LMWH use and outpatient treatment of DVTs becomes more routine in the medical community, these contraindications should be reevaluated. Read the rest of this entry »
This study suggests that objective criteria may be used to select patients for proximal lower extremity DVT home therapy. We showed that complications of bleeding, venous thromboembolism, and death were greater in those patients considered ineligible than in those patients considered eligible for home therapy. The ability of the criteria to identify patients safe for home therapy was demonstrated with the 100% sensitivity and the 100% negative predictive value of the criteria for predicting complications; none of the patients in the eligible or possibly eligible groups suffered any major complications.
Although the specificity and positive predictive value of the criteria were low, safety was the focus of this study. The criteria were intended to identify patients who would not have serious complications, and who therefore could be safely treated at home. Read the rest of this entry »
Two patients in the ineligible group had nonfatal symptomatic PE diagnosed by either high-proba-bility ventilation-perfusion scan (one patient) or pulmonary angiogram (one patient) while being treated for the previously diagnosed proximal lower extremity DVT. Both of these patients had adequate anticoagulation at the time of their PE with an activated partial thromboplastin time of > 1.5 times the control. Another patient in the ineligible group may have had a PE based on clinical suspicion, but a ventilation-perfusion scan was interpreted as intermediate probability and an angiogram was not performed. Read the rest of this entry »
Twelve hundred patients underwent lower extremity duplex ultrasound scanning during the 1-year period (Fig 1). Of these patients, 203 (17%) were diagnosed as having proximal lower extremity DVT, Of the 199 who had inpatient therapy, 195 had charts available for review, constituting our main study cohort. The mean (± SD) age of the study cohort was 70 (± 16) years with a range of 81 years, Fifty-nine percent of patients were women.
Eligibility for Outpatient Therapy
Thirty percent of patients had the diagnosis of proximal lower extremity DVT made in the outpatient setting, including the emergency department, whereas 70% of patients had the diagnosis made while already hospitalized (Fig 1). Nine percent of the study cohort were eligible for outpatient DVT therapy. Another 9% of the study cohort were possibly eligible. The remaining 82% of patients were ineligible for outpatient therapy. Read the rest of this entry »
Application of Eligibility Criteria and Determination of Complication Rates
By retrospectively applying the a priori eligibility criteria to the study cohort, we classified patients as eligible, possibly eligible, or ineligible for outpatient therapy (Fig 1). Hospital and laboratory records, ventilation-perfusion and pulmonary angiography reports, and autopsy documents were reviewed to see which patients had complications during their hospitalization for initial proximal lower extremity DVT therapy. For the purposes of this study, the relevant hospitalization began when the DVT was first diagnosed. We defined initial therapy as the period that began when patients received IV unfractionated heparin and ended when patients were converted to oral warfarin therapy for treatment of the newly diagnosed DVT. anti allergy
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Study Setting and Patients
Using a computerized registry, we identified all patients who underwent lower extremity duplex ultrasound scanning between July 1, 1993, and June 30, 1994, in the vascular laboratory at Jewish Hospital at the Washington University Medical Center in St. Louis, MO. Patients were selected for chart review if they had been hospitalized and had a new proximal lower extremity DVT diagnosed by duplex examination. During duplex evaluation, proximal lower extremity DVT was defined as a constant and incompressible intraluminal deep venous defect at or above the popliteal vein. Although all study patients were ultimately hospitalized, the timing of the duplex examination in relationship to hospital admission was used to classify each patient’s presentation as an outpatient or inpatient event. Duplex examinations performed in the emergency department prior to hospital admission were considered as part of an outpatient presentation (Fig 1). Read the rest of this entry »
Unfractionated IV heparin has been used traditionally for the treatment of hospitalized patients who have a newly diagnosed proximal lower extremity deep venous thrombosis (DVT). However, subcutaneously administered low-molecular-weight heparin (LMWH) has been demonstrated to be as safe and effective as therapy with continuous IV unfractionated heparin. The advantages of LMWH over unfractionated heparin include infrequent and subcutaneous dosing and safety without activated partial thromboplastin time monitoring. Given these advantages and their potential for cost savings, LMWHs provide an excellent opportunity for outpatient treatment of patients with uncomplicated proximal lower extremity DVT. Read the rest of this entry »