Outpatient-based treatment protocols in the management of venous thromboembolic disease

Clinical trial data are demonstrating that the safety and efficacy of treating deep vein thrombosis (DVT) on an outpatient basis with low-molecular weight heparin (LMWH) are equal to inpatient care with unfractionated heparin (UFH). Moreover, LMWH therapy offers multiple advantages, including improved bioavailability at lower doses, reduced heparin resistance, a longer half-life, and potentially, less bleeding. Although these potential advantages are acknowledged, patient selection and risk stratification criteria for patients being considered for LMWH therapy are discussed less frequently; nonetheless, they deserve careful consideration. The protocol utilized by Lovelace Health Systems, a staff model health maintenance organization, features an outpatient-based DVT treatment program that includes exclusionary risk factors for outpatient treatment of venous thromboembolic disease (VTE). Evidence from clinical findings at Lovelace suggests that patients without absolute exclusionary risk factors can successfully be treated with LMWH as outpatients. Specific study results show that 61% of patients were eligible for outpatient therapy and had fewer recurrences of VTE (1.9%) than those comorbid matched patients who were hospitalized with traditional UFH therapy the previous year (4.1%). These findings suggest that LMWH is both safe and efficacious in the home treatment of VTE in a managed care setting when established patient selection criteria and risk stratification strategies are carefully maintained.