Replacing Inpatient Care by Outpatient Care in the Treatment of Deep Venous Thrombosis – An Economic Evaluation

Abstract

SummaryTwo clinical trials in patients with acute deep venous thrombosis have indicated that the outpatient management with fixed-dose, subcutaneous low-molecular-weight heparin is at least as effective and safe as inpatient treatment with unfractionated intravenous heparin with respect to recurrent venous thromboembolism and major bleeding. We performed an economic evaluation alongside one of these trials to assess the cost consequences of the outpatient management strategy. Data were collected through case record forms, complemented by a prospective questionnaire in 78 consecutive patients, interviews with health care providers, and hospital data bases. Our study demonstrated that seventy-five percent of patients allocated to low-molecular-weight heparin received treatment either entirely at home or after a brief hospital stay. Fifteen percent of these patients required professional domiciliary care. Within-centre comparisons of resource utilisation in terms of natural units showed that outpatient management with low-molecular-weight heparin reduced the average number of hospital days in the initial treatment period in nine centres by 59 percent (95% CI: 43 to 71 percent) accompanied by a limited increase in outpatient and professional domiciliary care. The average reduction in hospital days at the end of follow up was 40 percent (95% CI: 25 to 54 percent). A cost-minimisation analysis, focusing on resource utilisation directly related to the treatment of deep venous thrombosis and associated costs in one centre demonstrated a cost reduction of 64 percent (95% CI: 56 to 72 percent) with the outpatient management with low-molecular-weight heparin. These data suggest that outpatient management of patients with proximal venous thrombosis using low-molecular-weight heparin reduces resource utilisation and total treatment cost. Implementation should be preceded by a cautious evaluation of a potential cost shifting and organisational prerequisites.

Clinical Outcome and Cost of Hospital vs Home Treatment of Proximal Deep Vein Thrombosis With a Low-Molecular-Weight Heparin

“…The cost consequences of replacing hospital treatment with outpatient care may be complex. 12 Some previous trials [13][14][15] investigated the efficacy, safety, and cost-effectiveness of outpatient treatment of DVT by LMWH. The present study was, therefore, designed to compare home with hospital treatment unambiguously, using the same treatment regimen of an LMWH plus oral anticoagulants, for clinical efficacy and cost.…”

A Pilot Study of Home Treatment of Deep Vein Thrombosis With Subcutaneous Once-Daily Enoxaparin Plus Warfarin

“…Moreover, the reduced number of hospital visits required with once-daily treatment at home offers potential savings in the costs of nursing staff, drugs, and consumables. [9][10][11] Such savings are due largely to reductions in costs associated with hospitalization. In the present study, outpatient treatment of DVT with enoxaparin once daily provided 74% lower costs when compared retrospectively with typical inpatient UFH therapy for the same treatment duration ( Table 4).…”

“…A prior retrospective analysis of average length of stay in those patients receiving UFH at our hospital found that, for the period 1998-2000, 165 patients were hospitalized for an average 5.5 days (range, [3][4][5][6][7][8][9]. Therefore, the savings in actual practice may be larger and will certainly be different in other medical centers.…”

“…This is supported by a previous study in which outpatient treatment with LMWH reduced the number of hospital days by 40% (7.2 vs. 12.1 days for UFH) and total treatment costs by 64% compared with UFH. 9 Compared with UFH, LMWH treatment has been shown to produce cost savings when as few as 8% of patients with DVT were treated as outpatients. 10 Moreover, studies comparing outpatient and inpatient treatment with LMWHs have shown that outpatient treatment can result in cost savings of up to 82%.…”

“…A major bleed was defined as a drop in hemoglobin of >2 g/dL or evidence of any intracranial bleed or retroperitoneal bleed. • ≥2 previous episodes of DVT [22] • Surgery in last 2 weeks [13] • Acute PE or clot with ileo-caval involvement [9] • Total body weight >150% of lean body weight [5] • Pregnancy [2] • Concurrent epidural analgesia [ Only descriptive statistics were used in this study. For the same study period, billing and payment data for daily home nursing visits were recorded for enrolled patients.…”