Dalteparin for deep enous thrombosis: a hospital‐in‐the‐home program

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Abstract
Objective: To assess the efficacy, safety and cost savings of home treatment of lower‐limb deep venous thrombosis (DVT). Setting: A hospital‐in‐the‐home treatment program. Patients: One hundred patients with acute lower limb DVT (53 proximal, 47 distal), and no contraindication to home treatment, were entered into the program from March 1995 to February 1997. Intervention: All patients received dalteparin, 200 units/kg subcutaneously, once daily for a minimum of five days, with commencement of oral anticoagulation (warfarin) on Day 2. Patients with proximal DVT had lung ventilation‐perfusion scans performed and were admitted to hospital for at least 24 hours. Patients with distal DVT were discharged directly to home treatment. Main outcome measures: Clinical responses and the results of sequential duplex ultrasonography at one week, one month, three months and six months. Results: There were no major, but six minor, bleeding complications, two of which led to dalteparin being withdrawn. Sixteen patients had lung ventilation‐perfusion scans showing a high probability of pulmonary embolism. All were asymptomatic, and follow‐up for at least three months showed no symptomatic thromboembolic events. Duplex ultrasonography showed progression of thrombosis in the first week of therapy in 13.2% of distal and 2.7% of proximal thromboses. Thereafter, distal DVT improved at a much greater rate than proximal DVT; after six months complete resolution was seen in 60.7% of distal and 18.5% of proximal thromboses, respectively. Cost saving was $197 per bed‐day equivalent compared with inpatient care. At 15 months' follow‐up, swelling and/or pain was reported by 49% of patients with distal DVT and 66% of those with proximal DVT. Conclusions: Once‐daily dalteparin therapy for DVT in a hospital‐in‐the‐home setting was safe, efficacious and cost effective. However, DVT resolution is a slow process, with significant long term morbidity.