REPLACING INPATIENT CARE BY OUTPATIENT CARE IN THE TREATMENT OF DEEP VENOUS THROMBOSIS - AN ECONOMIC-EVALUATION

Two clinical trials in patients with acute deep venous thrombosis have indicated that the outpatient management with fixed-dose, subcutaneou s low-molecular-weight heparin is at least as effective and safe as in patient 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 cos t consequences of the outpatient management strategy. Data were collec ted through case record forms, complemented by a prospective questionn aire in 78 consecutive patients, interviews with health care providers , and hospital data bases. Our study demonstrated that seventy-five pe rcent of patients allocated to low-molecular-weight heparin received t reatment either entirely al home or after a brief hospital stay. Fifte en percent of these patients required professional domiciliary care. W ithin-centre comparisons of resource utilisation in terms of natural u nits showed that outpatient management with low-molecular-weight hepar in reduced the average number of hospital days in the initial treatmen t period in nine centres by 59 percent (95% CI: 43 to 71 percent) acco mpanied by a limited increase in outpatient and professional domicilia ry care. The average reduction in hospital days at the end of follow u p was 40 percent (95% CI: 25 to 54 percent). A cost-minimisation analy sis, focusing on resource utilisation directly related to the treatmen t of deep venous thrombosis and associated costs in one centre demonst rated a cost reduction of 64 percent (95% CI: 56 to 72 percent) with t he outpatient management with low-molecular-weight heparin. These data suggest that outpatient management of patients with proximal venous t hrombosis using low-molecular-weight heparin reduces resource utilisat ion and total treatment cost. Implementation should be preceded by a c autious evaluation of a potential cost shifting and organisational pre requisites.