Outpatient treatment of deep venous thrombosis: A clinical care pathway managed by the emergency department

Study objective: We evaluate the effectiveness and safety of an outpatient clinical care pathway for the initial treatment of acute proximal lower-ext remity deep venous thrombosis (DVT) with low molecular weight heparin (LMWH ) managed by the emergency department of 2 affiliated community hospitals. Methods: This observational, retrospectively defined, population-based stud y with 391/2 months of preintervention analysis and 321/2 months of postint ervention analysis was conducted in 2 suburban EDs of a large group model h ealth maintenance organization. Our outpatient DVT clinical care pathway us ed careful patient selection and multidisciplinary follow-up. Ninety six pa tients before the intervention and 178 patients after the intervention met eligibility criteria for the pathway. Adverse events during the first 2 wee ks of treatment included symptomatic pulmonary embolism (PE), progressive D VT, minor and major bleeding, and death. Results: Demographic and baseline clinical characteristics of the 2 groups were similar. Five (5.2%) of 96 preintervention subjects (95% confidence in terval [CI] 2.4 to 8.1)developed adverse events compared with 5 (2.8%) of 1 78 postintervention subjects (95% CI 1.5 to 4.1; difference between groups 2.4%; P=.50). In each group, 1 (1.0% versus 0.6%) subject developed a PE, 2 (2.1% versus l.l%)developed progressive symptoms of progressive DVT, and 2 (2.1% versus 1.1%) developed minor bleeding. Major bleeding occurred in 1 (1.0%) preintervention subject and no postintervention subjects. No patient in either cohort died. Conclusion: Managed by the ED, an outpatient DVT clinical care pathway usin g careful patient selection and an integrated multidisciplinary approach ca n provide a similar degree of effectiveness and safety as customary inpatie nt therapy.