An outpatient program to treat deep venous thrombosis with low-molecular-weight heparin.
CONTEXT: Although recent trials have demonstrated the safety and efficacy of low-molecular-weight (LMW) heparin, clinicians may need help incorporating this drug into routine practice. OBJECTIVE: To describe the development, implementation, and early results of an outpatient LMW heparin program for acute deep venous thrombosis (DVT). DESIGN: Before-after study. SETTING: Eight health centers of Harvard Vanguard Medical Associates, a multispecialty group practice in Boston. PATIENTS: Patients with confirmed acute, lower-extremity DVT before (40 patients given a diagnosis from January to August 1996) and after (67 patients given a diagnosis from September 1996 to April 1997) implementation of the LMW heparin program. INTERVENTION: A centrally coordinated outpatient LMW heparin program. DATA SOURCES: Hospital and HMO financial databases; electronic patient medical records. OUTCOME MEASURES: Costs of care for 2-week episodes and short-term clinical outcomes. RESULTS: The proportion of patients with DVT treated in the hospital decreased from 90% to 46% after the introduction of the LMW heparin program. The mean cost of treatment for all patients with DVT decreased from $5465 to $3719 per patient. For the subset of patients actually treated in the outpatient program, the average cost was $1402 per patient. There were no deaths, no clinically recognized pulmonary emboli, and no cases of significant bleeding among patients treated in the program, although 3 patients were subsequently hospitalized for worsening leg pain. CONCLUSIONS: The cost of caring for patients with DVT decreased after introduction of the outpatient LMW heparin program. Given explicit selection criteria, short-term clinical outcomes after outpatient management have been excellent. This program may serve as a model for physicians and health plans interested in establishing a program for treating acute DVT in the outpatient setting.