CLINICAL RESEARCH STUDY

Home Treatment of Deep Venous Thrombosis

According to Comorbid Conditions
Paul D. Stein, MD, Fadi Matta, MD, Mary J. Hughes, DO
Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing.

ABSTRACT
BACKGROUND: Cautious exploration of the safety of home treatment of deep venous thrombosis has been
recommended by many. Our goal was to identify categories of patients with deep venous thrombosis who
typically are hospitalized, and categories frequently treated at home.
METHODS: The Nationwide Emergency Department Sample and the Nationwide Inpatient Sample,
2007-2012, were used to determine the number of patients seen in emergency departments throughout the
US with deep venous thrombosis and no diagnosis of pulmonary embolism, the proportion of such patients
hospitalized according to comorbid conditions and age, the proportion discharged early (
2 days), and
charges for hospitalization and emergency department visits.
RESULTS: From 2007-2012, home treatment was selected for 905,152 of 2,671,452 (33.9%) patients with
deep venous thrombosis. Home treatment was more frequent in those with no comorbid conditions than
with comorbid conditions, 58.0% compared with 15.5% (P <.0001). Early discharge (
2 days) was in
23.9% with no comorbid conditions, compared with 12.8% with comorbid conditions. Among patients aged
18-50 years, home treatment was selected in 62.9% with no comorbid conditions, compared with 24.2%
with comorbid conditions (P <.0001). Among hospitalized patients with no comorbid conditions, 40.7%
were aged 18-50 years. Their charges for hospitalization in 2012 were $494 million.
CONCLUSION: Patients aged 50 years or younger with deep venous thrombosis and no comorbid conditions
appear to be a group that can be targeted for more frequent home treatment, which would save millions of
dollars.
2016 Elsevier Inc. All rights reserved.  The American Journal of Medicine (2016) 129, 392-397
KEYWORDS: Deep venous thrombosis; Home treatment; Venous thromboembolism

In 1996, 2 randomized controlled trials showed that initial

home treatment of deep venous thrombosis with lowmolecular-weight heparin was effective and safe.1,2 Many
subsequent investigations that included some or all patients
treated entirely at home showed home treatment to be safe and
effective.3-17 There was a high degree of patient satisfaction

Funding: Blue Cross Blue Shield of Michigan Foundation, Study

number 2154.11.
Conict of Interest: The authors have no conicts of interest to report
with regard to this manuscript.
Authorship: All authors had access to the data and a role in writing the
manuscript.
Requests for reprints should be addressed to Paul D. Stein, MD,
Department of Osteopathic Medical Specialties, College of Osteopathic
Medicine, Michigan State University, 909 Fee Road, East Lansing,
MI 48824.
E-mail address: steinp@msu.edu
0002-9343/$ -see front matter 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjmed.2015.10.022

with home treatment.4 However, at least 23 editorials, reviews, and tutorials urged a exible, sensible, cautious
approach to home treatment, or cautioned for careful patient
selection, necessary logistical support, infrastructure, organization, patient education and compliance, or monitored
outcome.18 There was no decrease in the actual number of
hospitalizations of patients with a principal diagnosis of deep
venous thrombosis from 1979-2006.18 This did not take into
account the 33% increase in the population of the US during
that period.18 By 2006, the proportion of the adult population
hospitalized with a primary diagnosis of deep venous
thrombosis was only 21% less than the proportion hospitalized in 1996.18 This indicated a slow implementation of home
treatment of deep venous thrombosis or perhaps a declining
population-based incidence of deep venous thrombosis.18 Of
note, the proportion of hospitalized patients with a primary
diagnosis of deep venous thrombosis who were discharged in

Stein et al

Home Treatment of Deep Venous Thrombosis

393

1 or 2 days began to increase in 1994 and increased to 21%453.9, 671.3, and 671.4. Five-digit codes, such as 415.11
25% between 2004 and 2006.18
(included under the code 415.1), were not listed sepaIn view of the potential economic benet of home
rately, as they are included under the corresponding
treatment of deep venous thrombosis, as well as increased
4-digit codes.
patient satisfaction, we assessed the databases of the
Nationwide Emergency Department Sample and NationExclusions
wide Inpatient Sample from 2007Exclusions included patients aged
2012 to determine the extent of
<18 years and patients with pulCLINICAL
SIGNIFICANCE
home treatment of patients with
monary embolism in addition to
deep venous thrombosis according
 Throughout the US, only 33.9% of padeep venous thrombosis. The
to the most recent available data.
tients with deep venous thrombosis are
ICD-9-CM codes used for identiOur goal was to identify catetreated at home.
cation of patients with pulmogories of patients with deep
nary embolism are 415.1, 634.6,
 Those most frequently treated at home,
venous thrombosis who typically
635.6, 636.6, 637.6, 638.6, and
are hospitalized, and categories
62.9%, are relatively young (aged 18-50
673.2.
frequently treated at home.
years) with no comorbid conditions.

METHODS

 Hospital charges for relatively young

patients with deep venous thrombosis
and no comorbid conditions are millions
of dollars.

Comorbid Conditions

Patients with one or more of the

The
Nationwide
Emergency
comorbid conditions listed in the
Department Sample was used to
Charlson Index were dened as
determine the number of patients
 Relatively young patients with deep
having comorbidity. 21 Condiseen in emergency departments
tions listed in the Charlson
venous thrombosis and no comorbid
throughout the US with deep
Comorbidity Index and the ICDconditions may be a group to target for
venous thrombosis and no diag9-CM codes used to identify
more frequent home treatment.
nosis of pulmonary embolism, and
these conditions are shown in
the proportion of such patients
Table 1.
hospitalized according to age and
comorbid conditons.19 Emergency department charges were
also determined. The Nationwide Emergency Department
Table 1 International Classication of Diseases, 9th Edition,
Sample is a database developed as part of the Healthcare
Clinical
Modication (ICD-9-CM) Comorbid Conditions Included
Cost and Utilization Project of the Agency for Healthcare
in the Charlson Index21
Research and Quality. We analyzed the most recent 6 years
of data available, which is 2007-2012. This database each
ICD-9-CM Codes Used
year includes 26 million to 29 million emergency departComorbid conditions included in the Charlson Index
ment visits from 955-980 hospital-based emergency deAcute myocardial infarction
410
partments in 24-29 states.
Heart failure
428
The Nationwide Inpatient Sample was used to deterPeripheral vascular disease
440.2, 443.9
Cerebrovascular disease
430-438
mine the proportion discharged early (
2 days), and the
Dementia
290
charge for hospitalization in patients with deep venous
Chronic obstructive pulmonary 490-496
thrombosis. The Nationwide Inpatient Sample contains
disease
data from 5 to 8 million hospital stays from about 1000
20
Rheumatologic disease
710.0, 710.1, 710.4, 714.0,
hospitals. It is designed to approximate a 20% sample
714.1, 714.2, 714.8
of US nonfederal, short-term hospitals as dened by the
Ulcer disease
531-534
20
American Hospital Association. Although the National
Acute or chronic liver disease
570, 571
Emergency Department Sample also gives information
Diabetes mellitus
250.0-250.3
on admissions, the Nationwide Inpatient Sample gives
Hemiplegia and hemiparesis
342.0-342.9
the total number of all hospitalizations, so the proportion
Paraplegia
344.1
of patients hospitalized with deep venous thrombosis can
Moderate or severe renal disease 580-586, 588
Diabetes with chronic
250.4-250.6
be determined.

Method of Diagnosing Deep Venous Thrombosis

The International Classication of Diseases, 9th Edition,
Clinical Modication (ICD-9-CM) codes that were used
for identication of patients with deep venous thrombosis
are 451.1, 451.2, 451.8, 451.9, 453.2, 453.4, 453.8,

complications
Any neoplasms, leukemia,
lymphoma
Metastatic cancer
HIV and AIDS

140-195, 200-208
196-199
042

AIDS acquired immune deciency syndrome; HIV human immunodeciency virus.

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The American Journal of Medicine, Vol 129, No 4, April 2016

Statistical Analysis and Methodological

Considerations
Descriptive statistics were used to graphically display trends
over time in case volumes. Differences of categorical variables were calculated by the 2-tailed Fishers exact test
using GraphPad Software (San Diego, CA). Differences of
means of continuous variables were assessed by Students
unpaired t test.

RESULTS
From 2007-2012 throughout the US, 2,725,289 patients aged
18 years or older were seen in emergency departments with a
diagnosis of deep venous thrombosis and no identied pulmonary embolism. Among these, the disposition to home
treatment was determined in 2,671,452. A greater proportion
were female, 53.3% compared with 46.6% (P <.0001). Females were aged 60  18 years (mean  SD), males were aged
63  20 years (P <.0001). Comorbid conditions were present
in 1,515,923 of 2,671,452 (56.7%) (Table 2).

Trends in Home Treatment

During the years of investigation, 905,152 of 2,671,452
(33.9%) patients with deep venous thrombosis were treated
entirely at home. The proportion treated at home increased
from 133,224 of 421,747 (31.6%) in 2007 to 172,207 of
460,150 (37.4%) in 2012 (P <.0001).

Early Discharge
Among all hospitalized patients with deep venous thrombosis, 427,354 of 2,701,695 (15.8%) were discharged in
2
Table 2 Comorbid Conditions According to Sex of Patients
with Deep Venous Thrombosis Seen in Emergency Departments
(EDs), 2007-2012
ED Visits n

Home Treatment According to Comorbid

Conditions
The proportion of patients with deep venous thrombosis
who were treated at home was higher in those with no comorbid conditions than in those with comorbid conditions,
670,201 of 1,155,529 (58.0%), compared with 234,951 of
1,515,923 (15.5%) (P <.0001). The proportion treated at
home with no comorbid conditions increased 7.2% from
2007-2012, compared with 4.7% in those with any comorbid conditions (Figure 1).
Most patients with one or more comorbid conditions
were hospitalized. Among those with diabetes mellitus,
chronic obstructive pulmonary disease, any neoplasm, leukemia or lymphoma, rheumatologic disease, and paraplegia,
77%-89% were hospitalized (Table 3). With the other
comorbid conditions listed in Table 3, 90%-100% were
hospitalized.

Home Treatment According to Age

Among patients aged 18-50 years, home treatment was
selected in 335,165 of 532,585 (62.9%) with no comorbid
conditions, compared with 65,570 of 271,483 (24.2%) with
comorbid conditions (P <.0001 ) (Figure 2).
Among patients hospitalized with deep venous thrombosis and no comorbid conditions, 197,419 of 485,328
(40.7%) were aged 18-50 years, compared with 205,913 of
1,280,971 (16.1%) with comorbid conditions (P <.0001).
In patients with no comorbid conditions, the proportion
treated at home showed a sharp decrease with increasing age

Any Comorbid
Conditions n (%)

80
No Comorbid Condion

70

194,202
207,735
206,720
202,924
217,147
217,401
1,246,129*

85,855
88,131
86,945
87,268
93,301
95,739
537,238

(44)
(42)
(42)
(43)
(43)
(44)
(43)

108,348
119,605
119,775
115,656
123,845
121,662
708,891

(56)
(58)
(58)
(57)
(57)
(56)
(57)

227,517
242,964
236,744
232,075
242,987
242,729
1,425,015*

100,111
105,058
101,213
100,155
104,341
107,227
618,105

(44)
(43)
(43)
(43)
(43)
(44)
(43)

127,405
137,906
135,531
131,920
138,646
135,502
806,910

(56)
(57)
(57)
(57)
(57)
(56)
(57)

*Some data missing. Proportion with comorbid conditions vs no

comorbid conditions, P <.0001.

Home Treatment (%)

Males
2007
2008
2009
2010
2011
2012
Total
Females
2007
2008
2009
2010
2011
2012
Total

No Comorbid
Conditions n (%)

days. Among those with no comorbid conditions, 115,993

of 485,328 (23.9%) were discharged in
2 days compared
with 163,964 of 1,280,971 (12.8%) with comorbid
conditions.

60

54.7

55.9

56.8

58.1

13.4

13.8

14.7

15.2

60.3

61.9

17.6

18.1

50
40

30
20

10
Any Comorbid Condion
0
2007

2008

2009

2010

2011

2012

Years

Figure 1 Proportion of patients with deep venous thrombosis

treated at home according to comorbid conditions and year. The
proportion of patients treated at home increased in both groups
(P <.0001).

Stein et al

Home Treatment of Deep Venous Thrombosis

Table 3 Hospitalizations of Patients with Deep Venous

Thrombosis and No Pulmonary Embolisms According to Comorbid
Condition
Comorbid Condition*

Patients (n) Hospitalized (%)

Diabetes mellitus
Rheumatologic disease
Chronic obstructive pulmonary
disease
Any neoplasms, leukemia,
lymphoma
Paraplegia
Peripheral vascular disease
HIV and AIDS
Heart failure
Metastatic cancer
Diabetes with chronic
complications
Acute or chronic liver disease
Dementia
Moderate or severe renal disease
Cerebrovascular disease
Ulcer disease
Acute myocardial infarction
Hemiplegia and hemiparesis

436,107
60,456
417,812

77
81
84

276,891

88

15,076
87,661
15,828
332,626
150,497
77,490

89
90
91
92
94
94

50,086
19,934
567,174
147,511
36,358
56,261
37,371

94
94
95
95
95
98
100

above 70 years (Figure 2). In patients with comorbid

conditions, the proportion treated at home decreased with
increasing age above 40 years.

Charges
Average charge/patient, 2007-2012, for an emergency
department visit in those with no comorbid conditions was
$494, compared with $1152 with comorbid conditions
(Table 4). Emergency department charges increased from
2007 to 2012 and increased with age (Table 4).

80

Home Treatment (%)

62.5

63.9

No Comorbid Condion
62.9

61.4

60

59.5

51.4

50
39.7

40

30

25.6

26.1

23.0

20

19.5
15.9

12.5
8.8

10
Any Comorbid Condion
0
21-30

31-40

41-50

51-60

61-70

71-80

Average charge/patient, 2007-2012, for hospitalization

with deep venous thrombosis and no comorbid conditions
was $10,340, compared with $19,519 with any comorbid
condition. Charges for hospitalization increased from 2007
to 2012 and were higher in younger patients (Table 4).
Among all patients with deep venous thrombosis,
charges for hospitalizations from 2007-2012 were $40.53
billion. Charges for hospitalizations from 2007-2012 of
patients with no comorbid conditions were $7.66 billion,
compared with $32.87 billion for those with comorbid
conditions. In 2012, charges for hospitalizations were $7.37
billion. Charges in 2012 were $1.28 billion for those with no
comorbid conditions, compared with $6.09 billion for those
with comorbid conditions.
Charge for hospitalization for patients aged 18-50 years
with no comorbid conditions was $2.95 billion in 20072012. In 2012, the charge for hospitalizations of this group
was $494 million.

DISCUSSION

*Some patients had more than one comorbid condition.

70

395

>80

Age Group

Figure 2 Proportion of patients with deep venous thrombosis

treated at home in relation to comorbid conditions and age.

The proportion of patients treated entirely at home with deep

venous thrombosis from 2007-2012 was 33.9%. A larger
proportion with no comorbid conditions was treated entirely
at home, 58.0%, vs those with comorbid conditions, 15.5%.
The proportion of patients treated at home increased
signicantly from 2007-2012, but the increase was only
5.8%. Among those with no comorbid conditions, from
2007-2012 there was a 7.2% increase in home treatment,
compared with 4.7% for those with comorbid conditions.
Only 23.9% of patients with no comorbid conditions were
discharged in
2 days, and fewer with comorbid conditions
were discharged early. Among younger patients (ages 18-50
years), 62.9% with no comorbid conditions were treated
entirely at home. Charges for hospitalizations of patients
aged 18-50 years with no comorbid conditions, 2007-2012,
were $2.95 billion.
Home treatment of 12 patients with carcinoma6 and 20
patients with serious conditions14 has been described. We
are not aware of other published data related to home
treatment with comorbid conditions. To our knowledge,
there are no data by others on trends in home treatment
according to comorbidity, and rates of home treatment according to age.
Throughout most of the period of investigation, except
for 2 months, new oral anticoagulants were not yet approved
in the US. The oral factor Xa inhibitor rivaroxaban was
approved for treatment of deep venous thrombosis by the
US Food and Drug Administration on November 2, 2012.22
This drug would eliminate problems in home management
of deep venous thrombosis related to the necessity of injection of low-molecular-weight heparin. We retrospectively
assessed a cohort of patients from 4 regional emergency
departments in 2013 and in some through August or
September, 2014 to determine if the availability of new oral
anticoagulants impacted the proportion of patients with deep
venous thrombosis who were treated at home.23 During the

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The American Journal of Medicine, Vol 129, No 4, April 2016

Table 4 Charges According to Presence or Absence of Comorbid Conditions for Emergency Department (ED) Visits and Hospitalizations
for Deep Venous Thrombosis, No Pulmonary Embolism (2007-2012)

Year
2007
2008
2009
2010
2011
2012
Average
Age (y)
18-20
21-30
31-40
41-50
51-60
61-70
71-80
>80

Average ED Charge
No Comorbid
Conditions ($)

Average ED Charge
Any Comorbid
Conditions ($)

Average Hospital Charge

No Comorbid Conditions
($)

Average Hospital Charge

Any Comorbid Conditions
($)

335
402
450
493
634
607*
494

649
776
984
976
2090
1123*
1152

8021
9429
10,059
11,161
11,912
12,061*
10,340

12,985
14,883
16,153
17,657
19,470
19,519*
16,762

415
450
491
494
492
492
510
561

601
834
1062
1077
1188
1236
1199
1158

16,135
11,865
10,444
10,415
10,987
11,013
9956
8000

26,246
21,927
18,861
18,088
18,730
18,427
16,167
12,820

*Charges 2007 vs 2012, P <.0001.

period of investigation, 245,000 patients were seen in the

emergency departments of the participating hospitals.
Ninety-six patients were identied with a primary diagnosis
of deep venous thrombosis and no clinical evidence of
pulmonary embolism. Among these, only 11.5% were discharged to home and none received new oral anticoagulants.
Among those with no comorbid conditions, 11 of 40 (28%)
were treated at home. Among those with any comorbid
conditions listed in the Charlson index,21 none (0 of 56)
were treated at home. One-third of hospitalized patients
were discharged in 2 days or less, 25% of whom received
new oral anticoagulants.23 These data, although limited in
size, suggest that the availability of new oral anticoagulants
did not result in an increased rate of home treatment. In
some hospitals, the culture is to admit patients with deep
venous thrombosis.
Among 79 low-risk patients with deep venous thrombosis who were treated at home with rivaroxaban, none had
a recurrent deep venous thrombosis or major bleed while on
treatment.17 Three (3.8%) suffered a recurrent deep venous
thrombosis following the cessation of rivaroxaban.
At 2 metropolitan hospitals, median charge for hospital
treatment of deep venous thrombosis in 2013 was $6662.24
This was lower than average charges for hospitalization of
patients with deep venous thrombosis, no pulmonary embolism, and no comorbid conditions that we report for 2012:
$12,061.
The American Society of Health-System Pharmacists in
200425 indicated that outpatient treatment of deep venous
thrombosis offers the opportunity to substantially reduce the
cost of treating deep venous thrombosis and improve the
quality of life without compromising clinical outcomes. In

2012, the American College of Chest Physicians26 in their

evidence-based clinical guidelines recommended treatment
at home over treatment in the hospital for patients with acute
deep venous thrombosis whose home circumstances are
adequate and who do not have severe leg symptoms or
comorbidity.26 Home treatment of deep venous thrombosis
requires well-maintained living conditions, strong support
from family or friends, telephone access, and ability to
quickly return to the hospital if there is deterioration.26 The
recommendation for home treatment of deep venous
thrombosis is also conditional on the patient feeling well
enough to be treated at home, and requires that the patient
does not have comorbid conditions that would prevent home
treatment.26 These guidelines suggested treatment with
vitamin K antagonists or low-molecular-weight heparin over
new oral anticoagulants.26
A strength of this investigation is the large number of
patients of all ages 18 years and older, all races, and both
sexes from all regions of the US. A weakness is the accuracy
of ICD-9-CM codes. Although the accuracy of ICD-9-CM
codes is not perfect, their positive predictive value for
acute deep venous thrombosis as the principal diagnosis
(rst listed diagnosis) was 95% (95% condence interval,
93%-97%).27 Others found a positive predictive value of
91.4% for a primary or secondary diagnosis of deep venous
thrombosis using either ICD-9-CM or ICD-10-CM codes.28
Another weakness is that we were not able to determine
outcome with home or hospital treatment. In view of this,
charges for hospitalization were an underestimate, because
charges for patients who developed pulmonary embolism in
the hospital would not have been included. This would have
been a small proportion, 0.6% to 2.3%.1,2,10,15 Patients

Stein et al

Home Treatment of Deep Venous Thrombosis

hospitalized more than once in a given year and patients

seen more than once on the emergency service would be
counted more than once in the National Hospital Discharge
Survey and the Nationwide Emergency Department Sample.
Both the National Hospital Discharge Survey and the
Nationwide Emergency Department Sample survey a sample of hospitalizations or emergency service visits, and
therefore, are subject to sampling variability.

CONCLUSION
Patients aged 50 years or younger with deep venous
thrombosis and no comorbid conditions are frequently
treated at home. If a greater proportion of such patients were
treated at home, millions of dollars would be saved.

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