Outpatient treatment of low-risk venous thromboembolism with monotherapy oral anticoagulation: patient quality of life outcomes and clinician acceptance

Jeffrey A Kline,1,2 Zachary P Kahler,1,3 Daren M Beam1,2 1Department of Emergency Medicine, 2Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN, 3Department of Emergency Medicine, University of South Carolina Greenville School of Medicine, Greenville, SC, USA Background: Oral monotherapy anticoagulation has facilitated home treatment of venous thromboembolism (VTE) in outpatients. Objectives: The aim of this study was to measure efficacy, safety, as well as patient and physician perceptions produced by a protocol that selected VTE patients as low-risk patients by the Hestia criteria, and initiated home anticoagulation with an oral factor Xa antagonist. Methods: Patients were administered the Venous Insufficiency Epidemiological and Economic Study Quality of life/Symptoms ques­tionnaire [VEINEs QoL/Sym] and the physical component summary [PCS] from the Rand 36-Item Short Form Health Survey [SF36]). The primary outcomes were VTE recurrence and hemorrhage at 30 days. Secondary outcomes compared psychometric test scores between patients with deep vein thrombosis (DVT) to those with pulmonary embolism (PE). Patient perceptions were abstracted from written comments and physician perceptions specific to PE outpatient treatment obtained from structured survey. Results: From April 2013 to September 2015, 253 patients were treated, including 67 with PE. Within 30 days, 2/ 253 patients had recurrent DVT and 2/253 had major hemor­rhage; all four had DVT at enrollment. The initial PCS scores did not differ between DVT and PE patients (37.2±13.9 and 38.0±12.1, respectively) and both DVT and PE patients had similar improvement over the treatment period (42.2±12.9 and 43.4±12.7, respectively), consistent with prior literature. The most common adverse event was menorrhagia, present in 15% of women. Themes from patient-written responses reflected satisfaction with increased autonomy. Physicians’ (N=116) before-to-after protocol comfort level with home treatment of PE increased 48% on visual analog scale. Conclusion: Hestia-negative VTE patients treated with oral monotherapy at home had low rates of VTE recurrence and bleeding, as well as quality of life measurements similar to prior reports. Keywords: anticoagulants, quality of life, patient preference, menorrhagia, patient outcome assessment, health care, comorbidity, hemorrhage, pulmonary embolis