Management of pulmonary embolism in the home

Comprehensive Outpatient Management of Low-Risk Pulmonary Embolism: Can Primary Care Do This? A Narrative Review

INTRODUCTION

The evidence for outpatient management of hemodynamically stable, low-risk patients with acute symptomatic pulmonary embolism (PE) is mounting. Guidance in identifying patients who are eligible for outpatient (ambulatory) care is available in the literature and society guidelines. Less is known about who can identify patients eligible for outpatient management and in what clinical practice settings.

OBJECTIVE

To answer the question, "Can primary care do this?" (provide comprehensive outpatient management of low-risk PE).

METHODS

We undertook a narrative review of the literature on the outpatient management of acute PE focusing on site of care. We searched the English-language literature in PubMed and Embase from January 1, 1950, through July 15, 2019.

RESULTS

We identified 26 eligible studies. We found no studies that evaluated comprehensive PE management in a primary care clinic or general practice setting. In 19 studies, the site-of-care decision making occurred in the Emergency Department (or after a short period of supplemental observation) and in 7 studies the decision occurred in a specialty clinic. We discuss the components of care involved in the diagnosis, outpatient eligibility assessment, treatment, and follow-up of ambulatory patients with acute PE.

DISCUSSION

We see no formal reason why a trained primary care physician could not provide comprehensive care for select patients with low-risk PE. Leading obstacles include lack of ready access to advanced pulmonary imaging and the time constraints of a busy outpatient clinic.

CONCLUSION

Until studies establish safe parameters of such a practice, the question "Can primary care do this?" must remain open.

Best Clinical Practice: Controversies in Outpatient Management of Acute Pulmonary Embolism

BACKGROUND

Pulmonary embolism (PE) is a common condition managed in the emergency department (ED), with a wide range of morbidity and mortality. Patients are classically admitted for treatment and monitoring of anticoagulation.

OBJECTIVE

We sought to evaluate the controversy concerning outpatient therapy for patients with acute PE and investigate the feasibility, safety, and efficacy of outpatient management.

DISCUSSION

Patients with venous thromboembolism have historically been admitted for treatment and monitoring for concern of worsening disease or side effects of anticoagulation (bleeding). More than 90% of EDs admit patients with PE in the United States. However, close to 50% of patients may be appropriate for discharge and outpatient therapy. The published literature suggests that outpatient treatment is safe, feasible, and efficacious, with similar rates of recurrent venous thromboembolism and all-cause mortality, especially with novel oral anticoagulants. Multiple scoring criteria can be used, including the Pulmonary Embolism Severity Index (PESI), simplified PESI, Hestia criteria, Geneva Prognostic Score, European Society of Cardiology guidelines, Global Registry of Acute Coronary Events, and Aujesky score. Simplified PESI and the European Society of Cardiology guidelines have high-quality evidence, sufficient sensitivity, and ease of use for the ED. Patients considered for outpatient therapy should possess low hemorrhage risk, adequate social situation, negative biomarkers, ability to comply, and no alternate need for admission.

CONCLUSIONS

Patients with acute PE are often admitted in the United States, but a significant proportion may be appropriate for discharge. Patients with low risk for adverse events according to clinical scoring criteria, adequate follow-up, ability to comply, and no other need for admission can be discharged with novel oral anticoagulant therapy.

National Trends in Home Treatment of Acute Pulmonary Embolism

BACKGROUND

Management of patients with acute pulmonary embolism has evolved from obligatory hospitalization to home treatment of carefully selected low-risk patients. The purpose of this investigation is to determine national trends in the prevalence of home treatment of pulmonary embolism.

METHODS

The Nationwide Emergency Department Sample was used to determine the number of patients seen in emergency departments throughout the United States with a primary (first-listed) diagnosis of pulmonary embolism and the proportion hospitalized according to age, from 2007 to 2012. The National (Nationwide) Inpatient Sample was used to determine in-hospital all-cause mortality and length of stay of hospitalized patients. Patients were adults (≥18 years) of both genders and all races from all regions of the United States. Excluded patients were those in shock or on ventilator support. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify patients and comorbid conditions.

RESULTS

Home treatment was selected for 54 494 (6.0%) of 915 702 stable patients with acute pulmonary embolism. The proportion of patients treated at home was age-dependent, highest in those aged 30 years or younger, 12.1%, and lowest in those >80 years, 2.9%. Most patients treated at home, 66.8%, and had no comorbid conditions. In-hospital all-cause deaths were 2.6%. Deaths were ≤0.9% in those ≤40 years and 4.8% in those >80 years. Length of stay was 6 days or longer in 37.6% of patients.

CONCLUSION

In view of the lower death rate among younger patients, they might be a group in whom home treatment would be more advantageous than in elderly patients.

Home Treatment of Pulmonary Embolism in the Era of Novel Oral Anticoagulants

BACKGROUND

Outpatient therapy of patients with acute pulmonary embolism has been shown to be safe in carefully selected patients. Problems related to the injection of low-molecular-weight heparin at home can be overcome by use of novel oral anticoagulants. The purpose of this investigation is to assess the prevalence of home treatment in the era of novel oral anticoagulants.

METHODS

This was a retrospective cohort study of patients aged ≥18 years with acute pulmonary embolism seen in 5 emergency departments from January 2013 to December 2014.

RESULTS

Pulmonary embolism was diagnosed in 983 patients. Among these, 237 were considered ineligible for home treatment because of instability or hypoxia. Home treatment was selected for 13 of 746 (1.7%) patients who were potentially eligible. Anticoagulant treatment for those treated at home was low-molecular-weight heparin or warfarin in 9 (69.2%) and novel oral anticoagulants in 4 (30.8%). Hospitalization was chosen for 733 of 746 (98.3%). Discharge in ≤2 days was in 119 patients (16.2%). Treatment of these patients was low-molecular-weight heparin or warfarin in 76 (63.9%), novel oral anticoagulants in 34 (28.6%), and in 9 (7.6%), anticoagulants were not given because of metastatic cancer or treatment was not known.

CONCLUSION

Even in the era of novel oral anticoagulants, the vast majority of patients with acute pulmonary embolism were hospitalized, and only a small proportion were discharged in ≤2 days. Although home treatment has been found to be safe in carefully selected patients, and scoring systems have been derived to identify those at low risk of adverse events, home treatment was infrequently selected.

Is the Pulmonary Embolism Severity Index Being Routinely Used in Clinical Practice?

Background. The Pulmonary Embolism Severity Index (PESI) score can risk-stratify patients with PE but its widespread use is uncertain. With the PESI, we compared length of hospital stay between low, moderate, and high risk PE patients and determined the number of low risk PE patients who were discharged early. Methods. PE patients admitted to St. Joseph Mercy Oakland Hospital from January 2005 to August 2010 were screened. PESI score stratified acute PE patients into low (<85), moderate (86–105), and high (>105) risk categories and their length of hospital stay was compared. Patients with low risk PE discharged early (≤3 days) were calculated. Results. Among 315 PE patients, 51.7% were at low risk. No significant difference in hospital stay between low (7.11 ± 3 d) and moderate (6.88 ± 2.9 d) risk, p > 0.05, as well as low and high risk (7.28 ± 3.0 d), p > 0.05, was found. 9% of low risk patients were discharged ≤ 3 days. Conclusions. There was no significant difference in length of hospital stay between low and high risk groups and only a small number of low risk patients were discharged from the hospital early suggesting that risk tools like PESI may not have a widespread use.

New prospective for the management of low-risk pulmonary embolism: prognostic assessment, early discharge, and single-drug therapy with new oral anticoagulants

Patients with pulmonary embolism (PE) can be stratified into two different prognostic categories, based on the presence or absence of shock or sustained arterial hypotension. Some patients with normotensive PE have a low risk of early mortality, defined as <1% at 30 days or during hospital stay. In this paper, we will discuss the new prospective for the optimal management of low-risk PE: prognostic assessment, early discharge, and single-drug therapy with new oral anticoagulants. Several parameters have been proposed and investigated to identify low-risk PE: clinical prediction rules, imaging tests, and laboratory markers of right ventricular dysfunction or injury. Moreover, outpatient management has been suggested for low-risk PE: it may lead to a decrease in unnecessary hospitalizations, acquired infections, death, and costs and to an improvement in health-related quality of life. Finally, the main characteristics of new oral anticoagulant drugs and the most recent published data on phase III trials on PE suggest that the single-drug therapy is a possible suitable option. Oral administration, predictable anticoagulant responses, and few drug-drug interactions of direct thrombin and factor Xa inhibitors may further simplify PE home therapy avoiding administration of low-molecular-weight heparin.

Identification of patients with low-risk pulmonary embolism suitable for outpatient treatment using the pulmonary embolism severity index (PESI)

BACKGROUND

There is increasing evidence that outpatient treatment of patients with low-risk stable pulmonary embolism (PE) is safe, effective and potentially reduces costs. It is not clear how many patients presenting to an Irish Emergency Department (ED) are potentially suitable for outpatient management.

AIMS

To identify how many patients presenting to our ED over a 1-year period who were diagnosed with acute PE are potentially suitable for outpatient treatment.

METHODS

A retrospective observational study was conducted over a 1-year period. Clinical notes for patients who had a positive computed tomographic pulmonary angiogram (CTPA) within 24 h of presentation to the ED were examined to risk stratify the patients according to the pulmonary embolism severity index (PESI).

RESULTS

Forty-seven patients who presented to our ED were diagnosed with a PE. Clinical notes were missing for 3 cases, and 44 cases were analysed further. The mean age was 64.3 (±16.8 SD) years and 24 (54.5 %, 95 % CI 40-68.3 %) were males. Six patients (13.6 %, 95 % CI 6.4-26.7 %) had a background of cancer. Fifteen cases (34.1 %, 95 % CI 21.9-48.7 %) were deemed to be low risk as they were categorised as PESI risk class I or II. Our study found that 61/420 (14.5 %, 95 % CI 11.5-18.2) of CTPAs done were positive for PE.

CONCLUSION

This study suggests that a significant percentage of patients diagnosed with acute PE are low risk as per PESI and therefore potentially suitable for outpatient management.

Pulmonary thromboembolism in an East African tertiary referral hospital

Pulmonary thromboembolism (PTE) is a frequent cause of mortality in Kenya, but its characteristics are hardly reported in Subsaharan Africa. To describe the pattern of PTE among black Africans, in a Kenyan referral hospital. Retrospective study at Kenyatta National Hospital (KNH), Nairobi, Kenya. Records of patients seen between January 2005 and December 2009 were examined for mode of diagnosis, comorbidities, age, gender, treatment and outcome. Data were analyzed using SPSS version 15.0 and are presented in tables and bar charts. One hundred and twenty-eight (60 male; 68 female) cases were analyzed. Diagnosis was made by clinical evaluation, a Well's score of >4.0, high D-dimer levels and ultrasound demonstration of a proximal deep venous thrombosis (DVT, 35.9%), lung spiral computer tomography (CT, 50%), multidetector CT (7.8%) and angiography (6.3%). Most frequent comorbidities included DVT (36%); hypertension (18.8%); pulmonary tuberculosis (PTB, 12.5%); HIV infection (10.9%), pueperium, diabetes mellitus and cigarette smoking (9.4% each). Mean age was 40.8 years (range 5-86 years) with a peak between 30 and 50 years. Over 46% of patients were aged 40 years and less. Male:female ratio was 1:1.13. All the patients were treated with anticoagulants and thrombolytics with only one having embolectomy. Ninety-two patients (71.9%) recovered, 18.8% of them with cor pulmonale, while 28.1% died. PTE is not uncommon in Kenya. It affects many individuals below 40 years without a gender bias, and carries high morbidity and mortality. Associated comorbidities include venous thrombosis, lifestyle conditions and communicable diseases. Control measures targeting both are recommended.

Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study

BACKGROUND

Traditionally, patients with pulmonary embolism (PE) are initially treated in the hospital with low molecular weight heparin (LMWH). The results of a few small non-randomized studies suggest that, in selected patients with proven PE, outpatient treatment is potentially feasible and safe.

OBJECTIVE

To evaluate the efficacy and safety of outpatient treatment according to predefined criteria in patients with acute PE.

PATIENTS AND METHODS

A prospective cohort study of patients with objectively proven acute PE was conducted in 12 hospitals in The Netherlands between 2008 and 2010. Patients with acute PE were triaged with the predefined criteria for eligibility for outpatient treatment, with LMWH (nadroparin) followed by vitamin K antagonists. All patients eligible for outpatient treatment were sent home either immediately or within 24 h after PE was objectively diagnosed. Outpatient treatment was evaluated with respect to recurrent venous thromboembolism (VTE), including PE or deep vein thrombosis (DVT), major hemorrhage and total mortality during 3 months of follow-up.

RESULTS

Of 297 included patients, who all completed the follow-up, six (2.0%; 95% confidence interval [CI] 0.8-4.3) had recurrent VTE (five PE [1.7%] and one DVT [0.3%]). Three patients (1.0%, 95% CI 0.2-2.9) died during the 3 months of follow-up, none of fatal PE. Two patients had a major bleeding event, one of which was fatal intracranial bleeding (0.7%, 95% CI 0.08-2.4).

CONCLUSION

Patients with PE selected for outpatient treatment with predefined criteria can be treated with anticoagulants on an outpatient basis. (Dutch Trial Register No 1319; http://www.trialregister.nl/trialreg/index.asp).

Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial

BACKGROUND

Although practice guidelines recommend outpatient care for selected, haemodynamically stable patients with pulmonary embolism, most treatment is presently inpatient based. We aimed to assess non-inferiority of outpatient care compared with inpatient care.

METHODS

We undertook an open-label, randomised non-inferiority trial at 19 emergency departments in Switzerland, France, Belgium, and the USA. We randomly assigned patients with acute, symptomatic pulmonary embolism and a low risk of death (pulmonary embolism severity index risk classes I or II) with a computer-generated randomisation sequence (blocks of 2-4) in a 1:1 ratio to initial outpatient (ie, discharged from hospital ≤24 h after randomisation) or inpatient treatment with subcutaneous enoxaparin (≥5 days) followed by oral anticoagulation (≥90 days). The primary outcome was symptomatic, recurrent venous thromboembolism within 90 days; safety outcomes included major bleeding within 14 or 90 days and mortality within 90 days. We used a non-inferiority margin of 4% for a difference between inpatient and outpatient groups. We included all enrolled patients in the primary analysis, excluding those lost to follow-up. This trial is registered with ClinicalTrials.gov, number NCT00425542.

FINDINGS

Between February, 2007, and June, 2010, we enrolled 344 eligible patients. In the primary analysis, one (0·6%) of 171 outpatients developed recurrent venous thromboembolism within 90 days compared with none of 168 inpatients (95% upper confidence limit [UCL] 2·7%; p=0·011). Only one (0·6%) patient in each treatment group died within 90 days (95% UCL 2·1%; p=0·005), and two (1·2%) of 171 outpatients and no inpatients had major bleeding within 14 days (95% UCL 3·6%; p=0·031). By 90 days, three (1·8%) outpatients but no inpatients had developed major bleeding (95% UCL 4·5%; p=0·086). Mean length of stay was 0·5 days (SD 1·0) for outpatients and 3·9 days (SD 3·1) for inpatients.

INTERPRETATION

In selected low-risk patients with pulmonary embolism, outpatient care can safely and effectively be used in place of inpatient care.

FUNDING

Swiss National Science Foundation, Programme Hospitalier de Recherche Clinique, and the US National Heart, Lung, and Blood Institute. Sanofi-Aventis provided free drug supply in the participating European centres.

Safety of outpatient treatment in acute pulmonary embolism

INTRODUCTION

Data regarding outpatient treatment of pulmonary embolism (PE) is scarce. This study evaluates the safety of outpatient management of acute PE.

METHODS

This is a retrospective cohort study of consecutive patients presenting at the Ottawa Hospital with acute PE diagnosed between 1 January 2007 and 31 December 2008. PE was defined as an arterial filling defect on CTPA or a high probability V/Q scan. Patients were managed as outpatients if they were hemodynamically stable, did not require supplemental oxygenation and did not have contraindications to low-molecular-weight heparin therapy.

RESULTS

In this cohort of 473 patients with acute PE, 260 (55.0%) were treated as outpatients and 213 (45.0%) were admitted to the hospital. The majority of the patients were admitted because of severe comorbidities (45.5%) or hypoxia (22.1%). No outpatient died of fatal PE during the 3-month follow-up period. At the end of follow-up, the overall mortality was 5.0% (95% CI, 2.7-8.4%). The rates of recurrent venous thromboembolism (VTE) in outpatients were 0.4% (95% CI, 0.0-2.1%) and 3.8% (95% CI, 1.9-7.0%) within 14 days and 3 months, respectively. The rates of major bleeding episodes were 0% (95% CI, 0-1.4%) and 1.5% (95% CI, 0.4-3.9%) within 14 days and 3 months, respectively. Four (1.5%) outpatients were admitted to the hospital within 14 days.

CONCLUSIONS

A majority of patients with acute PE can be managed as outpatients with a low risk of mortality, recurrent VTE and major bleeding episodes.

Public hospital bed crisis: too few or too misused?

* Increasing demand on public hospital beds has led to what many see as a hospital bed crisis requiring substantial increases in bed numbers. By 2050, if current bed use trends persist and as the numbers of frail older patients rise exponentially, a 62% increase in hospital beds will be required to meet expected demand, at a cost almost equal to the entire current Australian healthcare budget. * This article provides an overview of the effectiveness of different strategies for reducing hospital demand that may be viewed as primarily (although not exclusively) targeting the hospital sector - increasing capacity and throughput and reducing readmissions - or the non-hospital sector - facilitating early discharge or reducing presentations and admissions to hospital. Evidence of effectiveness was retrieved from a literature search of randomised trials and observational studies using broad search terms. * The principal findings were as follows: (1) within the hospital sector, throughput could be substantially improved by outsourcing public hospital clinical services to the private sector, undertaking whole-of-hospital reform of care processes and patient flow that address both access and exit block, separating acute from elective beds and services, increasing rates of day-only or short stay admissions, and curtailing ineffective or marginally effective clinical interventions; (2) in regards to the non-hospital sector, potentially the biggest gains in reducing hospital demand will come from improved access to residential care, rehabilitation services, and domiciliary support as patients awaiting such services currently account for 70% of acute hospital bed-days. More widespread use of acute care and advance care planning within residential care facilities and population-based chronic disease management programs can also assist. * This overview concludes that, in reducing hospital bed demand, clinical process redesign within hospitals and capacity enhancement of non-hospital care services and chronic disease management programs are effective strategies that should be considered before investing heavily in creating additional hospital beds devoid of any critical reappraisal of current models of care.

A prospective study of the management of non-massive pulmonary embolism in the home

BACKGROUND

The objective of this study is to compare the characteristics, outcomes, and clinical complications of patients with pulmonary embolism (PE) who were treated at home as outpatients versus traditional hospitalization.

METHODS

Prospective study from January 2006 to June 2007. Selected patients diagnosed at the Emergency Department with stable non-massive pulmonary embolism that met standard inclusion criteria of Hospital at Home (HH) were treated at home. Patients that did not meet these criteria were admitted to Conventional Hospitalization (CH). Major and minor bleeding, re-thrombosis, clinical course, unexpected returns to hospital, and need for hospital re-admission in the following 3 months were recorded.

RESULTS

61 patients with PE were included (30 HH and 31 CH). Mean age 66.8 and 66.7 years in HH and CH, respectively. A history of neoplasm was found to be present in 13.3% and 9.7% of HH and CH patients. In the CH group, 19.3% of patients had prior thromboembolic disease. Concomitant DVT was seen in 40% and 29% of HH and CH patient. Pulmonary embolism was bilateral in 30% and 38.7% of HH and CH patients. No major bleeding, re-thrombosis, or death occurred. The home treatment was successfully completed in 100% of the patients. Three patients in the CH group had hospital-acquired infections.

CONCLUSIONS

Patients with stable non-massive pulmonary embolism may be safely treated under conditions of home hospitalization.

Bemiparin: second-generation, low-molecular-weight heparin for treatment and prophylaxis of venous thromboembolism

Low-molecular-weight heparins (LMWHs) form a heterogeneous group of compounds that exhibit an extended range of pharmacodynamic profiles and, potentially, different anti-thrombotic properties. Bemiparin has the lowest MW (3600 Da), the longest half-life (5.3 h) and the highest anti-FXa/anti-FIIa activity ratio (8:1) of any second-generation LMWH. The safety and efficacy of bemiparin has been demonstrated in several studies and it is currently licensed for treatment and prophylaxis of venous thromboembolism (VTE), as well as for the prevention of clotting in the extracorporeal circuit during hemodialysis. In particular, bemiparin is the only LMWH licensed in Europe for starting thromboprophylaxis after either general or orthopedic surgery. Results from multicenter pharmacoeconomic studies in the Spanish Health Care System indicate that bemiparin is more cost effective than enoxaparin for the prevention of VTE in total knee replacement and may be a safe, cost-saving alternative to unfractionated heparin in the short-term treatment of VTE, and a safe cost-neutral alternative to oral anticoagulant therapy in long-term treatment. In the near future, information from ongoing clinical trials could be key to establishing the potential of bemiparin in different clinical settings.

Outpatient management of stable acute pulmonary embolism: proposed accelerated pathway for risk stratification

Pulmonary embolism (PE) is a major health problem and a cause of worldwide morbidity and mortality. The current standard therapy for acute PE encourages admitting patients to the hospital for administration of parenteral anticoagulation therapy as a bridge to oral vitamin K antagonists. Prognostic models that identify patients with stable (nonmassive) acute PE (SPE) who are at low risk for adverse outcome have recently been reported. Based on these risk stratification models, hospital-based therapy is warranted for patients with PE who meet the criteria associated with a high risk for adverse outcome. However, a growing body of evidence suggests the feasibility of partial outpatient management and accelerated hospital discharge (AHD) in a subset of patients with SPE. Prospective validation of these risk stratification models for predicting patient suitability for AHD is needed.

Validation of a clinical prognostic model to identify low-risk patients with pulmonary embolism

OBJECTIVE

To validate the Pulmonary Embolism Severity Index (PESI), a clinical prognostic model which identifies low-risk patients with pulmonary embolism (PE).

DESIGN

Validation study using prospectively collected data.

SETTING

A total of 119 European hospitals.

SUBJECTS

A total of 899 patients diagnosed with PE.

INTERVENTION

The PESI uses 11 clinical factors to stratify patients with PE into five classes (I-V) of increasing risk of mortality. We calculated the PESI risk class for each patient and the proportion of patients classified as low-risk (classes I and II). The outcomes were overall and PE-specific mortality for low-risk patients at 3 months after presentation. We calculated the sensitivity, specificity and predictive values to predict overall and PE-specific mortality and the discriminatory power using the area under the receiver operating characteristic curve.

RESULTS

Overall and PE-specific mortality was 6.5% (58/899) and 2.3% (21/899) respectively. Forty-seven per cent of patients (426/899) were classified as low-risk. Low-risk patients had an overall mortality of only 1.2% (5/426) and a PE-specific mortality of 0.7% (3/426). The sensitivity was 91 [95% confidence interval (CI): 81-97%] and the negative predictive value was 99% (95% CI: 97-100%) for overall mortality. The sensitivity was 86% (95% CI: 64-97%) and the negative predictive value was 99% (95% CI: 98-100%) for PE-specific mortality. The areas under the receiver operating characteristic curve for overall and PE-specific mortality were 0.80 (95% CI: 0.75-0.86) and 0.77 (95% CI: 0.68-0.86) respectively.

CONCLUSIONS

This validation study confirms that the PESI reliably identifies low-risk patients with PE who are potential candidates for less costly outpatient treatment.

Low-molecular-weight heparin, bemiparin, in the outpatient treatment and secondary prophylaxis of venous thromboembolism in standard clinical practice: the ESFERA Study

The objective of this study is to assess the clinical and economic outcomes associated with outpatient treatment and secondary prophylaxis of acute venous thromboembolism (VTE) with a low-molecular-weight heparin, bemiparin. This study was designed as an open-label, multicentre, prospective, cohort study in standard clinical practice. Sixty-three investigators from 54 Spanish centres participated in the study. Five hundred eighty-three patients (434 outpatients and 149 inpatients) with acute VTE were followed up for 98 days (median). Outcome measures were costs and adverse events during initial VTE treatment with bemiparin (outpatient vs. inpatient cohorts) and long-term treatment [bemiparin (BEM) vs. vitamin K antagonists (VKA) cohorts]. Mean total costs per patient were lower in the outpatient cohort as compared with those in the inpatient cohort (1206 vs. 5191 euros; difference = -3985 euros; p < 0.001), with similar rates of adverse events (5.1 outpatient vs. 7.4% inpatient; p = 0.196) over 98 days. Mean total costs per patient were similar in the BEM/BEM and BEM/VKA cohorts (3616 vs. 3831 euros; difference = -215 euros; p = 0.412), but patients on long-term bemiparin treatment had lower rates of major bleeding (0.4 vs. 1.7%; p = 0.047), minor bleeding (1.8 vs. 6%; p = 0.032) and total adverse events (2.9 vs. 9.5%; p = 0.007) than patients in the BEM/VKA cohort. Outpatient management of VTE with bemiparin in selected patients resulted in significant cost-savings compared to inpatient treatment, while maintaining effectiveness and safety. Bemiparin may be a safer and cost-neutral alternative to VKA for long-term treatment of VTE.