If, however, diagnostic tests confirm or fail to rule out recurrence, then the options include better heparin or warfarin control, a switch from warfarin to heparin or a low molecular weight heparin, or from standard heparin to a low molecular weight heparin, or consideration of caval interruption. Recurrence and bleeding were not significantly different when patients were treated at home. Importantly, the patients managed at home felt, on average, better about their illness. The higher unit cost of low molecular weight heparins is partly balanced by the costs of giving and monitoring intravenous standard heparin. The cost becomes wholly irrelevant when put against the enormous expense of hospital care.
New costs incurred in the community are quite small by comparison.
The understandable enthusiasm for home treatment must be tempered with caution. Patients enrolled in clinical trials were carefully selected because of their willingness to be managed at home and their low bleeding risk. They were looked after by physicians with extensive experience of anticoagulants. Thrombosis and anticoagulants remain dangerous so that plans for home treatment must include contingencies for handling recurrence and bleeding. Starting warfarin remains a tricky business which requires daily blood tests until the maintenance dose is known.