ASH Leverages Recommendations From Other Medical Organizations, Advising Hematologists to Choose Wisely

Choosing Wisely is a national medical stewardship campaign led by the ABIM Foundation. Several professional medical organizations are now providing relevant tips and suggestions to avoid high utilization of unnecessary tests and treatments. Following-up on last year’s recommendations, the American Society of Hematology (ASH)’s Choosing Wisely Task Force launched a first-of-its kind review of all existing Choosing Wisely recommendations to identify those published by other professional societies that are highly relevant and important to the practice of hematology, said Lisa Hicks, MD, who chairs the task force. The task force of 13 hematologists chose the top 5 of 380 recommendations listed by 70 other societies and presented them on Monday, December 7, 2015, at the 57th annual meeting of ASH, in Orlando, Florida.

The following are the 5 new recommendations that ASH is promoting among hematologists. Each recommendation was introduced by a member of the task force.

1. Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability of PE. — American College of Radiology
2. Don’t routinely order thrombophilia testing on patients undergoing a routine infertility evaluation. — American Society for Reproductive Medicine
3. Don’t perform repetitive complete blood count (CBC) and chemistry testing in the face of clinical and lab stability. — Society for Hospital Medicine – Adult Hospital Medicine
4. Don’t transfuse red blood cells for iron deficiency without hemodynamic instability. — American Association of Blood Banks
5. Avoid using positron emission tomography (PET) or PET-CT scanning as part of routine follow-up care to monitor for a cancer recurrence in asymptomatic patients who have finished initial treatment to eliminate the cancer unless there is high-level evidence that such imaging will change the outcome. — American Society of Clinical Oncology

Using a rigorous methodology, the ASH Choosing Wisely Task Force scored 400 recommendations for relevance and importance over a series of iterations, resulting in this list of items deemed to be especially useful to hematologists. As with past ASH lists, harm avoidance was once again established as the campaign’s preeminent guiding principle, with cost, strength of evidence, frequency, relevance, and impact serving as additional factors.

“The Choosing Wisely initiative is a high visibility campaign that has increased awareness of overutilization in medicine, and at ASH we believe there is a potential for even greater impact when societies share information and work together to accomplish the same goals,” said ASH Choosing Wisely Task Force Chair Lisa Hicks, MD, from St. Michael’s Hospital and the University of Toronto. “ASH encourages all medical groups to follow its lead by examining other Choosing Wisely lists to find applicable recommendations that will improve quality of care and avoid harm from unnecessary tests and treatments.”

“ASH has shown tremendous leadership by identifying additional Choosing Wisely recommendations relevant to hematologists and creating new ways of disseminating this important information to their members,” said Richard Baron, MD, President and CEO of the ABIM Foundation. “By increasing awareness and understanding of what tests and treatments may be overused or unnecessary across all specialties, we’ll help clinicians be better prepared to join their patients in these critical conversations about their care.

Recommended by the American College of Radiology.

1. Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability of PE.

This recommendation was introduced by Michael Bettmann, MD, a radiologist affiliated with the Bowman Gray School of Medicine of Wake Forest University.

“For any test that is ordered, we have to assess the risk-benefit ratio, and especially with pulmonary embolism it’s important to make this assessment,” said Bettman. Based on a review of the available evidence, the task force recommends to avoid imaging for suspected PE without moderate to high pre-test probability. “Patients with low-risk can be safely excluded,” said Bettman.

Recommended by the American Society for Reproductive Medicine.

2. Don’t routinely order thrombophilia testing on patients undergoing a routine infertility evaluation.

This recommendation was introduced by Shannon Bates, MDCM, MSc, FRCP(C), a hematologist at McMaster University.

“Nearly 15% couples may receive an infertility evaluation. Considering this relatively high number, there needs to be a clear association of thrombophilia and infertility or failure of assisted reproduction in these couples,” insisted Bates.

Several population-based studies have found that thrombophilia is associated with infertility, resulting in couples being referred to IVF, said Bates, and an association between thrombophilia and failure of assisted reproduction has also been shown. “However, 2 large cohort studies have shown no association between, Factor V Leiden- or prothrombin gene mutations and assisted reproduction failure or infertility,” she said. Mutations in Factor V and in the prothrombin gene have been known to result in thrombophilia.

Bates also made another point with respect to treatment in this patient population, the use of low molecular weight heparin (LMWH) treatment in assisted reproduction. “Thrombophilia is not a predictor of who will benefit from LMWH treatment with respect to assisted reproduction. There is no consistent evidence showing association between thrombophilia and assisted reproduction or infertility,” said Bates, reminding the audience that LMWH treatment is not benign and could have its own adverse effects.

Recommended by the Society for Hospital Medicine and Adult Hospital Medicine.

3. Don’t perform repetitive complete blood count (CBC) and chemistry testing in the face of clinical and lab stability.

This recommendation was introduced by Christopher Moriates, an assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco.

Moriates began by saying that half of the testing in hospitals is unnecessary. “Ordering complete blood counts (CBCs) has become a ritual for most of us, which we now know is unnecessary,” he said.

We need to curb this because we are causing a lot of harm, explained Moriates. Critically ill patients, he said, do not have the bone marrow reserve or erythropoietin drive to compensate for iatrogenic blood loss. To add to that are the risks of phlebotomy. It’s not economical either, he explained, considering laboratory tests are not individually reimbursed and ordering too many unnecessary CBCs can be a loss to the hospital. “Disposing the biohazard waste of the blood samples is also an avoidable cost,” Moriates said.

So what are the options? What can be done? Moriates assured the audience that several studies have pointed out that reducing the frequency of CBC does not cause any adverse downstream effects, as is feared. “Multiple studies have shown that there’s no difference in readmission rates, length of stay, rates of adverse events, etc. by reducing unnecessary daily lab tests.”

Recommended by the American Association of Blood Banks.

4. Don’t transfuse red blood cells for iron deficiency without hemodynamic instability.

This recommendation was introduced by Jeannie Callum, MD, FRCPC, from the Sunnybrook Research Institute.

“The wise options for a patient in the emergency department (ED), who has iron deficiency, are either oral iron or an intravenous infusion,” said Callum. While oral iron is cheap, it causes GI disturbances, which are responsible for 50% adherence rates. Oral iron, however, is as effective as IV iron in terms of heme response at 6 to 8 weeks, she explained.

But what we find most often, according to Callum, is unnecessary blood transfusion to compensate a person’s iron deficiency. “Research has shown that 20% of blood donors are iron deficient…so that’s another ethical challenge, at least for me.”

Callum directed the audience to a podcast that encourages cautious use of transfusions, and explains why IV iron might be a much better option for certain subsets of ED patients.

Recommended by the American Society of Clinical Oncology.

5. Avoid using positron emission tomography (PET) or PET-CT scanning as part of routine follow-up care to monitor for a cancer recurrence in asymptomatic patients who have finished initial treatment to eliminate the cancer unless there is high-level evidence that such imaging will change the outcome.

This recommendation was introduced by Gary Lyman, MD, MPH, co-director of the Hutchinson Institute for Cancer Outcomes Research.

“Until high-level evidence demonstrates that routine surveillance with PET/PET-CT prolongs life or promotes well-being, they should not be regularly performed.”

CT scans expose patients to small doses of radiation, Lyman said. Although the clinical implications of these doses may not be significant, the cost implications definitely are.

Lyman concluded that high-quality evidence supporting the routine use of intensive surveillance to improve survival or enhance quality of life is lacking and he pointed out that professional organizations like ASCO, ESMO, and NCCN do not include surveillance PET in disease-specific guidelines.