In 2012, the American Board of Internal Medicine launched the Choosing Wisely campaign, which attempts to curb wasteful medical spending by limiting the use of unnecessary tests and procedures. Prominent medical societies were invited to issue recommendations that clinicians and providers could use to reduce costs while individualizing patient care. Since 2013, the American Society of Hematology (ASH) has drafted 10 Choosing Wisely recommendations and endorsed five further recommendations offered by other medical societies. Many hematologists have wondered to what degree these guidelines have affected day-to-day practices within the subspecialty.
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The answer—according to three abstracts presented at the 2016 ASH Annual Meeting and Exposition (Dec. 2-6; San Diego, CA)—appears to be not much. Researchers found that despite ASH’s initial Choosing Wisely recommendations, hematologists continued to inappropriately transfuse red blood cells (RBCs) and perform aggressive computed tomography (CT) scanning on asymptomatic patients following aggressive lymphoma treatment. Additionally, despite a decrease in repeated testing for heparin-induced thrombocytopenia, physicians have not widely adapted a scoring system used to recommend patients for initial thrombocytopenia testing.
ASH discourages liberal RBC transfusions, recommending instead that only the minimum number of units be transfused to alleviate anemia symptoms and maintain a safe hemoglobin range. Shoshana Revel-Vilk, MD, MSc, pediatric hematologist at Haddassah-Hebrew University Medical Center (Jerusalem, Israel), and colleagues reviewed 584 RBC transfusions to determine the percentage of which occurred off-protocol, which they defined as receiving more than one consecutive unit or any transfusion in a non-bleeding, non-active cardiac patient with a stable hemoglobin range.
In total, 48.1% of RBC transfusions were considered off-protocol. Factors associated with off-protocol transfusion included older patient age (OR = 1.02; 95% CI, 1.01-1.03), treatment in the surgical department (OR = 7.4; 95% CI, 3.7-14.7), undergoing a major invasive or surgical procedure (OR = 1.7; 95% CI, 1.1-2.8), and receipt of antithrombotic therapy (OR = 1.7; 95% CI, 1.2-2.4). Other factors—including underlying diseases or pre-transfusion factors such as blood pressure or pulse rate—did not significantly increase the odds of receiving inappropriate transfusion.
“Although clinical considerations, such as underlying diseases or patients’ pre-transfusion signs, may explain non-adherence to guidelines, no clear pattern was observed in the current study to support this explanation,” Revel-Vilk and colleagues wrote. “The study findings highlight the need to further our understanding of clinical decision making leading to RBC transfusion and call for establishing clear guidelines to facilitate wise-transfusion related choices.”
Patients with diffuse large B-cell lymphoma (DLBCL) frequently undergo CT surveillance while in remission, despite high testing costs and a lack of demonstrated benefit. ASH has recommended that DLBCL patients treated with rituximab (Rituxan; Genentech, Biogen Idec) plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) discontinue CT surveillance after 2 years if they are asymptomatic.
Matthew C Cheung, MD, SM, FRCPC, of Sunnybrook Health Sciences Centre’s Odette Cancer Centre (Toronto, ON), and colleagues reviewed administrative data from 2,838 adult DLBCL patients to determine rates of CT surveillance, finding that 55.6% (95% CI, 38.3-41.9) continued to receive imaging up to 5 years beyond the end of R-CHOP treatment. Factors associated with increased imaging likelihood included age older than 65 years and higher comorbidity burdens (P < .01 for both). The researchers, however, observed a decrease in inappropriate CT screening as the follow-up period progressed (2006 vs. 2013, 65.5% vs. 47.4%; P < .01).
“During a time-frame in which surveillance imaging is deemed unnecessary by the Choosing Wisely campaign, the practice in a large population remains excessive,” Cheung and colleagues wrote. “This study represents a real-world baseline from which future efforts to reduce surveillance imaging can be benchmarked.”
Hospitalized patients receiving heparin frequently develop heparin-induced thrombocytopenia (HIT), which is confirmed by thrombocytopenia testing. However, because thrombocytopenia testing can needlessly interrupt heparin treatment or lead to overtreatment with other anticoagulants, ASH recommended that patients with a low pretest probability of HIT not undergo testing. A four-question scoring system (4T) can aid in predicting pretest HIT probability; external validation showed that it is accurate in nearly 100% of cases.
Anmol Baranwal, MBBS, and Sindhu Joseph, MD, both of MacNeal Hospital (Berwyn, IL), reviewed data from randomly selected patients who underwent HIT testing at their institution, in periods preceding and following ASH’s Choosing Wisely issuance. The study included data from 257 patients, tested prior to January 2015 (pre-recommendation, n = 129) or between January 2015 and March 2016 (post-recommendation, n = 128).
Baranwal and Joseph determined that 24% of patients (n = 31) tested pre-recommendation would be considered at intermediate or high risk for HIT based on 4T testing, as would 20.3% (n = 26) of patients tested post-recommendation. Despite the lack of significant differences in testing, the researchers observed that repeated HIT testing decreased following ASH’s recommendation (P = .038).
“More efforts need to be taken to improve the quality of care in this population,” Baranwal and Joseph wrote.
