In 2018, the American Society of Hematology (ASH) has continued its efforts to develop and publish evidence-based clinical practice guidelines to help practicing hematologists and other clinicians improve the quality of care for patients with various hematologic conditions. Here, we update readers on the status of ASH Clinical Practice Guidelines for two nonmalignant hematologic conditions: venous thromboembolism (VTE) and von Willebrand disease (VWD).
In November 2015, ASH and the McMaster University GRADE Center announced a collaboration to develop clinical practice guidelines on the diagnosis and treatment of VTE – a commonly encountered clinical concern for hematologists and for other medical specialties and disciplines. ASH is the sponsoring organization providing all funding for the work, while the GRADE Center has offered expertise in systematic evidence review and guideline development methods. This project represents the first large-scale guideline development effort by ASH, undertaken as part of a larger Quality Initiative approved by the Society in 2014.
“We are very excited about all of these topics,” said Adam Cuker, MD, MS, chair of the ASH VTE Guideline Coordination Panel and director of the Penn Comprehensive and Hemophilia Thrombosis Program at the University of Pennsylvania. He noted that the Society is devoted to ensuring that the methodology of the VTE guidelines are as rigorous as possible. “Collectively, they will include more than 200 questions and involve more than 100 experts on VTE from around the world, as well as expert methodologists and patient representatives.”
The VTE clinical practice guidelines will focus on 10 areas:
- prevention of VTE in surgical patients
- prevention of VTE in nonsurgical patients
- diagnosis of VTE
- treatment of VTE (deep vein thrombosis and pulmonary embolism)
- optimal management of anticoagulation therapy
- heparin-induced thrombocytopenia
- prevention and treatment of VTE in patients with cancer
- VTE in the context of pregnancy
- VTE in pediatric populations
Dr. Cuker noted that, as of fall 2018, several of the guideline chapters had been submitted for publication and are expected to be published in advance of the ASH annual meeting in December. In addition, the Society is developing a number of tools and resources to support their dissemination and implementation.
All stakeholders share the continued goal of creating guidelines that “meet the highest standards for rigor and credibility, that would be useful for and used by clinicians and – most important – that would improve the quality of care received by our patients,” said Holger Schünemann, MD, PhD, MSc, chair of the Department of Health Research Methods, Evidence, and Impact at McMaster University in Ontario.
“We are very excited about this effort,” Dr. Cuker added. “We see it as truly a comprehensive guideline on VTE – a very common disease – and are hopeful that it will be useful to clinicians and, ultimately, will help improve outcomes for our patients.”
von Willebrand Disease
In June 2018, ASH announced that it will be collaborating with the International Society on Thrombosis and Haemostasis (ISTH), the National Hemophilia Foundation (NHF), the World Federation of Hemophilia (WFH), and the University of Kansas (KU) Medical Center to develop clinical practice guidelines on the diagnosis and management of VWD.
Although VWD is considered a rare disease, it is the most common inherited bleeding disorder, affecting approximately one percent of the world’s population. Symptoms may vary from patient to patient – or in a single patient over the course of his or her life – and this complex clinical presentation makes diagnosis challenging for hematologists and referring physicians.
“These guidelines will provide clinicians and patients with clear recommendations for the timely diagnosis of VWD and appropriate management of symptoms,” said ASH President Alexis A. Thompson, MD, MPH, of Ann & Robert H. Lurie Children’s Hospital of Chicago, in a press release. “ASH is pleased to collaborate with ISTH, NHF, and WFH to convene diverse expert panels and expand the reach of the guidelines across the globe.”
To create and maintain these state-of-the-art guidelines, two expert panels will produce recommendations for VWD diagnosis and management. The panels comprise more than 20 individuals, including U.S.-based and international hematologists, patients with VWD, and scientists with expertise in evidence synthesis and appraisal and guideline development methodology.
Panel members will identify and prioritize guideline questions based on the frequency with which a question arises in clinical practice, the degree to which there is variation in clinical practice, the extent to which the question has already been addressed by high-quality guidelines, and implications for resource use.
Once the questions are formed, researchers at KU Medical Center will conduct a systematic review of available evidence, from which clinical recommendations will be developed. As with ASH’s other clinical practice guidelines in development, a public comment period will follow.
The publication of the guidelines is anticipated in 2020, with tools and resources provided to help clinicians implement the recommended guidelines.