Choosing Wisely Across the Spectrum of Internal Medicine

The Choosing Wisely® campaign, an initiative of the American Board of Internal Medicine (ABIM) Foundation, encourages clinicians and patients to engage in conversations to reduce overuse of tests, procedures, and treatments that may not benefit patients. Through this program, more than 60 medical societies, including ASH, have produced sets of evidence-based recommendations.

Here, Lisa Hicks, MD, MSc, from St. Michael’s Hospital at the University of Toronto, and chair of the ASH Choosing Wisely Task Force, highlights areas where ASH’s recommendations overlap with those from other medical societies, focusing on items that hematologists/oncologists should be aware of.

There are a large number of Choosing Wisely recommendations from other medical societies relevant to the practice of hematology. Some directly overlap with existing ASH Choosing Wisely recommendations, while others are relevant due to shared clinical responsibility for certain disorders or a focus on blood product transfusions and hematology labs.

For instance, the ASH Choosing Wisely recommendation to use only the minimum necessary units of packed red blood cells is very similar to recommendations from the American Association of Blood Banks (AABB), the American Society of Anesthesiologists (ASA), the Society of Hospital Medicine (SHM), and the Critical Care Societies Collaborative (CCSC).

Not surprisingly, the Choosing Wisely recommendations from AABB and the American Society of Clinical Oncology (ASCO) are the most immediately relevant to hematologists. The American Thoracic Society/the American College of Chest Physicians (ATS/ACCP) and
SHM both have also developed items important to the practice of hematology, highlighted in the TABLE.

When the ASH Choosing Wisely Task Force was selecting our recommendations, a few items made it to the “semi-finalist” stage but were ultimately not pursued – in part because the recommendations had already been included in other societies’ Choosing Wisely lists.

One prime example is a recommendation from the ATS/ACCP to avoid performing computed tomography (CT) to test for pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay. Unnecessary CTs are costly and expose patients to excessive radiation.

Similarly, SHM and others have recommended limiting complete blood cell and chemistry testing in the face of clinical and lab stability. This item is relevant to hematologists for two reasons:

  • First, we order many lab tests for our patients – particularly for inpatients with malignancies – so there may be opportunities to improve our practice in this area.
  • Second, many hematologists have important leadership roles in laboratory medicine and may be able to limit unnecessary testing across an institution.

Choosing Wisely from the Patient Perspective

Patients tend to be interested in pursuing “less care” when it translates to a tangible decrease in risk and cost to them. In considering a decrease in risk (for example, of a transfusion reaction or of allo-immunization), it is important for patients to question all transfusions. This does not mean they should refuse all transfusions, but they should certainly question a transfusion to ensure that blood products are really necessary – whether red cells, platelets, or a different product.

This practice is supported by a number of medical societies’ Choosing Wisely recommendations. Focusing on reducing a patient’s personal costs, ASCO recommends avoiding white cell–stimulating factors for primary prevention of febrile neutropenia for low-risk patients. Filgrastim is an expensive medication; using white cell–stimulating factors only when appropriate could save patients thousands of dollars.

ASCO also recommends against using some of the newer (and more expensive) anti-emetics designed for highly emetogenic chemotherapy regimens in patients with a low to moderate risk of nausea. These types of recommendations can lead to both personal and societal benefits.

Patients should also be sensitive about over-testing because it could detect clinically non-significant findings, which could lead to inappropriate downstream management – and even to difficulty obtaining insurance. The American Society for Reproductive Medicine (ASRM) and the Society for Maternal-Fetal Medicine (SMFM) have taken a stance against routine thrombophilia testing in patients being evaluated for infertility, and against screening for inherited thrombophilia in women with a history of pregnancy complications.

From Development to Implementation

The first step to implementation is knowledge. In collaboration with Consumer Reports, the ABIM Foundation has produced a number of informative pamphlets for patients on specific Choosing Wisely recommendations – available at their website. Many medical societies have also developed teaching tools and educational resources available through their Web sites.

The National Business Coalition on Health has also prepared a toolkit for employers to help them implement Choosing Wisely recommendations and to educate employees about the dangers and issues associated with the overuse of health-care services.

Beyond raising awareness, many of the excess use issues identified by Choosing Wisely are amenable to local, targeted projects designed to address that specific area of overutilization. (On February 4, 2015, ASH hosted a webinar showcasing three projects that have tried to tackle specific overutilization issues. The webinar is available through ASH On Demand.)

Competitive funding for initiatives addressing specific Choosing Wisely recommendations is available through the ABIM Foundation, and teams wanting to tackle these issues at their own institution can also seek inspiration from the previous recipients of the ABIM’s Choosing Wisely Grants. In April 2013, the ABIM Foundation awarded funding to 21 state medical societies, specialty societies, and regional health collaboratives to help physicians and patients engage in conversations aimed at promoting the goals of the Choosing Wisely campaign.

 Society Choosing Wisely Recommendation
ATS/ACCP Don’t perform chest computed tomography (CT angiography) to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay.
SHM Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability.
ASCO Avoid using 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.
ASCO Don’t use white cell stimulating factors for primary prevention of febrile neutropenia for patients with less than 20% risk for this complication.
AABB Don’t transfuse red blood cells for iron deficiency without hemodynamic stability.