Investment Will Bolster Growing Subspecialty
Five years ago, the American Society of Hematology (ASH) introduced the concept of a new subspecialty called the systems-based hematologist.1 This specially trained hematologist is employed by a hospital, medical center, or health system, to optimize individual patient care and the overall system of health care delivery for patients with blood disorders.
“This subspecialty came into being as we saw an increasing demand for hematologic consultation, but with a limited pool of hematologists available to satisfy that demand,” explained Steven Allen, MD, System Head of Benign Hematology at Northwell Health in New York, past chair of the ASH Committee on Practice, and ASH Councillor in Practice. “The systems-based hematologist could promote high-quality, cost-effective, evidence-based care in a specialty that deals with rare and complex diseases that manifest in multiple organ systems and are treated with drugs that are used infrequently, even by some hematologists.”
Put more simply, the goal of this unique position is to scrutinize the health care system for opportunities to improve hematology care delivery, according to Jori E. May, MD, Assistant Professor of Medicine in the Division of Hematology/Oncology at the University of Alabama at Birmingham. This seems like a natural goal, but health care systems are often set up with fragmented or siloed teams. A system-based hematologist is tasked with taking a more global view.
Dr. May and colleagues recently published a review article in Blood Advances that provided an update on the subspecialty and reported on successful systems-based initiatives in the field of hematology.2 These include efforts to improve stewardship in the diagnosis and management of complex hematologic disorders, the development of programs to promote appropriate use of hematologic therapies, and changes in care delivery infrastructure to improve access to hematologic expertise.
The authors begin their report with a framework for classifying and evaluating systems-based initiatives in terms of their scope (targeted or comprehensive) and method of intervention. Methods of intervention fall into three categories:
- Clinician education, to improve provider understanding of best practice to influence patient care
- Clinical tools, to influence practice by guiding providers through clinical decision making
- Care delivery infrastructure, to facilitate the development of modified or novel systems to provide more efficient or effective patient care
Successful examples often incorporate elements from one of more of these categories.
In one example, clinicians from the University of Texas Southwestern Medical Center addressed the role of thrombophilia testing, which most in the hematology community believe has limited utility in the management of venous thromboembolism.3
“Many times, patients come in with a venous thromboembolism and primary care providers are anxious to have a patient evaluated for an underlying condition that may predispose the patient to a clot,” Dr. Allen said. “However, that is not appropriate in the acute setting, and it may not be appropriate to do that at any time because it does not change the management. The evaluations are very complex and costly.”
After identifying significant overuse of thrombophilia testing, center staff developed guidelines to reduce unnecessary testing. After implementation, inpatient testing dropped from an average of 87 to 18 inpatients per month – a 79% reduction. In addition, the center’s Transfusion Medicine Hemostasis Service reviewed all orders for testing and was able to further decrease testing from an average of 18 to 5 inpatients per month. These efforts netted an estimated savings of $1.2 million per year.
Another example of systems-based efforts to improve care tackles the use of inferior vena cava (IVC) filters to prevent pulmonary embolism.
“There are clear guidelines on when IVC filters should and should not be used,” said Nathan T. Connell, MD, MPH, clinical chief of hematology at Brigham and Women’s Faulkner Hospital in Boston, and a coauthor of the report. “Ever-expanding datasets are showing this, but it can be difficult to change institutional practice.”
At Staten Island University in New York, clinicians created a strict indication policy for use of IVC filters for the entire health system. After implementation, the average number of filters placed decreased by 41%.4
“The issue is not just with placing the filter at the correct time, but also making sure the filter is removed,” Dr. Connell said. “Systems-based hematologists can help develop processes to follow up with patients about IVC filter retrieval to avoid complications down the road.”
The examples outlined above involve targeted initiatives, but comprehensive, interventions by focusing on areas like blood product use or electronic consultations. According to Dr. May, in the current health care setting, systems-based hematologists’ skillsets could also be applied to adjusting care and practice in the management of COVID-19.
“We know that COVID-19 infection is associated with what appears to be an increased risk for thrombosis and there has been significant discussion about the appropriate use of anticoagulation in this setting,” she said. ASH recently released guidance on this clinical issue, and “a systems-based hematologist is uniquely equipped to synthesize information and collaborate with critical care providers and hospitalists to make a comprehensive plan for how to manage anticoagulation in these patients.”
In addition, COVID-19 has escalated the need for virtual care, Dr. May said. A systems-based hematologist would have the skill set to build that infrastructure within a hematology division.
The Blood Advances report highlights successful systems-based initiatives, but she noted that establishing systems-based hematology as a subspecialty is not without challenges.
“A goal of a systems-based hematologist is improved efficiency, which is often associated with decreased costs, but a new role like this requires upfront investment from the institution,” she said. “The hematologist will require protected time or resources to realize these cost savings or improvements in patient outcomes.”
Another barrier to overcome is creating a career pathway that encourages physicians to become systems-based hematologists.
“Having a mentor in the field, seeing someone who has been successful in what they are doing, is always good,” Dr. Connell said. “However, this is a relatively new field and trainees may not yet know someone focused on this area.”
Dr. Allen said that the ASH Committee on Practice is enthusiastic about encouraging fellows to consider systems-based hematology as a subspecialty.
“We think that fellows can contribute tremendously to the practice of hematology,” he said. “This approach would provide a challenging and satisfying professional career for individuals who are interested. It is a new field with new challenges associated with it, but it will put them at the cutting edge of delivering high-quality patient care.”
- Wallace PJ, Connell NT, Abkowitz JL. The role of hematologists in a changing United States health care system. Blood. 2015;125(16):2467-2470.
- May JE, Irelan PC, Boedeker K, et al. Systems-based hematology: highlighting successes and next steps. Blood Adv. 2020;4(18):4574-4583.
- Smythe MA, Mehta TP, Koerber JM, et al. Development and implementation of a comprehensive heparin-induced thrombocytopenia recognition and management protocol. Am J Health Syst Pharm. 2012;69(3):241-248.
- Russo N, D’Alessandro M, Tyson A, et al. Patterns of inferior vena cava filter placement before and after implementation of a strict indication policy. J Vasc Surg. 2016;64(3):P850.