Ten Things Doctors and Patients Should Question: An Update from the Choosing Wisely Task Force

Choosing Wisely®, an initiative of the American Board of Internal Medicine (ABIM) Foundation, is a campaign that encourages clinicians and patients to engage in conversations aimed at reducing waste and overuse in health care. The Choosing Wisely campaign challenges medical societies, including the American Society of Hematology, to identify tests, procedures, or treatments within each specialty’s clinical domain that are offered to patients despite evidence that they may not benefit patients, and in some cases may be harmful.

In December 2013, the ASH Choosing Wisely Task Force delivered its first product: a five-item list of procedures, tests, and treatments that practicing hematologists and patients should carefully consider before using because, in the circumstances described, the risk of harm and/or cost of the specified interventions likely outweigh the anticipated benefits.1

The second Choosing Wisely list, released December 3, 2014, and published in Blood, adds five more items to question – ranging from limiting computed tomography (CT) scans in patients with chronic lymphocytic leukemia (CLL) to using the “4T” score in patients with suspected heparininduced thrombocytopenia.2 (For the complete list, see the FIGURE, and visit www.hematology.org/ChoosingWisely.)

ASH Clinical News spoke with some of the Task Force members about how this list was created and what it could mean for practitioners and patients.

How This List Was Created

To create this list, the Society used the same methods developed in 2013. The ASH Choosing Wisely Task Force – composed of 13 hematologists with expertise in malignant, nonmalignant, adult, pediatric, clinical, and laboratory hematology – was convened. The Task Force solicited suggestions from members of the ASH Committee on Practice; the ASH Committee on Quality; ASH Consult-a-Colleague volunteers; and members of the ASH Practice Partnership (APP), a group within the Society that was formed to better represent the interests of practicing hematologists. The APP is made up of practicing hematologists from across the nation; participants must be board-certified in hematology and active members of ASH.

Respondents were asked to consider six principles in prioritizing items:

  • avoidance of harm to patients
  • evidence of recommendations
  • cost of tests and treatments
  • frequency of tests and treatments
  • clinical purview of the hematologist
  • potential impact of recommendations

Guided by these six principles, the Task Force scored all suggestions and selected 10 semi-finalist items. Systematic literature reviews for each of the 10 semi-finalist items were then conducted. The Task Force then selected five recommendations to comprise the second half of ASH’s Choosing Wisely list.

Completing the List

The second set of items (#6 – #10) represents the result of months of careful data analysis and review, as well as input from the ASH membership, using the best available evidence about management and treatment options.

According to Lisa K. Hicks, MD, of St. Michael’s Hospital and the University of Toronto and chair of the ASH Choosing Wisely Task Force, these items are designed to promote conversations between patients and providers about the necessity and potential harm of certain practices. “Both hematologists and patients are encouraged to use the ASH Choosing Wisely list as a springboard for discussion,” Dr. Hicks told ASH Clinical News. “The list is not intended to replace thoughtful, patient-centered care. It is intended to spur discussions between practitioners and patients about particular tests and treatments that, in some circumstances, may not be necessary.”

For instance, patients may request tests that may not be indicated based on best evidence, or physicians may recommend procedures that have little demonstrated value. This Choosing Wisely list is designed to empower patients and physicians to be better consumers of health care – not to limit health care, but to help patients and providers choose the best health care at the best time.

Changing Patient and Provider Perspectives on Value

Recent evidence has only underscored the need for this dialogue: At least 27 percent of investigations ordered on admission to a hospital are avoidable, and this number increased to 63 percent on subsequent days.3 The Institute of Medicine also estimates that 1 of every 3 dollars spent on health care is wasted – particularly on inefficient diagnostic testing.4

So, of the five new items, which will have the greatest impact on practice? “I think the CLL item could have a big impact on practice, as it addresses an area of practice that is, in my view, fairly common,” Dr. Hicks said. “We hope that the heparin-induced thrombocytopenia item will also have a big impact because HIT tests done in low-risk patients are more likely to mislead care (through false-positive results) than to aid care.”

Adam Cuker, MD, MS, who will be discussing the “4T” score to calculate the pre-test probability of HIT (item #9) at the Choosing Wisely session at the annual meeting, highlighted the necessity of effectively ruling out HIT before initiating treatment.

“Treatment for HIT involves two major steps: first, discontinuation of heparin, and second, initiation of a non-heparin anticoagulant,” Dr. Cuker, from the Perelman School of Medicine at the University of Pennsylvania, told ASH Clinical News. “Both steps can cause harm in a patient without HIT. Unnecessary suspension of heparin may expose patients to undue thrombotic risk. Approved agents for the treatment of HIT are costly, associated with roughly a 1 percent daily risk of major hemorrhage, and irreversible.”

The 4Ts score is a simple-to-use clinical scoring system for estimating the likelihood of HIT, in which patients are scored based on four criteria: thrombocytopenia, timing (of the platelet count fall in relation to heparin exposure), thrombosis (or other clinical sequelae), and the presence of other potential causes of thrombocytopenia (TABLE).

“I hope that hematologists will calculate a 4T score in patients with suspected HIT and use the result to guide management,” Dr. Cuker noted. “In patients with a low probability score, HIT is effectively ruled out. Heparin may be continued and other causes of thrombocytopenia should be sought.”

Since its launch in April 2012, the Choosing Wisely campaign has collaborated with 92 national and state medical specialty societies, regional health collaborative organizations, and consumer partners in this important conversation about appropriate care. These lists, taken as a whole, identify more than 325 tests and procedures that clinicians and patients should discuss before ordering.

“Hematology is a specialty with many new and increasingly expensive tests and treatments. While these new diagnostic and treatment strategies represent important advances, there is also potential to pose significant harm and cost to patients if over- or misused,” said Dr. Hicks. “The ASH Choosing Wisely list serves as a reminder to hematologists to take a step back and question whether certain routinely used procedures are really necessary and to gradually change their practices to maximize the value of care.”


References

  1. Hicks LK, Bering H, Carson KR, et al. The ASH Choosing Wisely® campaign: five hematologic tests and treatments to question. Blood. 2013;122:3879-83.
  2. Hicks LK, et al. The second ASH Choosing Wisely® campaign: five hematologic tests and treatments to question. Blood. 2014 December 3. [Epub ahead of print]
  3. Miyakis S, Karamanof G, Liontos M, Mountokalakis TD. Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy. Postgrad Med J. 2006;82:823–9.
  4. Smith MD, Institute of Medicine (U.S.). Committee on the Learning Health Care System in America. Best care at lower cost: the path to continuously learning health care in America. 2012. National Academies Press, Washington, DC.

How to Calculate 4T Score

Adam Cuker, MD, MS: Patients are scored based on four criteria: thrombocytopenia, timing of platelet count fall, thrombosis, and other potential causes of thrombocytopenia (below TABLE). Scores of 0-3, 4-5, and 6-8 are classified as low, intermediate, and high probability of HIT, respectively. The recommendation not to order HIT laboratory testing or administer treatment for HIT with an alternative anticoagulant is based on observations from a meta-analysis of 13 studies that found that a low probability 4T score was associated with a negative predictive value of 99.8% (95% CI 97.0-100.0).

2 Points 1 Point 0 Point
Thrombocytopenia Platelet count fall >50% fall or platelet nadir 20–100 × 109/L Platelet count fall 30–50% or platelet nadir 10–19 × 109/L Platelet count fall <30% or platelet nadir <10 × 109/L
Timing of the platelet count fall in relation to heparin exposure Clear onset between days 5 and 10 Onset after day 10, or consistent with immunization but not clear Platelet count fall too early (without recent heparin exposure)
Thrombosis or other clinical sequelae  Confirmed new thrombosis, skin necrosis, post-heparin systemic reaction Progressive, recurrent, or suspected thrombosis No thrombosis
oTher potential causes of thrombocytopenia No other alternative cause Possible alternative cause Definite alternative cause

FIGURE

American Society of Hematology’s Second Choosing Wisely List: Five More Things Physicians and Patients Should Question

  1. Don’t treat with an anticoagulant for more than three months in a patient with a first venous thromboembolism (VTE) occurring in the setting of a major transient risk factor.
  2. Don’t routinely transfuse patients with sickle cell disease (SCD) for chronic anemia or uncomplicated pain crisis without an appropriate clinical indication.
  3. Don’t perform baseline or routine surveillance computed tomography (CT) scans in patients with asymptomatic, early-stage chronic lymphocytic leukemia (CLL).
  4. Don’t test or treat for suspected heparin-induced thrombocytopenia (HIT) in patients with a low pre-test probability of HIT. (Editor’s Note: For an explanation of how to use the 4T score with patients, see the TABLE.)
  5. Don’t treat patients with immune thrombocytopenic purpura (ITP) in the absence of bleeding or a very low platelet count.

Disclaimer: These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

To read ASH’s previously released Choosing Wisely recommendations (items #1 – #5), visit www.hematology.org/ChoosingWisely.

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