Choosing Wisely Across the Internal Medicine Spectrum: Which Recommendations Should Hematologists Pay Attention To?

In collaboration with the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely® campaign, ASH released a list of hematology-related tests and procedures to question based on recommendations from other medical societies at the 2015 annual meeting.

Choosing Wisely encourages clinicians and patients to engage in conversations to reduce waste and overuse in health care. As part of this effort, medical societies, including ASH, 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 2013 and 2014, ASH issued two five-item lists 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. (Read the list of 10 at www.hematology.org/Clinicians/Guidelines-Quality/502.aspx).

In 2015, ASH’s Choosing Wisely Task Force launched a review of all existing Choosing Wisely items to identify recommendations published by other professional societies that are highly relevant and important to the practice of hematology. Items were scored for relevance, resulting in a list of interventions that were deemed to be especially useful to hematologists.

The final recommendations are relevant to malignant hematology, non-malignant hematology, thrombosis, transfusion, and laboratory medicine. The list was presented at the “ASH Choosing Wisely® Campaign: Top 5 Non-ASH Choosing Wisely® Recommendations of Relevance to Hematology” annual meeting session, chaired by Lisa K. Hicks, MD, MSc, of St. Michael’s Hospital in Toronto.

“This year we did something different,” Dr. Hicks told ASH Clinical News. “We wanted to take the opportunity to learn from and leverage the work of others.” As of 2015, more than 70 different specialty societies have participated in the ABIM initiative, resulting in more than 380 individual recommendations.

“None of us in medicine practice in a silo,” she added. “Many of the diseases and patients that we treat overlap with other specialties, and many of the recommendations that ASH has made are relevant to other specialties. The reverse is also true, as we’ve shown with this new list.”

The five non-ASH Choosing Wisely recommendations with the greatest relevance to hematology are:

  1. Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability of PE. (From the American College of Radiology)
    Dr. Hicks: “Instead of using CT imaging, which is extremely helpful and powerful in the right circumstances, in all patients, we should really be trying to isolate its use to patients with moderate or high pretest probability of PE. Current science supports the use of other clinical tools, such as the Wells’ Criteria and certain laboratory tests, to distinguish patients who would benefit from a CT pulmonary angiogram to identify PE from those in whom PE can be effectively ruled out without the use of CT.”
  2. Don’t routinely order thrombophilia testing on patients undergoing a routine infertility evaluation. (From the American Society for Reproductive Medicine)
    Dr. Hicks: “Infertility is extremely common, and it typically occurs in otherwise healthy young women, so we thought this was an important recommendation to highlight.”
  3. Don’t perform repetitive complete blood count (CBC) and chemistry testing in the face of clinical and lab stability. (From the Society for Hospital Medicine – Adult Hospital Medicine)
    Dr. Hicks: “Anyone who works in a hospital setting, like I do, knows that a large amount of routine bloodwork is done, and this has implications for patients. It can contribute to anemia, it can be uncomfortable, and it has cost implications. Bloodwork should be thoughtful and intended to address a specific clinical question.”
  4. Don’t transfuse red blood cells for iron deficiency without hemodynamic instability. (From the American Association of Blood Banks)
    Dr. Hicks: “The patients I typically see with this condition are young women who may have iron deficiency anemia due to menorrhagia. They may have significant anemia, but because they are young and otherwise healthy and have a very healthy hematopoietic system, they are actually able to tolerate that. So, the AABB recommends resisting giving red blood cells, unless a patient is unstable or having chest pain or some other marker of high risk, and giving iron instead.”
  5. Avoid using positron emission tomography (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. (From the American Society of Clinical Oncology)
    Dr. Hicks: “PET-CT is a very powerful new technology that is extremely helpful in certain circumstances, but it has not been demonstrated to improve overall survival or other important patient outcomes when it is used as a surveillance technology. Using it in this fashion also has important implications for cost, for radiation exposure, and for the detection of incidental findings – which can then cascade into a whole other set of investigations.”

These lists are developed to aid clinicians and patients in decision-making, but, Dr. Hicks noted, “None of the recommendations that we or anyone else makes in the realm of Choosing Wisely replace clinical judgment.”

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