SUMMARY: CHOOSING WISELY® is a quality improvement initiative led by the American Board of Internal Medicine Foundation in collaboration with leading medical societies in the United States such as the American Society of Hematology (ASH). This organization was established to improve quality of medical care, after it was noted that about 25% of the tests ordered at the time of hospital admission and 65% of the tests ordered on subsequent days were avoidable. Further, there is ample evidence to suggest that, reducing unneeded investigations can decrease costs, increase patient satisfaction and quality of care. CHOOSING WISELY® has challenged 70 medical societies to identify 5 tests, procedures or treatments, within each specialty’s clinical domain, that are offered to patients, despite the lack of evidence demonstrating its benefit. The goal is to make positive changes in the actual delivery of patient care without harming the patient. The ASH CHOOSING WISELY® Task Force comprised of 13 individuals, represents a broad spectrum of hematologic expertise including malignant, benign, adult, and pediatric specialists. The five final recommendations of the 2015 ASH Choosing Wisely Campaign is an addition to the 10 prior recommendations made by ASH over the past 2 years. These top 5 recommendations were presented on December 7, 2015, at the 57th annual meeting of ASH, in Orlando, Florida. Practicing hematologists should give due consideration to these recommendations which are evidence based and cost effective.
Don’t image for suspected Pulmonary Embolism (PE) without moderate or high pre-test probability of PE
The American College of Radiology has recommended that assessment of the risk-benefit ratio is important especially with pulmonary embolism and imaging can be avoided for suspected PE, without moderate to high pre-test probability.
Don’t routinely order thrombophilia testing on patients undergoing a routine infertility evaluation
With Nearly 15% couples of patients receiving an infertility evaluation, the American Society for Reproductive Medicine has recommended that even though several population-based studies have found association of infertility or failure of assisted reproduction with thrombophilia, 2 large cohort studies have shown no association between thrombophilias such as Factor V Leiden or Prothrombin gene mutations and assisted reproduction failure or infertility. Further, thrombophilia is not a predictor of who will benefit from Low Molecular Weight Heparin (LMWH) treatment with respect to assisted reproduction and LMWH can be associated with adverse events.
Don’t perform repetitive Complete Blood Count (CBC) and chemistry testing in the face of clinical and lab stability
The Society for Hospital Medicine and Adult Hospital Medicine noted that ordering routine complete blood counts (CBCs) during hospitalization is common practice and is unnecessary. Critically ill patients do not have the bone marrow reserve or erythropoietin stimulus to compensate for iatrogenic blood loss. Reducing the frequency of CBC’s does not result in inferior outcomes and several studies have shown that there is no difference in readmission rates, length of hospital stay and rates of adverse events. In addition to the risks of phlebotomy, this practice is economically disadvantageous, as they may not be reimbursable and will be an additional avoidable cost to dispose the biohazard waste of the blood samples.
Don’t transfuse red blood cells for iron deficiency without hemodynamic instability
The American Association of Blood Banks has recommended against PRBC transfusions for patients with hemodynamically stable iron deficiency anemia. These patients when evaluated in the Emergency Department (ED) can be prescribed oral or IV iron with similar responses noted at 6-8 weeks. The compliance rate in those receiving oral iron may only be 50% due to GI side effects. Therefore parenteral iron may be a better treatment option for certain groups of patients seen in the ED.
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
Professional organizations like ASCO, ESMO and NCCN do not include surveillance PET in disease-specific guidelines because, routine use of intensive surveillance does not improve survival or enhance quality of life. Besides cost implications, CT scans may in fact expose patients to small doses of radiation.
The ASH Choosing Wisely® Campaign: Top 5 Non-ASH Choosing Wisely® Recommendations of Relevance to Hematology. Presented on December 7, 2015, at the 57th annual meeting of ASH, in Orlando, Florida.