ASH "Choosing Wisely Champions" Share Their Practice-Changing Success

IN COOPERATION WITH THE AMERICAN BOARD

of Internal Medicine Foundation, the American Society of Hematology (ASH) introduced the “Choosing Wisely Champions” to recognize the efforts of practitioners who are working to eliminate costly and potentially harmful overuse of tests and procedures. These winners were invited to showcase their work at the 58th Annual Meeting & Exposition of ASH to provide attendees with an opportunity to learn and potentially implement these changes in their own practices. The session was chaired by Lisa K. Hicks, MD, oncological hematologist at St. Michael’s Hospital, Toronto, Canada.

Ravindra Sarode, MD, medical director of clinical laboratory services, University of Texas Southwestern Medical Center, Dallas, Texas, spoke during the session, “Reduction in Unnecessary or Misapplied Thrombophilia Testing in Patients with DVT, PE, or Other Thrombotic Disorders Using Combination of Education and EMR Alerts. “The ASH Choosing Wisely guiding principles aim to reduce harm to patients, reduce costs, and are within the clinical domain of hematology,” Sarode said. For his presentation, Sarode referred to recommendation 2 by ASH:

Don’t test for thrombophilia in adult patients with venous thromboembolism (VTE) occurring in the setting of major transient risk factors (surgery, trauma, or prolonged immobility).¹

“Unfortunately, there are no thrombophilia-testing guidelines,” he told the audience. “Why, whom, what, and when to test are always open-ended questions.” Confusion over whether testing should be done in-house and the lack of testing guidelines in the adult and pediatric populations make for complicated decisions on testing.

Unnecessary testing can result in serious harm because of the following:

1. Testing is often conducted in provoked venous thromboembolism (VTE) during an acute event of anticoagulation
2. VTE testing often yields false-positive results
3. Testing often results in an unnecessary increase in healthcare costs

At their healthcare center, Sarode and his team analyzed consecutive thrombophilia testing orders during October and November of 2009, based on electronic health records (EHRs).² They evaluated indication, timing, comprehensiveness of tests, anticoagulation therapy at the time of testing, and confirmatory repeat testing, if any. Of the 173 patient records that were evaluated, a majority (72%) of patients were female.

• 70% had VTE or pregnancy loss (34%, unprovoked VTE or >3 pregnancy losses; 35%, provoked VTE; 31%, no documented reason)
• 51% were tested within 7 days of an index clinical event
• 51% were tested on anticoagulation therapy results affected by anticoagulation therapy
• 16% had a complete work-up with 1 work draw
• 84% had incomplete or fragmented testing, including unnecessary blood draws, which was a waste of time for the nurse and the technician
• 46% had abnormal results, and only 46% of these had abnormal tests repeated for confirmation; 54% potentially had a wrong diagnosis with long-term anticoagulation.

“We estimated a conservative loss of $1 million annually, over and above the incalculable loss of unnecessary long-term anticoagulation and related complications,” Sarode said. “We implemented local guidelines for thrombophilia testing for clinicians, resulting in a reduction in healthcare costs and improved patient care. Twenty-two months after guideline implementation, a 92% reduction in testing was observed.” However, the process was fraught with challenges, and communication was key, he acknowledged, which included verbal communication through meetings and grand rounds as well as changes within the Epic EHR system to flag testing each time it was ordered.

Maria I. Juarez, MD, from the Cancer Institute of Dallas, Mansfield, Texas, spoke during “Reduction of RBC Transfusion Via Updated Guidelines, Modified Workflow, and Physician Education.” She detailed the project at their cancer institute that addressed recommendation 1 by ASH:

Don’t transfuse more than the minimum number of red blood cell (RBC) units necessary to relieve symptoms of anemia or to return a patient to a safe hemoglobin range (7 to 8 g/dL in stable, noncardiac in-patients).¹

“Transfusions do not necessarily improve outcomes; rather, they can increase care costs and expose patients to unnecessary harm,” Juarez said.

“Our goal was to optimize PRBC, or packed red blood cell, utilization and develop a system-wide set of recommendations on the use of blood-based products.” The team then developed and shared system-wide guidelines on RBC transfusion. “Our intent was to modify the practice in the emergency department, with order sets configured for clinical decision support.”

Their goal was to achieve a 20% reduction overall, and they ended up with a 27% reduction across the network. “Two hospitals within our network individually achieved a 35% reduction,” she said.

Juarez told the audience that their project has been carried over as a system goal into 2017. “Guidelines have been developed for platelets, [fresh frozen plasma], and cryoprecipitate, and we hope to develop a system-analysis tool in parallel as well.” The reason for our success was persistence, she emphasized.

The final presentation was by Javier Munoz, MD, Banner MD Anderson Cancer Center, Gilbert, Arizona, who spoke about their project during “Reduction of Post-Treatment Scanning Using EMR Alerts.” This project stemmed from recommendation 5 by ASH:

Limit surveillance computed tomography (CT) scans in asymptomatic patients following curative-intent treatment for aggressive lymphoma.¹

“Most patients with relapsed aggressive lymphomas are diagnosed outside of planned follow-up with scheduled imaging,” Munoz said. “Imaging is costly and unnecessarily exposes asymptomatic patients to radiation, which builds up over time.”

According to the National Comprehensive Cancer Network Guidelines, patients with stage 3 or 4 diffuse large B-cell lymphoma should undergo a CT scan every 6 months for 2 years and then yearly if needed, he said. Particularly for Hodgkin lymphoma, CT should not be done routinely because it can lead to false-positives, he added.

“To bring about this system and behavior change, our hypothesis was that a combination of provider education and automatic EHR alerts could stop physicians from sending a patient for unnecessary scans,” Munoz said. Their team developed the following clinical practice statement: limit surveillance in asymptomatic patients with lymphoma. They engaged both providers and patients to raise awareness and implement changes, he said.

“Our preliminary results found that automatic alerts generated within the EHR may decrease imaging,” Munoz said, adding, “Education is definitely important for the success of such system-wide projects.” REFERENCES

1. Ten things physicians and patients should question. Choosing Wisely^® website. http://www. choosingwisely.org/societies/american-society-of-hematology/. Accessed December 9, 2016.
2. Shen YM, Tsai J, Taiwo E, et al. Analysis of thrombophilia test ordering practices at an academic center: a proposal for appropriate testing to reduce harm and cost. PLoS One. 2016;11(5):e0155326. doi: 10.1371/journal.pone.0155326.

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