ASH Presents Second Round of Tests, Treatments to Question Under Choosing Wisely Initiative

Hematologists received recommendations about how long to use anticoagulants, when to transfuse sickle cell patients and when to perform surveillance scans in patients with early-stage chronic lymphocytic leukemia (CLL), as the American Society of Hematology (ASH) issued its second list of tests and treatments that should be questioned under the Choosing Wisely initiative.

This year’s list was announced at the start of the 2014 Annual Meeting of ASH, which concludes today in San Francisco, California. The first round of recommendations, numbers 1-5, were announced December 4, 2013; details of recommendations 6-10 were presented at a session Monday.

Choosing Wisely is the initiative of the American Board of Internal Medicine Foundation that asks each specialty to identify tests or treatments that might be overused and unnecessary, with potential harm to patients. While saving healthcare dollars is not the only consideration of Choosing Wisely, its efforts will have that effect if patients and their doctors are more judicious in their medical decisions.

The 2014 ASH Choosing Wisely recommendations are:

• Don’t use anticoagulants for more than 3 months in patients with a first venous thromboembolism (VTE) occurring in the setting of a major transient risk factor. This was presented by Mark Crowther, MD, MSc, of McMaster University, who described this recommendation as a basic calculation of benefit-versus-risk; a VTE triggered by a major event such as surgery are at low risk for recurrence once the major event has passed and recovery has occurred, assuming adequate care and anticoagulant therapy. After that, such patients have a low risk of thrombosis, “and have the same risk of bleeding as other patients.” The ASH recommendation does not apply to VTE linked to non-major risks, such as pregnancy or travel-associated immobility.

• Don’t routinely transfuse patients with sickle cell disease for chronic anemia or an uncomplicated pain crisis without an appropriate clinical indication. Presented by George R. Buchanan, MD, of the University of Texas Southwestern in Dallas, this recommendation starts from the mandate, “First, do no harm.” Unnecessary red blood cell transfusions can cause iron overload and other complications that require additional treatment, and unnecessary transfusions can make it difficult for sickle cell patients to find compatible blood supplies when they are truly needed. Dr Buchanan said it is critical to ask: is this a routine transfusion specific to a clinical indication? What is the patient’s gene type? As Dr Buchanan discussed, and the companion paper in Blood and Hematology notes, stable patients with severe disease “can have baseline hemoglobin values between 7 and 10 g/dL and can tolerate 1-2 g/dL decreases without developing symptoms of anemia.”¹ Most importantly, Dr Buchanan said, using transfusions for chronic pain management does not work.

• Don’t perform baseline or routine surveillance computed tomography (CT) scans in patients with asymptomatic, early-stage CLL. This recommendation incorporates a theme heard this year at ASH about overuse of scans, which has been a broad theme across managed care and cancer care especially. John Byrd, MD, of Ohio State University discussed this item, which states that in these circumstances of CLL, a CT scan does not improve survival for either staging or prognostic purposes. If anything, scans uncover incidental, irrelevant findings that drive up costs. The ASH recommendation calls for blood monitoring, and Dr Byrd was among the speakers at ASH who urged clinicians to counsel patients about the value of biomarkers instead of radiation.

• Don’t test or treat for suspected heparin-induced thrombocytopenia (HIT) in patients with a low pre-test probability. Adam C. Cuker, MD, MS, of the University of Pennsylvania, described the “4T” score, a widely used system that allows clinicians to evaluate the timing a degree of thrombocytopenia and whether it might be caused by heparin. Dr Cuker said this is one the tough calls in medicine—for once a patient is taken off heparin, other anticoagulants are much more expense; what’s more, even taking the test brings the risk of a false positive. Even if that turns out to be incorrect, once that information lands in a patient’s file, it can be difficult for the patient to receive heparin again. Thus, Dr Cuker emphasize the importance of not only not treating, but not testing for HIT unless scores call for it.

• Don’t treat patients with immune thrombocytopenic purpura (ITP) in the absence of bleeding or low platelet count. Cindy R. Neunert, MD, of Georgia Regents University noted that the ASH recommendation applies to adults, and that pediatric cases have difficult criteria. In all cases, treatment should be aimed at improving quality of life without exposing patients to unnecessary risks, and is always conditioned on prior bleeding episodes, activity levels, and social factors. Generally, ITP treatment is rarely indicated in adults if platelet counts are above 30,000/microL unless they are facing surgery or other invasive procedures.

Reference

Hicks LK, Bering H, Carson KR et al. Five hematologic tests and treatments to question. Hematology 2014; 2014: 599-60