New Orleans, LA—To improve the quality of care in hematology, and to eliminate waste and reduce costs, the American Society of Hematology (ASH) has embraced the Choosing Wisely initiative of the American Board of Internal Medicine Foundation.
The Institute of Medicine estimated that in 2009, some $750 billion was wasted in healthcare, of which $210 billion was spent on unnecessary services across all specialties, according to ASH’s Choosing Wisely Task Force Chair Lisa K. Hicks, MD, MSc, of St Michael’s Hospital and the University of Toronto, Ontario, Canada. “If we could redirect even a fraction of this to real people with real unmet healthcare needs, think of the good that we can do,” Dr Hicks said at a press briefing during the 2013 ASH meeting.
“We need to take a step back and decide whether the tests and procedures we order are truly necessary,” Dr Hicks said. “We need a conversation about cost and value.” The task force recommendations focus on unnecessary treatments and testing.
The evidence-based recommendations were developed to initiate conversation within the hematologic community about quality of care in hematologic malignancies and other disorders. The dominant principle was to avoid harm, while taking into account evidence, cost, frequency, and scope of practice.
5 Ways to Reduce Waste
The following 5 items named by the task force represent an important step in trimming waste and reducing harm to patients with hematologic malignancies and other blood-related conditions.
- Limit scans in asymptomatic patients after curative-intent treatment for aggressive lymphoma. In this common malignancy, treatment with chemotherapy and radiotherapy carries the expectation of cure, “but the question is how best to monitor these patients,” said Joseph Connors, MD, Clinical Professor of Medical Oncology, University of British Columbia, Vancouver, Canada. “It is intuitively appealing to ‘hover’ over these patients to detect recurrences as soon as possible, but at the end of the day, ‘hovering’ can be counter-productive if the tests themselves are harmful. Use of computed tomography scanning and whole body scanning can be reduced and eliminated a short time after treatment,” Dr Connors said.
He noted that unnecessary scans are associated not only with physical harm (ie, radiation exposure) and psychological harm (ie, anxiety), but also with economic harm. Dr Connors estimated that the new recommendation could save the healthcare system in North America $1 billion over 10 years.
- Avoid the routine use of inferior vena cava filters in patients with acute venous thromboembolism. “Inferior vena cava filters [IVC] are costly, can cause harm, and do not have a strong evidence base,” said Mark Crowther, MD, MSc, Professor, Department of Medicine, McMaster University, Hamilton, Ontario, Canada. He noted that acute venous thromboembolism (VTE) is the main indication for IVC filters, and some lesser indications may be reasonable, such as some cases of pulmonary embolism (PE). Retrievable filters are recommended over permanent filters, with the removal of the filter when the risk of PE has resolved and/or when anticoagulation can be safely resumed. Dr Crowther estimated that only 10% of the 250,000 IVC filters inserted annually in the United States are currently being used appropriately.
- Do not transfuse more than the minimum number of red blood cell units necessary to relieve symptoms of anemia or to reach a safe hemoglobin range (7-8 g/dL in stable inpatients without heart disease). Clinical trials of red blood cell (RBC) transfusions have demonstrated that liberal transfusion strategies do not improve outcomes compared with the use of less blood (ie, a reduction from 10 g/dL to the range of 7-8 g/dL). “Using more generates higher costs and exposes patients to adverse effects,” said Jeffrey L. Carson, MD, Chief, Division of General Internal Medicine, Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, New Brunswick. “Avoid the routine use of 2 units of RBC if 1 is sufficient,” Dr Carson recommended.
- Avoid testing for thrombophilia in adults with VTE in the setting of major transient risk factors, such as surgery, trauma, or prolonged immobility. “Thrombophilia testing is costly and harmful if the duration of anticoagulation is inappropriately prolonged or incorrectly labeled as thrombophilic,” according to John A. Heit, MD, Professor of Medicine, Mayo Clinic, Rochester, MN. This recommendation for testing does not change the approach when this testing is known to be important.
- Do not administer plasma or prothrombin complex concentrates for the nonemergent reversal of vitamin K antagonists. “Many people are on Coumadin [warfarin] for stroke prevention, and there may be a need to reverse the effect of that drug, as well as a tendency to accomplish this as quickly as possible with plasma or prothrombin complex concentrates. However, there is little evidence that this benefits the patient, and it is adequate to hold the next dose of Coumadin or administer vitamin K instead,” said Robert Weinstein, MD, University of Massachusetts Medical School, Worcester, who added that unnecessary blood products also expose patients to potential harm.
“Results of multiple audits suggest that 30% of the 4 million units used each year are given inappropriately. That’s a lot of plasma,” Dr Weinstein noted, estimating that up to 200 unnecessary deaths could be avoided annually.