ASH Releases List of 5 Unnecessary and Potentially Harmful Tests

New Orleans—With more attention in healthcare focused on ways to control spending and improve health, industry professionals have spent the past few years reexamining delivery and payment methods and questioning the status quo. In April 2012, the American Board of Internal Medicine (ABIM) Foundation launched an initiative called Choosing Wisely^® that could help shape the future.

As part of the campaign, 46 major medical societies, representing dozens of specialties, have created lists of 5 common tests, treatments, and procedures that physicians and patients should evaluate and consider if they are useful on a case-by-case basis. Although the recommendations are not requirements, they are evidence-based and formed through the work of several experts in each medical discipline.

In early December, the American Society of Hematology (ASH) released its Choosing Wisely^® list and published the recommendations in Blood [2013;122(24):3879-3883]. The 11-person ASH task force examined 154 suggestions from 57 ASH committee members and implemented systematic reviews of the evidence pertaining to 10 suggestions for several months before submitting the final list to the ABIM Foundation.

“The practice of hematology is complex and changing quickly and has a strong basis in science and in evidence,” said Lisa Hicks, MD, the chair of ASH’s Choosing Wisely^® task force. “We knew that if we were going to create a list that would be impactful in our community, the science also had to be rigorous, so we took our time. We did not want to rush.”

At the ASH annual meeting, a committee member who helped select the list and other individuals who reviewed the items discussed each recommendation.

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

As part of his job at the Robert Wood Johnson Medical School in New Jersey, Jeffrey Carson, MD, reviews clinical trials. Dr. Carson, who has a particular interest in red blood cell transfusions, has found the smallest effective dose of red blood cells is most appropriate because giving more blood (typically in the 10 g/dL threshold range) does not improve outcomes compared with using less blood (usually in the 7-8 g/dL threshold range).

“Unnecessary transfusions generate costs and exposes patients to potential adverse effects without any likelihood of benefit,” Dr. Carson said. “High quality research has demonstrated that it is safe to use lower transfusion thresholds, and therefore, when extra blood is given you are exposing patients to unnecessary transfusion, which can be harmful.”

Dr. Carson also suggested clinicians avoid administering 2 units of red blood cells if 1 unit is enough and recommended weight-based dosing for red blood cells in children.

2. Do not test for thrombophilia in adult patients with venous thromboembolism (VTE) occurring in the setting of major transient risk factors (surgery, trauma, or prolonged immobility).

VTE, blood clots in the veins that can be serious and fatal, consist of deep vein thrombosis and pulmonary embolism. John Heit, MD, said there are 2 major genetic mutations (factor V leiden and prothrombin gene mutation) known as inherited thrombophilia that predispose people to blood clots.

Still, the ASH Choosing Wisely^® task force found that testing for thrombophilia is expensive and does not alter the management of the disease before or after treatment of patients with VTE and a transient risk factor.

“Thrombophilia testing is costly, and it can result in harm to patients if the duration of anticoagulation is inappropriately prolonged or if patients are incorrectly labeled as thrombophylic,” said Dr. Heit, former director of the Mayo Clinic’s thrombophilia center.

Pregnant women, patients receiving hormonal therapy and people with a family history of VTE should consult with their doctors before undergoing thrombophilia testing, according to Dr. Heit.

3. Do not use inferior vena cava (IVC) filters routinely in patients with VTE.

Of the approximately 250,000 IVC filters used in the United States each year, fewer than 10% are inserted in patients who have an approved indication for their use, according to Mark Crowther, MD. The filters are expensive, costing between $10,000 and $20,000 to insert and a similar range to remove. They are also small and inserted using a catheter through a blood vessel in the leg, which can reduce the frequency of pulmonary embolism, although patients can suffer from leg fractures if the filters are not removed in time or removed correctly.

Other than for people with acute blood clots who cannot receive blood thinners, IVC filters should not be used, according to Dr. Crowther. Instead of inserting IVC filters, he said the standard of care to prevent pulmonary embolism should be using blood thinners that are common, inexpensive, and effective.

“For the vast majority of settings in which [IVC filters] are inserted, there is simply no evidence that they are effective,” Dr. Crowther said.

4. Do not administer plasma or prothrombin complex concentrates for nonemergent reversal of vitamin K antagonists (ie, outside of the setting of major bleeding, intracranial hemorrhage, or anticipated emergent surgery).

To prevent VTE or stroke, patients are typically prescribed vitamin K antagonists. If patients fall or experience other trauma or are accidentally over-treated, they may be given plasma to reverse the effects of vitamin K antagonists. However, Robert Weinstein, MD, said that evidence does not indicate plasma reverses the effects of the drugs and suggested withholding the next dose or using a vitamin in these circumstances.

“When you administer blood products in a setting where there is no demonstrable benefit, all you do is expose the patient to harm,” said Dr. Weinstein, chief of the division of transfusion medicine at the University of Massachusetts Memorial Medical Center. “It does not really matter what drug you are trying to reverse or why you are giving them plasma. If there is no potential benefit, you should not give it.”

Dr. Weinstein noted that approximately 30% of the 4 million units of plasma transfused each year are inappropriately administered to reverse the effect of vitamin K antagonists in nonemergency settings. If patients received vitamins instead, Dr. Weinstein estimates that 100 to 200 unnecessary deaths associated with the adverse effects of plasma could be prevented in the United States.

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

For more than 50 years, the incidence of lymphoma has increased. With the population increasing and longer life spans, the number of lymphoma cases doubles in North America every 15 to 20 years, according to Joseph Connors, MD, acting head of the division of medical oncology at the University of British Columbia.

Dr. Connors and other members of the task force believe that using CT scans and whole body scans should be reduced and eliminated shortly after completing treatment rather than continuing to scan for several years, which is now common. Even when lymphoma spreads through the body, Dr. Connors said most patients could be cured through chemotherapy and radiation.

He added that scanning causes unnecessary anxiety in people and that the rate of false positivity in CT scans is consistent even though the risk of lymphoma recurring is decreasing. Further, 1 in 300 patients develop cancer because of radiation associated with scanning.

If the industry follows this recommendation, Dr. Connors said a “very reasonable estimate” is that the healthcare system in North America could save more than $1 billion over 10 years.

Next steps for ASH and Choosing Wisely^®

Although the Choosing Wisely^® campaign only requested a list of 5 recommendations, the task force included a sixth suggestion in the Blood article: do not diagnose or initiate treatment of lymphoma on the basis of tissue obtained exclusively with fine needle aspiration. Dr. Hicks said there are unnecessary tests, treatments, and procedures conducted in additional areas of hematology, but ASH has not decided if it will publish a list of more suggestions.

“If you look at the genesis of the Choosing Wisely^® campaign, the intention was to really go after what was described as the low hanging fruit, the things that were really the most obvious and the most evidence-based where we thought we could make the biggest impact,” Dr. Hicks said. “There is opportunity to address other things.”

In addition to participating in the Choosing Wisely^® campaign, ASH is developing evidence-based guidelines to improve the quality of care, which will likely influence insurance companies and other payers.

“Payers are looking for guidance about what they are going to support and what they are not going to support,” Dr. Crowther said. “Having a recommendation for or against something in the form of a guideline will inevitably have an influence on how and why payers provide reimbursement for specific items.”