ASH offers 5 Choosing Wisely recommendations for unnecessary hematology tests, procedures

Since 2012, the American Board of Internal Medicine Foundation’s Choosing Wisely initiative has been shining a spotlight on the important issue of unnecessary medical testing, procedures and practices. As part of this eye-opening effort, various medical associations have formulated and submitted their lists of practices within their fields that might be overused or unnecessary.

In its list, the American Society of Hematology (ASH) placed a special emphasis on tests, procedures and treatments which, if overused, would have the potential to increase the risk of harm to patients.

According to ASH’s Choosing Wisely chair Lisa Hicks, MD, of St. Michael’s Hospital and the University of Toronto, unnecessary tests and treatments are sometimes an intended outcome of innovation.

“Hematology is a specialty with many new and increasingly expensive tests and treatments. While these new diagnostic and treatment strategies represent important advances, there is also potential to pose significant harm and cost to patients if over- or misused,” Hicks said in a press release. “The ASH Choosing Wisely list serves as a reminder to hematologists to take a step back and question whether certain routinely used procedures are really necessary, and to gradually change their practices to maximize the value of care.”

HemOnc Today presents ASH’s list of tests, procedures and treatments that might not warrant routine use.

1. Surveillance CT scans in asymptomatic aggressive lymphoma patients after treatment.

In asymptomatic patients in remission from aggressive non-Hodgkin lymphoma surveillance through CT scans may introduce a small but mounting risk of radiation-induced malignancy. Moreover, ASH’s Choosing Wisely list notes that CT surveillance is expensive and has not been found to extend survival.

2. Transfusions exceeding the minimum units of red blood cells (RBC) to achieve relief from anemia or restore a safe hemoglobin range.

According to ASH’s list, transfusing liberally does not yield better outcomes than conservative strategies, and may expose patients to adverse effects. ASH therefore recommends using the minimum dose of RBCs required to achieve a hemoglobin range of 7 to 8 g/DL in hospitalized patients who are stable and without cardiac issues.

3. Testing for thrombophilia in adult patients with venous thromboembolism presenting with major transient VTE risk factors.

In addition to potentially causing risks to venous thromboembolism (VTE) patients if anticoagulation is extended or if a patient is misdiagnosed as thrombophilic, thrombophilia testing does not alter the course or duration of treatment in VTE patients with major transient risk factors. Major transient risk factors are defined as major surgery, trauma or prolonged immobility.

4. Routine use of inferior vena cava filters in patients with venous thromboembolism.

ASH points out that there is no strong evidence to support the routine use of inferior vena cava (IVC) filters in patients with venous thromboembolism (VTE), and that they are costly and potentially harmful to VTE patients. According to the ASH list, IVC filters are primarily indicated for patients with acute VTE with active bleeds or high bleeding risks that would preclude the use of anticoagulants.

5. Non-emergency use of plasma of prothrombin complex concentrates to reverse vitamin K antagonists.

Except in cases of major bleeding, intracranial hemorrhage, or the expectation of emergency surgery, the ASH list noted that plasma and prothrombin complex concentrates can have serious harmful effects and are infrequently indicated for vitamin K protagonist reversal.