American Society of Hematology

Choosing Wisely

Choosing Wisely® is a multi-year effort led by the ABIM Foundation to support and engage physicians in being better stewards of finite health care resources. As part of Choosing Wisely, ASH and other medical societies have developed evidence-based recommendations to prompt conversations between patients and clinicians about the necessity and potential harm of certain procedures. In 2016, ASH introduced the Choosing Wisely Champions initiative to recognize the efforts of practitioners who are working to eliminate costly and potentially harmful overuse of tests and procedures.

The ASH Choosing Wisely List

The ASH Choosing Wisely list provides 10 recommendations. The first five were released in 2013 and highlighted in a manuscript published in Blood. With input from the Society's membership, the recommendations represent months of careful data analysis and review, and use the most current evidence about management and treatment options.

In 2014, the list was updated to include five additional commonly used tests, treatments, and procedures in hematology that physicians and patients should question in certain circumstances. A December 2014 manuscript published in Blood highlights these “tests and treatments to question" and further describes the methods in development of the list, along with the evidentiary basis of the recommendations.

The ASH Choosing Wisely recommendations include:

  1. Do not 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, non-cardiac, in-patients).
  2. 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).
  3. Don't use inferior vena cava (IVC) filters routinely in patients with acute venous thromboembolism (VTE).
  4. Don't administer plasma or prothrombin complex concentrates for non-emergent reversal of vitamin K antagonists (i.e. outside of the setting of major bleeding, intracranial hemorrhage or anticipated emergent surgery).
  5. Limit surveillance computed tomography (CT) scans in asymptomatic patients following curative-intent treatment for aggressive lymphoma.
  6. Don't treat with an anticoagulant for more than three months in a patient with a first venous thromboembolism occurring in the setting of a major transient risk factor.
  7. Don't routinely transfuse patients with sickle cell disease for chronic anemia or uncomplicated pain crisis without an appropriate clinical indication.
  8. Don't perform baseline or routine surveillance computed tomography (CT) scans in patients with asymptomatic, early stage chronic lymphocytic leukemia.
  9. Don't test or treat for suspected heparin-induced thrombocytopenia (HIT) in patients with a low pre-test probability of HIT.
  10. Don't treat patients with immune thrombocytopenic purpura in the absence of bleeding or a very low platelet count.

In support of the Choosing Wisely initiative, the ASH Choosing Wisely Task Force has produced an educational presentation to serve as a companion to the ASH Choosing Wisely list. The presentation describes in detail how the list was created, and the underlying evidence supporting the recommendations. The presentation can be downloaded as a PowerPoint slide deck or a PDF document for printing. Members are encouraged to use the presentation and share it among colleagues.

Non-ASH Choosing Wisely Recommendations Relevant to Hematology

Recognizing the immense benefit of collaboration between medical societies, and to avoid duplicating the efforts of other medical societies taking part in the ABIM Foundation's Choosing Wisely campaign, ASH released a list of hematology-related tests and procedures to question based on recommendations from other medical societies taking part in the initiative.

Using a rigorous methodology, the ASH Choosing Wisely Task Force scored 400 recommendations for relevance and importance over a series of iterations, resulting in this list of five items deemed to be especially useful to hematologists. As with past ASH lists, harm avoidance was once again established as the campaign's preeminent guiding principle, with cost, strength of evidence, frequency, relevance, and impact serving as additional factors.

The five Choosing Wisely recommendations being promoted to hematologists include:

  1. Don't image for suspected pulmonary embolism (PE) without moderate or high pre-test probability of PE. — American College of Radiology
  2. Don't routinely order thrombophilia testing on patients undergoing a routine infertility evaluation. — American Society for Reproductive Medicine
  3. Don't perform repetitive complete blood count (CBC) and chemistry testing in the face of clinical and lab stability. — Society for Hospital Medicine — Adult Hospital Medicine
  4. Don't transfuse red blood cells for iron deficiency without hemodynamic instability. — American Association of Blood Banks
  5. Avoid using positron emission tomography (PET) or PET-CT scanning as part of routine follow-up care to monitor for a cancer recurrence in asymptomatic patients who have finished initial treatment to eliminate the cancer unless there is high-level evidence that such imaging will change the outcome. — American Society of Clinical Oncology
Download a PDF brochure listing the ASH and non-ASH recommendations.

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