Developed as part of Choosing Wisely®, an initiative of the ABIM Foundation, the ASH Choosing Wisely list provides evidence-based recommendations in an effort to prompt conversations between patients and physicians about the necessity and potential harm of certain practices. The list was developed after months of careful data analysis and review, as well as input from the Society’s membership, using the most current evidence about management and treatment options. The list identifies the following five tests, treatments, and procedures that hematologists and their patients should question:
- 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).
Transfusion of the smallest effective dose of RBCs is recommended because liberal transfusion strategies do not improve outcomes when compared to restrictive strategies. Unnecessary transfusion generates costs and exposes patients to potential adverse effects without any likelihood of benefit. Clinicians are urged to avoid the routine administration of 2 units of RBCs if 1 unit is sufficient and to use appropriate weight-based dosing of RBCs in children.
- 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).
Thrombophilia testing is costly and can result in harm to patients if the duration of anticoagulation is inappropriately prolonged or if patients are incorrectly labeled as thrombophilic. Thrombophilia testing does not change the management of VTEs occurring in the setting of major transient VTE risk factors. When VTE occurs in the setting of pregnancy or hormonal therapy, or when there is a strong family history plus a major transient risk factor, the role of thrombophilia testing is complex and patients and clinicians are advised to seek guidance from an expert in VTE.
- Don’t use inferior vena cava (IVC) filters routinely in patients with acute venous thromboembolism (VTE).
IVC filters are costly, can cause harm and do not have a strong evidentiary basis. The main indication for IVC filters is patients with acute VTE and a contraindication to anticoagulation such as active bleeding or a high risk of anticoagulant-associated bleeding. Lesser indications that may be reasonable in some cases include patients experiencing pulmonary embolism (PE) despite appropriate, therapeutic anticoagulation, or patients with massive PE and poor cardiopulmonary reserve. Retrievable filters are recommended over permanent filters with removal of the filter when the risk for PE has resolved and/or when anticoagulation can be safely resumed.
- 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).
Blood products can cause serious harm to patients, are costly and are rarely indicated in the reversal of vitamin K antagonists. In non-emergent situations, elevations in the international normalized ratio are best addressed by holding the vitamin K antagonist and/or by administering vitamin K.
- Limit surveillance computed tomography (CT) scans in asymptomatic patients following curative-intent treatment for aggressive lymphoma.
CT surveillance in asymptomatic patients in remission from aggressive non-Hodgkin lymphoma may be harmful through a small but cumulative risk of radiation-induced malignancy. It is also costly and has not been demonstrated to improve survival. Physicians are encouraged to carefully weigh the anticipated benefits of post-treatment CT scans against the potential harm of radiation exposure. Due to a decreasing probability of relapse with the passage of time and a lack of proven benefit, CT scans in asymptomatic patients more than 2 years beyond the completion of treatment are rarely advisable.
For more information, please see the ASH Choosing Wisely list.
Choosing Wisely® is part of a multi-year effort led by the ABIM Foundation to support and engage physicians in being better stewards of finite health care resources. Participating specialty societies are working with the ABIM Foundation and Consumer Reports to share the lists widely with their members and convene discussions about the physician’s role in helping patients make wise choices. Learn more at www.ChoosingWisely.org.
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