ASH to Recognize Choosing Wisely Champions and Guideline Implementation Champions

(WASHINGTON, Dec. 9, 2022) – The American Society of Hematology (ASH) will recognize three Choosing Wisely® Champions working to tackle the overuse of hematology tests and treatments at the 64th ASH Annual Meeting and Exposition, December 10-13 in New Orleans, Louisiana. ASH will also honor three Guideline Implementation Champions, a new ASH initiative recognizing practitioners working to implement evidence-based guideline recommendations in their clinical settings.

Choosing Wisely is an initiative of the ABIM Foundation that seeks to advance a national dialogue on avoiding unnecessary medical tests, treatments, and procedures. ASH has identified 15 commonly used tests, treatments, and procedures in hematology that clinicians and patients should question in certain circumstances to avoid overuse, waste, and harm. Guideline Implementation Champions is an ASH initiative, newly established this year, that seeks to facilitate the use of the ASH clinical practice guidelines. Both programs recognize clinicians who have implemented successful projects in their practice, institution, or hospital system, and they provide clinicians, administrators, and other medical professionals opportunities to learn about projects that might be translated to their own practices.

The three ASH Guideline Implementation Champions will speak at a Special-Interest Session on Sunday, December 11, and the three ASH Choosing Wisely Champions will speak at a Special-Interest Session on Monday, December 12. During these annual meeting sessions, the Society will recognize the champions’ efforts and offer attendees the opportunity to ask questions and learn about strategies for implementing similar projects into their own practices.

The 2022 ASH Choosing Wisely Champions are:

Carol M. Mathew, MD (University of Florida)
Reducing Unnecessary Pre-medication Prior to Parenteral Iron Therapy

Intravenous (IV) iron administration carries risks of patient reactions, ranging from mild infusion reactions to life-threatening anaphylaxis. Often providers try to mitigate these risks by prescribing pre-medications prior to iron administration. However, the benefit of pre-medication use is unclear. Dr. Mathew and her colleagues noticed that the use of pre-medications varied across different providers, so they worked to implement a process for reducing unnecessary use. They educated hematology faculty, advanced practice providers, and fellows in a presentation highlighting current evidence against universal administration of pre-medications. They also amended the IV iron informed consent form to improve patient education about possible reactions, and revised their electronic order system so that the pre-medications were no longer the default, but rather had to be specifically ordered by providers. The interventions led to a decrease in the percentage of low-risk patients who received the pre-medications (79% pre-intervention compared to 65% post-intervention).

Kamal Kant Sahu, MD (Huntsman Cancer Institute, University of Utah)
Implementation of New Electronic Medical Record Algorithm to Streamline the Appropriate Use of Rasburicase

Tumor lysis syndrome, an emergency condition that occurs when cancer cells rapidly die off and release their contents into the bloodstream, is typically treated with rasburicase, a medication to help clear uric acid from the blood. Dr. Sahu and his team noticed a lack of consistent, evidence-based use of rasburicase in clinical practice. To reduce inappropriate rasburicase orders, Dr. Sahu’s team changed the electronic medical record system, so that rather than a one-click order, the order was multi-click and followed a guideline-based algorithm to prompt providers to double check the appropriateness of rasburicase prescription for each patient. As a result of the intervention, clinicians following the appropriate guidelines in prescribing rasburicase improved from 67.74% to 88.96%. The work showed that inappropriate rasburicase use could be significantly reduced by incorporating a multistep, algorithm-based order set.

Daanish Hoda, MD (Intermountain Healthcare, LDS Hospital)
Decreasing the rate of Clostrididoides difficile infection (CDI) overdiagnoses and treatment by instituting an algorithm for clinicians to follow prior to testing

A hospital-acquired Clostridioides difficile infection (CDI) is typically diagnosed in the presence of diarrhea associated with a positive stool test for CD toxin and/or toxin genes. However, people in inpatient care, including those receiving hematopoietic stem-cell transplant (HSCT) may be overdiagnosed with CDI given that they are more likely to experience diarrhea and CD colonization during their hospital stay and treatment. Overdiagnosis and treatment of CDI leads to unnecessary costs and toxicities, so Dr. Hoda and team created an algorithm to address the issue. After the algorithm was put into use, the incidence of stool submissions for CD analysis decreased from 36.6/1000 inpatient days to 20.6/1000. Furthermore, the number of CDI diagnosed and treated decreased from 5.5 to 2.4/1000 inpatient days.

The 2022 ASH Guideline Implementation Champions are:

W. Andrés Vásconez Samaniego, MD (Jackson Memorial Medical Center, University of Miami/Holtz Children’s Hospital)
Reducing time to analgesia in the care of Sickle Cell Disease vaso-occlusive events

Dr. Vasconez Samaniego and colleagues investigated the average time to delivery of first dose of pain-relief medicine among individuals living with sickle cell disease (SCD) who were treated in the pediatric emergency department of University of Miami/Holtz Children’s Hospital at Jackson Memorial Medical Center, and found it was higher than the national average. They used current guidelines from ASH and the National Heart Lung Blood Institute to streamline pain management in the hospital. Following current evidence-based medicine, a multi-disciplinary team assisted health care providers in delivering optimal care to patients with SCD vaso-occlusive episodes. As a result, time-to-first-analgesic-dose was reduced by 47%, meaning that many young patients with SCD were able to receive more timely treatment.

Jordan Schaefer, MD, FACP (University of Michigan, Ann Arbor, Michigan)
Reducing Excess Aspirin Use Among Patients on Chronic Anticoagulation for Venous Thromboembolic Disease

The ASH Guidelines for the Management of Venous Thromboembolism (VTE) suggest that aspirin use for either primary prevention of cardiovascular disease or treatment of stable coronary artery disease can be suspended while the patients are taking anticoagulant therapy. Dr. Schaefer and colleagues in the Michigan Anticoagulation Quality Improvement Initiative (MAQI2) participated in a quality improvement project between October 2017 and June 2018 at six clinical sites. They implemented the ASH guideline recommendation to reduce excess aspirin use among patients receiving anticoagulants for VTE, and they sustained this effort over several years. Having followed thousands of warfarin-anticoagulated patients with VTE, they have shown a more than 40% reduction in excess aspirin use. Across MAQI2, reduced aspirin use was associated with lower rates of bleeding without an observed increase in thrombosis. Similar interventions have recently been implemented at several other medical centers.

Jori E. May, MD (University of Alabama at Birmingham)
Improving the Diagnosis and Management of Heparin Induced Thrombocytopenia (HIT) with Automatic Electronic Consultation

Dr. May and colleagues observed frequent deviation from guideline-supported care in patients with suspicion for, and confirmed, heparin-induced thrombocytopenia (HIT). They developed an electronic consultation system to consult hematologists when patients had a positive screening immunoassay for HIT. Through this e-consult, the hematologist would review the patient medical record (without contacting the patient) and communicate recommendations to the treatment team. Automatic e-consult for patients with suspected or confirmed HIT improve adherence to ASH guidelines and improved care outcomes: namely, there was a significant decline in hospital-wide use of bivalirudin and an increase in the use of oral factor Xa inhibitors and fondaparinux in appropriate patients. In patients with confirmed HIT, length of hospital stays decreased because of the intervention, from 39 days to 17 days.

The American Society of Hematology (ASH) (www.hematology.org) is the world’s largest professional society of hematologists dedicated to furthering the understanding, diagnosis, treatment, and prevention of disorders affecting the blood. For more than 60 years, the Society has led the development of hematology as a discipline by promoting research, patient care, education, training, and advocacy in hematology. ASH’s flagship journal, Blood (www.bloodjournal.org), is the most cited peer-reviewed publication in the field, and Blood Advances (www.bloodadvances.org) is the Society’s online, peer-reviewed open-access journal.

Contact:
Leah Enser, American Society of Hematology
lenser@hematology.org; 202-552-4927