The American Society of Hematology (ASH) recognized three Choosing Wisely® Champions, practitioners working to tackle the overuse of hematology tests and treatments, at its 2019 Annual Meeting & Exposition in Orlando: Stephen L. Wang, MD, of Kaiser Permanente Santa Clara Medical Center, Santa Clara, California; Rachael Grace, MD, of Dana-Farber/Boston Children’s Cancer and Blood Disorders Center; and Jordan Schaefer, MD, of the University of Michigan, Ann Arbor.
Stephen L. Wang, MD
Rachael Grace, MD
Jordan Schaefer, MD
Choosing Wisely is a program of the American Board of Internal Medicine (ABIM) Foundation and Consumer Reports that aims to prompt conversations between patients and clinicians about the necessity and potential harm of certain procedures. As a part of this initiative, 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. Choosing Wisely Champions, an initiative of the ABIM Foundation, recognizes clinicians who have implemented successful projects to improve quality at their institutions and advance the goals of the campaign.
Focus of Projects
- “Reduction in Inferior Vena Cava Filter (IVCF) Utilization and Increase in IVCF Retrievals” by Dr. Wang. A total of 14 CME-approved in-hospital grand rounds covering evidence-based review of the inferior vena cava filter efficacy, guidelines, and complications were performed at 14 medical centers across a large U.S. health-care region. Physician attendance was recorded, and a computer-based inferior vena cava filter tracking system was deployed simultaneously. The use, rates of retrieval, and fulfillment of guidelines were evaluated for 12 months, before and after intervention. Following this educational campaign, inferior vena cava filter utilization was decreased, and inferior vena cava filter retrieval was increased. This project focuses on education to change long-held practice patterns and leveraging new technology to improve tracking and follow-up of these potentially risky devices.
- “Recommendations for Newly Diagnosed Children with Immune Thrombocytopenia” by Dr. Grace. The recommendation for an observational approach in newly diagnosed children with immune thrombocytopenia that was highlighted in the 2014 ASH Choosing Wisely Campaign has been adopted by Boston Children’s Hospital, with some variations proving to be highly effective in aiding management and treatment decisions for this population. A modifiable practice guideline was established in 2012; since its inception, it has unified the center’s initial laboratory approach, pharmacologic treatment, and timing of follow-up for all newly diagnosed children with immune thrombocytopenia. When no impact on observation rates was made, a second iteration of the guideline was implemented. This version was modified to stratify low- and high-risk grade 3 bleeding. With this change, observation rates have increased from 40% to 74%, with no increase in bleeding complications. A toolkit for this project includes the management algorithm for newly diagnosed children with immune thrombocytopenia, data-collection forms, and the elements of a REDCap database.
- “Warfarin Monotherapy in Place of Combination Therapy of Aspirin and Warfarin” by Dr. Schaefer. Because guidelines advocate for warfarin monotherapy rather than combination therapy with warfarin and aspirin, the Michigan Anticoagulation Quality Improvement Initiative (MAQI2) implemented a common intervention to reduce the inappropriate use of aspirin. Each of the six participating sites used a tailored screening process to identify potential inappropriate aspirin use based on an agreed-upon set of criteria. If the indication for a patient’s aspirin use was unclear or potentially inappropriate, the primary care provider was alerted to prompt a discussion about the patient’s aspirin use. To allow for local tailoring of the intervention, the various sites differed in the personnel carrying out the intervention, how technology was used, and how providers were contacted. Monthly assessments of inappropriate aspirin use were conducted, and an “Anticoagulation Toolkit” has been developed. ■
