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ASH "Choosing Wisely Champions" Share Their Practice-Changing Success

Surabhi Dangi-Garimella, PhD
At the 2016 annual meeting, the American Society of Hematology introduced the “Choosing Wisely Champions” to recognize the efforts of practitioners who are working to eliminate costly and potentially harmful overuse of tests and procedures.
Don’t 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, noncardiac in-patients).1

“Transfusions do not necessarily improve outcomes; rather, they can increase care costs and expose patients to unnecessary harm,” Juarez said.

“Our goal was to optimize PRBC, or packed red blood cell, utilization and develop a system-wide set of recommendations on the use of blood-based products.” The team then developed and shared system-wide guidelines on RBC transfusion. “Our intent was to modify the practice in the emergency department, with order sets configured for clinical decision support.”

Their goal was to achieve a 20% reduction overall, and they ended up with a 27% reduction across the network. “Two hospitals within our network individually achieved a 35% reduction,” she said.

Juarez told the audience that their project has been carried over as a system goal into 2017. “Guidelines have been developed for platelets, [fresh frozen plasma], and cryoprecipitate, and we hope to develop a system-analysis tool in parallel as well.” The reason for our success was persistence, she emphasized.

The final presentation was by Javier Munoz, MD, Banner MD Anderson Cancer Center, Gilbert, Arizona, who spoke about their project during “Reduction of Post-Treatment Scanning Using EMR Alerts.” This project stemmed from recommendation 5 by ASH:

Limit surveillance computed tomography (CT) scans in asymptomatic patients following curative-intent treatment for aggressive lymphoma.1

“Most patients with relapsed aggressive lymphomas are diagnosed outside of planned follow-up with scheduled imaging,” Munoz said. “Imaging is costly and unnecessarily exposes asymptomatic patients to radiation, which builds up over time.”

According to the National Comprehensive Cancer Network Guidelines, patients with stage 3 or 4 diffuse large B-cell lymphoma should undergo a CT scan every 6 months for 2 years and then yearly if needed, he said. Particularly for Hodgkin lymphoma, CT should not be done routinely because it can lead to false-positives, he added.

“To bring about this system and behavior change, our hypothesis was that a combination of provider education and automatic EHR alerts could stop physicians from sending a patient for unnecessary scans,” Munoz said. Their team developed the following clinical practice statement: limit surveillance in asymptomatic patients with lymphoma. They engaged both providers and patients to raise awareness and implement changes, he said.

“Our preliminary results found that automatic alerts generated within the EHR may decrease imaging,” Munoz said, adding, “Education is definitely important for the success of such system-wide projects.”  

REFERENCES
  1. Ten things physicians and patients should question. Choosing Wisely® website. http://www. choosingwisely.org/societies/american-society-of-hematology/. Accessed December 9, 2016.
  2. Shen YM, Tsai J, Taiwo E, et al. Analysis of thrombophilia test ordering practices at an academic center: a proposal for appropriate testing to reduce harm and cost. PLoS One. 2016;11(5):e0155326. doi: 10.1371/journal.pone.0155326.
Choosing Wisely Champions" Share Their Practice-Changing Success"> PDF
 
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