choosing wisely–hematology

as many as you know, several of the medical professional organizations have submitted a list of 5 suggestions which they feel would decrease the use of unnecessary tests or treatments.  the most recent addition is from the American Society of Hematology, which I am circulating even though I'm not sure it's really helpful (they are focusing on very low hanging fruit). see choosing wisely hematology 2013 in dropbox, or http://bloodjournal.hematologylibrary.org/content/122/24/3879.full.pdf+html. in brief,

--In situations where RBC transfusions are necessary, transfuse the minimum number of units required to relieve symptoms of anemia or return the patient to a safe hemoglobin range (7-8 g/dL in stable noncardiac in-patients)  -- [transfusing more than is necessary does not improve outcomes and increases the potential risk]

--do not test for thrombophilia in adult patients with venous thromboembolism occurring in the setting of major transient risk factors (e.g. surgery, trauma, or prolonged immobility) -- [the correlation between positive tests of thrombophilia and actual clinical events is quite imperfect, with a lot of false positives.  Therefore, testing when not clinically indicated may lead to inappropriately prolonged duration of anticoagulation]

--Do not use inferior vena cava filters routinely in patients with acute venous thromboembolism -- although there are indications for IVC filters (eg acute venous thromboembolism with a contraindication to anticoagulation, PE despite appropriate therapeutic anticoagulation, and massive PE with poor cardiopulmonary reserve), there is no evidence of their utility for primary prophylaxis of a PE.  There was a recent report of 6000 patients undergoing bariatric surgery which found that prophylactic IVC filters actually increased the risk of death or disability. When IVC filters are indicated, it is recommended that retrievable filters are used and should be removed if the risk for PE has resolved]

--do not administer plasma or prothrombin complex concentrates for nonemergent reversal of vitamin K antagonists (i.e. outside of the setting of major bleeding, intracranial hemorrhage, or anticipated emergent surgery) -- [aggressive reversal of the effects of vitamin K antagonist is both costly and potentially harmful.  For non-bleeding patients with an INR greater than 10, even though there are no randomized control trials, these patients can usually be managed safely by administering small doses of vitamin K rather than blood products]

--limit surveillance CT scans in asymptomatic patients after curative-intent treatment for aggressive lymphoma -- [as noted in a plethora of prior emails/blogs, CT scans are not benign since the attendant radiation may well increase the risk of malignancy over the long-term.  Review of the literature shows no survival benefit from surveillance CT scans of asymptomatic aggressive non-Hodgkin's lymphoma survivors.  Relapses are heralded in general by clinical symptoms.  There is no evidence of a survival benefit if a relapse is detected on a routine scan]