Choosing Wisely Initiative Aims to Lower Cost, Improve Quality of Care

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To improve the quality of care in hematology, and to eliminate waste and reduce costs, ASH has embraced the Choosing Wisely initiative of the American Board of Internal Medicine Foundation.

The Institute of Medicine estimated that in 2009, some $750 billion was wasted in healthcare, of which $210 billion was spent on unnecessary healthcare services across all specialties, according to Lisa Hicks, MD, University of Toronto and St. Michael’s Hospital, Toronto, Canada, and chair of the ASH Choosing Wisely Task Force.

“If we could redirect even a fraction of this to real people with real unmet healthcare needs, think of the good that we can do,” she said.
Mark Crowther, MD, McMaster University in Hamilton, Canada, added, “The landscape in quality improvement is changing” as reimbursement is being tied to outcome measures, quality, and maintenance of certification. “With the initiation of the Affordable Care Act and onwards, clinical practice based on quality management will become more and more important,” he suggested.

The evidence-based recommendations were developed after a careful review of data by the ASH task force, followed by input from ASH members. The goal was to initiate conversation within the hematologic community about quality of care in hematologic malignancies and other disorders. The dominant principle of these recommendations was to avoid harm, while also taking into account evidence, cost, frequency, and scope of practice.

At a press briefing during ASH, members of the task force described the recommendations, which primarily targeted unnecessary treatments and testing.

“We need to take a step back and decide whether the tests and procedures we order are truly necessary,” Hicks said. “We need a conversation about cost and value.”

Five Recommendations
The 5 items named by the task force represent an important step in trimming waste and reducing harm to patients with hematologic malignancies and other blood-related conditions. They are:

1. Limit the use of CT scans in asymptomatic patients following curative-intent treatment for aggressive lymphoma.

In this common malignancy, treatment with chemotherapy and radiotherapy carries the expectation of cure, “but the question is how best to monitor these patients,” said Joseph Connors, MD, University of British Columbia, Vancouver, Canada.

“It is intuitively appealing to hover over these patients to detect recurrences as soon as possible, but at the end of the day hovering can be counterproductive if the tests themselves are harmful. Use of CT scanning and whole body scanning can be reduced and eliminated a short time after treatment,” he said.

Connors noted that unnecessary scans are associated not only with physical harm (ie, radiation exposure) and psychological harm (ie, anxiety) but also economic harm. He estimated that the new recommendation could save the healthcare system in North America $1 billion over 10 years.

2. Avoid the routine use of inferior vena cava (IVC) filters in patients with acute venous thromboembolism (VTE).

“IVC filters are costly, can cause harm, and do not have a strong evidence base,” said Mark Crowther, MD, McMaster University, Hamilton, Canada. He noted that acute VTE is the main indication for IVC filters, and some lesser indications may be reasonable – such as some cases of pulmonary embolism. Retrievable filters are recommended over permanent filters, with removal of the filter when the risk of pulmonary embolism has resolved and/or when anticoagulation can be safely resumed.

Crowther estimated that only 10% of the 250,000 IVC filters inserted each year in the United States are currently being used appropriately.

3. 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 safe hemoglobin range (7-8 g/dL in stable noncardiac inpatients).

Clinical trials of RBC transfusion have demonstrated that liberal transfusion strategies do not improve outcomes compared with the use of less blood, ie, a reduction from the 10 g/dL range to the range of 7 to 8 g/dL. “Using more generates higher costs and exposes patients to adverse effects,” said Jeffrey Carson, MD, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ. “Avoid the routine use of 2 units of RBC if 1 is sufficient,” he recommended.

4. Clinicians should not test for thrombophilia in adults with VTE occurring in the setting of major transient risk factors such as surgery, trauma, or prolonged immobility.

“Thrombophilia testing is costly and harmful if the duration of anticoagulation is inappropriately prolonged or incorrectly labeled as thrombophilic,” according to John Heit, MD, Mayo Clinic, Rochester, MN. This recommendation for testing does not change management occurring in the setting of certain factors for which it is known to be important.

5. Do not administer plasma or prothrombin complex concentrates for nonemergent reversal of vitamin K antagonists (ie, outside the setting of major bleeding, intracranial hemorrhage, or anticipated surgery).

“Many people are on coumadin for stroke prevention, and there may be a need to reverse the effect of that drug as well as a tendency to accomplish this as quickly as possible with plasma or prothrombin complex concentrates. However, there is little evidence that this benefits the patient, and it is adequate to hold the next dose of coumadin or administer vitamin K instead,” said Robert Weinstein, MD, University of Massachusetts Medical School, Worcester, who added that the use of unnecessary blood products also exposes patients to unnecessary potential harm.

“Results of multiple audits suggest that 30% of the 4 million units used each year are given inappropriately. That’s a lot of plasma,” Weinstein noted, estimating that up to 200 unnecessary deaths could be avoided each year in the United States if this recommendation was followed.

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