5 Hematology Procedures that should Stop

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The American Society of Hematology (ASH) has issued a list of 5 hematologic tests and/or procedures that should not be continued, or that should be used less than they currently are.

The complete list was published online December 4 in the journal Blood. It is part of the Choosing Wisely campaign spearheaded by the American Board of Internal Medicine Foundation that aims to reduce wasteful practices.

Red blood cell transfusion – use smallest effective dose: 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 inpatients). Liberal transfusion strategies do not improve outcomes, compared with restrictive strategies. Clinicians are urged to avoid the routine administration of 2 units of RBCs if 1 unit is sufficient, and to use appropriate weight–based dosing of RBCs in children.
Limit use of thrombophilia testing: Thrombophilia testing involves a series of blood tests that are carried out on patients who develop venous thromboembolism (VTE) for no apparent reason to check if the patient has protein deficiencies or genetic abnormalities that are involved in blood clotting. The new recommendation is not to use the test in adults with VTE that occurs in the setting of major transient risk factors such as surgery, trauma, and prolonged immobility. If a VTE occurs in a patient who has just undergone surgery, the clot is very likely to be due to the surgery, and even if this patient had a thrombophilia test, it would not change the way the VTE would be treated. Thrombophilia testing is costly. It can result in harm to patients if the duration of anticoagulation is inappropriately prolonged or if patients are incorrectly labeled as thrombophilic (which could influence subsequent insurability). In addition, thrombophilia testing does not change the management of VTEs occurring in the setting of major transient VTE risk factors. One caveat to the above recommendation is when VTE occurs in the setting of a major risk factor but in patients who also have additional risk factors such as pregnancy, concurrent exposure to hormonal therapy, or when there is a strong positive family history. In these cases, the role of thrombophilia testing is complex and patients and clinicians are advised to seek guidance from an expert in VTE.
Stop routine use of inferior vena cava filters in acute VTE: IVC devices are used in some patients with acute VTE in order to prevent a clot from reaching the lungs and causing a pulmonary embolism, which is fatal in about 1 out of 10 cases. The idea with these devices, which look like a small upside down umbrella, is that they sit in the large blood vessel below the heart and catch clots that break off from the long veins in the legs, before they lodge in the lungs. IVC filters are costly, can cause harm and do not have a strong evidentiary basis.
Limit use of plasma/PCCs to emergencies: This recommendation concerns the use of plasma or prothrombin complex concentrates (PCC) to reverse immediately the anticoagulation effects of vitamin K antagonists such as warfarin. These products should not be used outside of emergency situations, such as patients presenting with major bleeding or intracranial hemorrhage or for whom emergency surgery is anticipated — for example, after a trauma or accident. These plasma and PCCs can cause serious harm to patients, are costly, and are rarely indicated in the reversal of vitamin K antagonists, the society comments.
Limit CT surveillance of lymphoma after curative therapy: The full recommendation is “limit the use of CT scans in asymptomatic patients following curative–intent treatment for aggressive lymphoma.” A lymphoma patient who has undergone curative–intent treatment and is now in remission typically goes back to the oncology/hematologist every 3 to 6 months for a check-up. What ASH is suggesting is that, particularly for patients who have been in remission and have been asymptomatic out to 2 years, for most of the time, routine CT scans are not required,” she said. In these cases, the potential negative consequences would outweigh any benefit.

Basis of Lymphoma Diagnosis

This final shortlist of 5 practices was whittled down from around 20 that were considered in great detail. One of the practices that nearly made it onto the shortlist, but didn’t, concerns procedures used in the diagnosis of lymphoma. The recommendation was that a diagnosis of lymphoma should be based on excisional biopsies, and clinicians should not initiate treatment of lymphoma based of tissue obtained exclusively from fine-needle aspirations.