As part of the ABIM Foundation’s Choosing Wisely® initiative, the American Society of Hematology (ASH) annually recognizes practitioners who have successfully implemented quality improvement projects at their institution that reduce unnecessary tests, treatments, and procedures and improve patient care outcomes.
This year, three Choosing Wisely Champions will present their projects and findings at the 65th ASH Annual Meeting and Exposition, to be held in San Diego from December 9-12. Read on to learn more about these individuals, their projects, and what you can expect at the annual meeting’s Choosing Wisely Champions session.
Five-Year Outcomes of an Outpatient Chemotherapy Model
Luluh Bin Dayil, MSN
In recent years, there has been an increasing shift toward administering intensive chemotherapy on an outpatient basis, rather than in the traditional inpatient setting, because of potential improvements in patients’ quality of life and reductions in hospital resource use. In 2018, Luluh Bin Dayil, MSN, and her colleagues at King Abdulaziz Medical City in Saudi Arabia decided to implement an outpatient treatment model for patients with hematologic neoplasms receiving intensive chemotherapy.
Using the Plan-Do-Study-Act quality improvement methodology, the team retrospectively reviewed records of patients who had received inpatient chemotherapy from 2016 to 2017. Process mapping was then used to design interventions to facilitate the outpatient delivery of chemotherapy. These interventions included establishing an outpatient chemotherapy clinic, creating clinical pathways for chemotherapy protocols, developing educational materials for patients and health care staff, and facilitating access to emergency care services. From 2018 to 2022, patients were prospectively identified and enrolled to receive outpatient chemotherapy.
Although the project has achieved several successes, the team did encounter challenges along the way. “Patients receiving intensive chemotherapy are profoundly immunosuppressed; therefore, fever (as a sign of sepsis) has to be treated promptly,” Ms. Bin Dayil explained. “A major challenge was ensuring immediate access to specialized medical care, which [we overcame] by creating emergency beds in the inpatient unit with direct access for such patients.”
After five years, the implementation of such interventions has resulted in improved patient safety outcomes, enhanced patient satisfaction, and an estimated $2.88 million in savings. “Although carrying out this project required major efforts in rewriting chemotherapy protocols, creating an outpatient intensive chemotherapy clinic, and many other strategies to ensure safety, it surely paid off by improving patient satisfaction, saving beds, and leading to better outcomes,” Ms. Bin Dayil said.
Treatment Algorithm for Abnormal Uterine Bleeding
Alessandra Ferrajoli, MD
Among patients with hematologic malignancies, abnormal uterine bleeding can lead to recurrent vaginal bleeding and an increased need for blood transfusions. Alessandra Ferrajoli, MD, and her colleagues at the University of Texas MD Anderson Cancer Center in Houston recognized that clinicians there weren’t following the same procedures when caring for patients with abnormal uterine bleeding.
“This project originated from the identification of lack of a uniform approach to prevention and treatment of abnormal uterine bleeding in patients with hematologic malignancies,” Dr. Ferrajoli said. To standardize treatment approaches and improve patient outcomes, the team undertook a project to create an algorithm to help guide clinicians to the administration of leuprolide with or without oral contraceptive pills (OCPs).
The group then worked to review all available literature and seek out content matter experts to ensure that the algorithm’s recommendations were evidence-based. Once the clinical management algorithm was finalized, an educational initiative was launched to disseminate the information to the clinical teams working with these patients. Additionally, Dr. Ferrajoli noted, the algorithm is available to everyone through the MD Anderson website, and it could be a particularly useful resource for trainees across several different specialties, including obstetrics, gynecology, hematology, and oncology.
To date, Dr. Ferrajoli and the team have seen substantial improvements in patient care. After the algorithm’s implementation, the percentage of patients with hematologic malignancies receiving leuprolide increased from 19.2% to 30.3%. Furthermore, in patients who had undergone an allogeneic hematopoietic cell transplant, the administration of leuprolide with or without OCPs led to a reduction in both red blood cell (RBC) transfusions (odds ratio [OR] = 0.91; 95% CI 0.85-0.98) and platelet transfusions (OR=0.84; 95% CI 0.79-0.91) when compared with patients who were not treated with leuprolide.
Reduced Blood Transfusions for Pediatric IDA
Vilmarie Rodriguez, MD, MS
While pediatric patients with moderate to severe iron-deficiency anemia (IDA) are often transfused, ASH and the American Society of Pediatric Hematology/Oncology’s (ASPHO) collaborative Choosing Wisely® Pediatric-Focused List recommends against transfusing packed RBCs in asymptomatic patients with IDA when there isn’t evidence of hemodynamic instability or bleeding. If the patient is not actively bleeding, IDA is a chronic condition, and hemodynamic instability is rare or unlikely. Blood transfusions improve patients’ hemoglobin levels but do not correct the iron-deficiency component of the disease, meaning anemia can recur if IDA is left uncorrected.
Blood transfusions are effective in treating symptomatic anemia (hypotension) or in the setting of active or ongoing bleeding; however, patients are at risk for transfusion reactions, blood-borne infections, volume overload, and risk for RBC alloimmunization. Transfusions also significantly add to the cost of care – for example, the average cost of a blood transfusion at Nationwide Children’s Hospital (NCH) in Ohio is $1,000 per transfusion. From 2019 to 2020, the mean rate of RBC transfusion for IDA at NCH was 74%. Based on a retrospective review, the primary indications for transfusions were hemoglobin numbers, tachycardia, and chronic fatigue.
Vilmarie Rodriguez, MD, MS, led a multidisciplinary team using quality improvement methodology to develop key drivers and interventions with the goal of reducing blood transfusions for patients with IDA from 72% to 50%. A secondary aim was to increase the appropriateness of RBC transfusions from 68% to 85% by July 2023, following recommendations from clinical practice guidelines.
Since these interventions were implemented in March 2022, the rate of blood transfusions at NCH decreased to an average of 44%, and the appropriateness of blood transfusion increased to 88%, exceeding both the primary and secondary goals of the initiative.
According to Dr. Rodriguez, it was challenging “to change the culture of not transfusing children with moderate or severe IDA if there is no evidence of hemodynamic instability and to sustain this change,” but “creating clinical practice guidelines that were available to all admitting hospital services provided a standardized and clear direction for providers on how to diagnose, treat, and manage this common pediatric hematologic diagnosis.”
Choose Wisely at the ASH Annual Meeting
To learn more about this year’s Champions and how they’re working to improve patient care, be sure to attend the “ASH Choosing Wisely® Campaign: 2023 ASH Choosing Wisely Champions” Special Interest Session at the ASH annual meeting on Monday, December 11, at 12:15 pm.
“I highly encourage attendees to visit the Choosing Wisely Champions session to hear about these diverse projects and how they have been successfully implemented in clinical practice, institutions, or hospital systems,” said session chair Ming Y. Lim, MBBChir, of the University of Utah. Presenters will discuss the unique barriers and challenges they faced when developing and implementing their projects and how they were overcome.
“Although no two health care systems are alike, I hope that the solutions offered will be helpful to attendees when translating these projects to their own practices locally,” Dr. Lim said.