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Hematology High Value Care Recommendations The American College of Physicians, in collaboration with . Patients with anemia of kidney disease who have a multiple other organizations, is engaged in a worldwide hemoglobin level greater than 10 g/dl (tOO glf-) should initiative to promote the practice of High Value Care (HVC). not receive erythropoiesis-stimulating agents. The goals of the HVC initiative are to improve health o Treatment for cobalamin deficiency should be instituted care outcomes by providing care ofproven benefit and with oral cobalamin rather than parenteral therapy. reducing costs by avoiding unnecessary and even harmful r. Persons with hereditary hemochromatosis and a hetero- interventions. The initiative comprises several programs zygous HFEmutation, without symptoms or elevated iron that integrate the important concept of health care value indices, do not require treatment or monitoring (see Item 63). (balancing clinical benefit with costs and harms) for a e Antiplatelet antibody testing in the diagnosis of immune given intervention into a broad range of educational thrombocltopenic purpura should not be performed. materials to address the needs of trainees, practicing o Most patients taking heparin who develop thrombocyto- physicians, and patients. penia but have a low 4T score need no further evaluation. o Platelet transfusion is not generally indicated in patients HVC content has been integrated into MKSAP 19 in several with thrombocltopenia in the absence of trauma, surgery important ways. MKSAP 19 includes HVC-identified key or bleeding unless the platelet count decreases to less points in the text, HVC-focused multiple-choice questions, than 1O,0OO to 20,000/pL (rO-ZO x 10e/L) (see Item 25). and, in MKSAP Digital, an HVC custom quiz. From the text r Granuloc).te colony-stimulating factor is not indicated for and questions, we have generated the following list of HVC most patients with neutropenia who are afebrile, as a rou- recommendations that meet the definition below of high tine adjunct to empiric antibiotics for patients presenting value care and bring us closer to our goal of improving with febrile neutropenia, or for patients undergoing patient outcomes while conserving finite resources. induction chemotherapy for acute leukemia (see Item 13). High Value Care Recommendation: A recommendation to o Patients with factor XI deficiency who are aslmptomatic do choose diagnostic and management strategies for patients in not require prophylactic intervention for most surgeries. specific clinical situations that balance clinical benefit with r Prothrombin complex concentrates should not be used to cost and harms with the goal of improving patient outcomes. manage the coagulopathy of liver disease. o Thrombophilia testing results generally do not change Below are the High Value Care Recommendations for the immediate management, except in high risk antiphos- Hematology section of MKSAP 19. pholipid antibody syndrome (see Item 45). . Lymphopenia without clinical consequences or an r Testing for methylene tetrahydrofolate reductase, as well associated illness does not require treatment. as measuring homocysteine levels, factor VIII levels, and o Bone marrow evaluation need not be undertaken in patients plasminogen activator inhibitor activity, should not be with a monoclonal gammopathy and low-risk features. part of the standard thrombophilia evaluation because o Patients with low-risk monoclonal gammopathy of unde- results do not influence management. termined significance can be clinically observed and do not o Patients with a Pulmonary Embolism Rule-Out Criteria require follow-up testing (see Item 51). score of zero do not require further testing with D-dimer . A low mean corpuscular volume, elevated red cell distri- or imaging (see Item 56). bution width, and peripheral blood smear showing micro- o Patients with low probability for deep venous thrombosis cytosis and anisopoikilocytosis are virtually diagnostic of or pulmonary embolism should undergo D dimer testing; iron deficiency, especially in premenopausal women; these if the results are normal, no further imaging is necessary. findings may render additional testing unnecessary. o Most patients with deep venous thrombosis and those . Iron deficiency is typically treated with oral iron salts, with pulmonary embolism who have a good prognosis optimally dosed once daily or every other day; oral ferrous can be safely managed without hospitalization. sulfate is the preferred preparation because of its tolera- o Bridging anticoagulation therapy is not indicated for bility, efficacy, and cost (see Item 59). most patients because it is associated with more bleed- . Supplemental erythropoietin improves anemia of inflam- ing complications without any reduction in thrombotic mation, but it is associated with worsening hypertension, events. thrombotic complications, and, in patients with cancer, o Patients with gestational thrombocy'topenia do not require increased mortality and is not recommended. treatment.

Hematology High Value Care Recommendations The American College of Physicians, in collaboration with . Patients with anemia of kidney disease who have a multiple other organizations, is engaged in a worldwide hemoglobin level greater than 10 g/dl (tOO glf-) should initiative to promote the practice of High Value Care (HVC). not receive erythropoiesis-stimulating agents. The goals of the HVC initiative are to improve health o Treatment for cobalamin deficiency should be instituted care outcomes by providing care ofproven benefit and with oral cobalamin rather than parenteral therapy. reducing costs by avoiding unnecessary and even harmful r. Persons with hereditary hemochromatosis and a hetero- interventions. The initiative comprises several programs zygous HFEmutation, without symptoms or elevated iron that integrate the important concept of health care value indices, do not require treatment or monitoring (see Item 63). (balancing clinical benefit with costs and harms) for a e Antiplatelet antibody testing in the diagnosis of immune given intervention into a broad range of educational thrombocltopenic purpura should not be performed. materials to address the needs of trainees, practicing o Most patients taking heparin who develop thrombocyto- physicians, and patients. penia but have a low 4T score need no further evaluation. o Platelet transfusion is not generally indicated in patients HVC content has been integrated into MKSAP 19 in several with thrombocltopenia in the absence of trauma, surgery important ways. MKSAP 19 includes HVC-identified key or bleeding unless the platelet count decreases to less points in the text, HVC-focused multiple-choice questions, than 1O,0OO to 20,000/pL (rO-ZO x 10e/L) (see Item 25). and, in MKSAP Digital, an HVC custom quiz. From the text r Granuloc).te colony-stimulating factor is not indicated for and questions, we have generated the following list of HVC most patients with neutropenia who are afebrile, as a rou- recommendations that meet the definition below of high tine adjunct to empiric antibiotics for patients presenting value care and bring us closer to our goal of improving with febrile neutropenia, or for patients undergoing patient outcomes while conserving finite resources. induction chemotherapy for acute leukemia (see Item 13). High Value Care Recommendation: A recommendation to o Patients with factor XI deficiency who are aslmptomatic do choose diagnostic and management strategies for patients in not require prophylactic intervention for most surgeries. specific clinical situations that balance clinical benefit with r Prothrombin complex concentrates should not be used to cost and harms with the goal of improving patient outcomes. manage the coagulopathy of liver disease. o Thrombophilia testing results generally do not change Below are the High Value Care Recommendations for the immediate management, except in high risk antiphos- Hematology section of MKSAP 19. pholipid antibody syndrome (see Item 45). . Lymphopenia without clinical consequences or an r Testing for methylene tetrahydrofolate reductase, as well associated illness does not require treatment. as measuring homocysteine levels, factor VIII levels, and o Bone marrow evaluation need not be undertaken in patients plasminogen activator inhibitor activity, should not be with a monoclonal gammopathy and low-risk features. part of the standard thrombophilia evaluation because o Patients with low-risk monoclonal gammopathy of unde- results do not influence management. termined significance can be clinically observed and do not o Patients with a Pulmonary Embolism Rule-Out Criteria require follow-up testing (see Item 51). score of zero do not require further testing with D-dimer . A low mean corpuscular volume, elevated red cell distri- or imaging (see Item 56). bution width, and peripheral blood smear showing micro- o Patients with low probability for deep venous thrombosis cytosis and anisopoikilocytosis are virtually diagnostic of or pulmonary embolism should undergo D dimer testing; iron deficiency, especially in premenopausal women; these if the results are normal, no further imaging is necessary. findings may render additional testing unnecessary. o Most patients with deep venous thrombosis and those . Iron deficiency is typically treated with oral iron salts, with pulmonary embolism who have a good prognosis optimally dosed once daily or every other day; oral ferrous can be safely managed without hospitalization. sulfate is the preferred preparation because of its tolera- o Bridging anticoagulation therapy is not indicated for bility, efficacy, and cost (see Item 59). most patients because it is associated with more bleed- . Supplemental erythropoietin improves anemia of inflam- ing complications without any reduction in thrombotic mation, but it is associated with worsening hypertension, events. thrombotic complications, and, in patients with cancer, o Patients with gestational thrombocy'topenia do not require increased mortality and is not recommended. treatment. xt