Choose Your Tests Wisely: Advice From the AASLD

Lauri R. Graham; Raphael B. Merriman, MD, FRCPI


November 10, 2014

Medscape: Your fifth recommendation is: Don't routinely transfuse fresh frozen plasma (FFP) and platelets prior to abdominal paracentesis or endoscopic variceal band ligation.

Dr Merriman: This recommendation stems from the common practice of attempting to correct coagulopathies often present in patients with cirrhosis such as an elevated international normalized ratio (INR) or thrombocytopenia for procedures such as paracentesis or endoscopic variceal band ligation. Recently, it has been acknowledged that these routine tests of coagulation do not accurately reflect the bleeding risk in patients with cirrhosis. Indeed, bleeding complications associated with these procedures are very rare. So we strongly encourage patients to discuss with their physicians whether routine transfusion of FFP and/or platelets in patients with an elevated INR or thrombocytopenia is indicated for these procedures. This recommendation has the potential to reduce the unnecessary transfusion of finite and costly blood product resources.

Medscape: Is the AASLD planning to add any further recommendations beyond these first "five things"?

Dr Merriman: The AASLD, in both its stewardship and leadership capacity, would definitely be enthusiastic about adding to this first "five things" list. This, in part, also reflects the transformational changes occurring in therapeutics for such very common liver diseases as hepatitis C and nonalcoholic fatty liver disease. Those changes bring about the possibility of further optimizing the delivery of healthcare in a manner that is responsible from both the patient and the societal perspective.

Medscape: How do you see these recommendations affecting both clinicians and patients?

Dr Merriman: These recommendations really address two audiences: patients and physicians. It prompts both parties to discuss testing and treatment and to make informed and prudent decisions about the most appropriate care based upon the patient's individual clinical condition. So, in many ways, it spurs a discussion about what is clinically and medically appropriate and necessary. Conversations about the overuse of medical tests or about procedures that have little benefit (and in some cases may be harmful) are very relevant to both parties.

The Choosing Wisely campaign is an educational process and has the potential to revise and reshape both patient expectations and physician practice patterns in a beneficial way.

Finally, the broad acceptance of the Choosing Wisely campaign and the AASLD list reflects and reinforces the belief that the AASLD and physicians are responsible leaders in healthcare reform.

Medscape: Since this list was released, have you seen a change in clinical practice, or is it too soon to tell?

Dr Merriman: While formal data are not available, the positive response from patients and colleagues has been highly encouraging. I have witnessed the Choosing Wisely list posted prominently in clinics and have personally referred to it when patients have questions about topics addressed. Just last week, for example, a patient who had hepatitis C but who is not going to be treated any time soon wanted a viral load checked. I was able to point to the recommendation on the Choosing Wisely list. That initiated a conversation ultimately recommending against such testing, based upon the Choosing Wisely data and emanating from a credible and responsible organization. In that way, this list can evolve into a powerful tool in educating patients about good healthcare practices.


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