From the 2018 HVPAA National Conference
Matthew Schefft (Virginia Commonwealth University School of Medicine)
Immune thrombocytopenic purpura (ITP) is a common condition treated by hematologists that is rarely associated with clinically significant bleeding. While the American Society of Hematology recommends against treating ITP based solely on platelet counts, clinicians continue to frequently treat patient who lack bleeding symptoms.
To decrease the percentage of patients presenting to our institution with first episode of acute ITP who are unnecessarily treated from 80% to 40% within 12 months of implementing treatment guideline.
A three phase intervention was designed. Phase 1 was a standard of practice conference given to the pediatric hematology/oncology division. During the conference, literature was reviewed detailing the risks and benefits of treatment versus observation only. At the end of the conference, two treatment guidelines were proposed to the faculty: one that did not include platelet count in the decision to treat and another that allowed for treatment for platelet counts <20 at the clinicians’ discretion. The guideline that did not include platelet count in the treatment decision was unanimously chosen. Phase 2 included revisions and final consensus development of the treatment algorithm for faculty not present at the conference. The final treatment guideline was distributed to the clinic, inpatient unit, and ED. The guideline was rolled out at the end of September 2015. Phase 3 was creation of an article in the American Academy of Pediatrics Virginia Newsletter detailing the evidence behind our practice change that was published in January 2016. The purpose of the article was to educate community pediatricians about unnecessary treatment, helping them to appropriately counsel families when a diagnosis of ITP is made. Unnecessary treatment was defined as treatment of any patient who only had bruising and/or self-resolving nose bleeds. SPC charts were used to track progress and midline shifts were determined by Nelson’s rules.
A total of 89 children with acute ITP have been seen in our health system from January 2013 to December 2017. Since guideline creation, we have decreased the percentage of unnecessary ITP treatment from a baseline of 80% to a sustained rate of 31% since September 2016. We have decreased our admission rate for ITP patients seen in our health system from 100% to 52% and decreased the total percentage of patients treated from 100% to 48% with both numbers continuing to decline. We have not had any adverse bleeding events in any of our ITP patients during this time period. We estimate that 12 admissions have been avoided annually for a decrease in hospital charges of $170,918 per year.
Through local practice change and community education, we have successfully reduced the percentage of children unnecessarily treated for ITP in our health system by 61% in the 12 months following our initial practice change intervention leading to decreased hospital utilization, decreased costs, and avoidance of harm.
Implications for the Patient
Overuse continues to be a significant barrier to high value care in the US. Thoughtful practice change can reduce overuse and the associated downstream harm and financial toxicity.