Don’t treat with an anticoagulant for more than three months in a patient with a first venous thromboembolism (VTE) occurring in the setting of a major transient risk factor.
Anticoagulation is potentially harmful and costly. Patients with a first VTE triggered by a major, transient risk factor such as surgery, trauma or an intravascular catheter are at low risk for recurrence once the risk factor has resolved and an adequate treatment regimen with anticoagulation has been completed. Evidence-based and consensus guidelines recommend three months of anticoagulation over shorter or longer periods of anticoagulation in patients with VTE in the setting of a reversible provoking factor. By ensuring a patient receives an appropriate regimen of anticoagulation, clinicians may avoid unnecessary harm, reduce health care expenses and improve quality of life. This Choosing Wisely® recommendation is not intended to apply to VTE associated with non-major risk factors (e.g., hormonal therapy, pregnancy, travel-associated immobility, etc.), as the risk of recurrent VTE in these groups is either intermediate or poorly defined.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
1-5: The American Society of Hematology (ASH) Choosing Wisely® Task Force utilized a modified Delphi technique to collect suggestions from committee members and recipients of its clinically focused newsletter, the ASH Practice Update. Respondents were asked to consider the core values of harm, cost, strength of evidence, frequency and control. Fifty-nine of 167 ASH committee members (35%) and 2 recipients of the ASH Practice Update submitted 81 unique suggestions. The Task Force used a nominal group technique (NGT) to identify the top 20 items, which were scored by ASH committee and practice community members, with a 46 percent participation rate. ASH’s Task Force reviewed all scores to develop a 10-item list. A professional methodologist conducted a systematic literature review on each of the 10 items; the Task Force chair served as the second reviewer. Evidence reviews and source material for the 10 items were shared with ASH’s Task Force, which ranked the items according to the core values. The Task Force then identified the top 5 items plus 1 alternate. ASH member content experts provided external validation for the veracity and clarity of the items.
6–10: Suggestions for the second ASH Choosing Wisely list were solicited from members of the ASH Committee on Practice, the ASH Committee on Quality, the ASH Choosing Wisely Task Force, ASH Consult-a-Colleague volunteers and members of the ASH Practice Partnership. Six principles were used to prioritize items: avoiding harm to patients, producing evidence-based recommendations, considering both the cost and frequency of tests and treatments, making recommendations in the clinical purview of the hematologist, and considering the potential impact of recommendations. Harm avoidance was established as the campaign’s preeminent guiding principle. Guided by the 6 principles, the ASH Choosing Wisely Task Force scored all suggestions. Modified group technique was used to select 10 semi-finalist items. Systematic reviews of the literature were then completed for each of the 10 semi-finalist items. Guided by the 6 core principles outlined above, and by the systematic reviews of the evidence, the ASH Choosing Wisely Task Force selected 5 recommendations for inclusion in ASH’s second Choosing Wisely Campaign.
ASH’s disclosure and conflict of interest policy can be found at www.hematology.org.
Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M, Kahn SR; American College of Chest Physicians. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.[Erratum appears in Chest. 2012 Dec;142(6):1698-1704]. Chest. 2012 Feb;141(2 Suppl):e419S–94S.
Chalmers E, Ganesen V, Liesner R, Maroo S, Nokes T, Saunders D, Williams M; British Committee for Standards in Haematology. Guideline on the investigation, management and prevention of venous thrombosis in children. Br J Haematol. 2011 Jul;154(2):196–207.
Monagle P, Chan AK, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Göttl U, Vesely SK; American College of Chest Physicians. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e737S–801S.