Lauri R. Graham, Raphael B. Merriman, MD, FRCPI
November 10, 2014
Editor's Note: Choosing Wisely®, an initiative of the American Board of Internal Medicine (ABIM) Foundation, comprises evidence-based recommendations from specialty organizations on commonly used tests and procedures. The goal of the campaign is to use these recommendations as the starting point for discussions between clinicians and patients about avoiding unnecessary care. Choosing Wisely launched in 2012 with five recommendations each from nine specialties; more than 60 specialty societies have now joined the campaign, with new lists continuing to be published through 2014 and more planned beyond that. Medscape interviewed Raphael B. Merriman, MD, of the American Association for the Study of Liver Diseases (AASLD), who helped craft its Choosing Wisely recommendations.
Medscape: Would you give a brief history of AASLD's involvement in the Choosing Wisely campaign, and why you believed this would be important?
Dr Merriman: We welcomed the opportunity to embrace this leadership challenge to help physicians be better stewards of finite healthcare resources.
The AASLD established the Choosing Wisely task force in December 2013 to develop its list of recommendations. Members were selected from the AASLD practice guidelines committee to broadly represent varying practice settings and subspecialty expertise within the field of hepatology. Hepatologists with methodological experience in evidence-based medicine were also included. The working group solicited recommendations from the entire AASLD membership that would be considered for inclusion in the list of five tests or treatments that physicians and patients should question. These recommendations were then rated on the basis of judgments related to harm, benefit, and excess resource utilization.
On the basis of voting by the working group, as well as a literature review of supporting data, a total of 10 suggestions were identified. Subsequently, voting by the working group generated the final top five recommendations. These top five recommendations were submitted and approved by the AASLD Governing Board.
Medscape: I'd like to go through the recommendations and ask you how they were selected. Could you also speak briefly about the evidence behind the recommendations? The first recommendation is: Don't perform surveillance esophagogastroduodenoscopy (EGD) in patients with compensated cirrhosis and small varices without red signs treated with nonselective beta-blockers for preventing a first variceal bleed.
Dr Merriman: This first recommendation is based on a recommendation in the AASLD practice guidelines related to portal hypertension and variceal bleeding. It relates to patients with cirrhosis and small varices that have not bled and do not have criteria for an increased risk for bleeding (that is, Child-Pugh class A and the absence of red signs on endoscopic variceal evaluation); for these patients, beta-blockers can be used. In patients with cirrhosis and medium or large varices that have not bled and, again, are not at the highest risk for bleeding (that is, Child-Pugh class A and no red signs), beta-blockers are preferred. The doses of the beta-blockers should be adjusted to the maximum tolerated dose.
In both of these clinical scenarios, follow-up EGD is not necessary. This practice would reduce the need for non-indicated upper gastrointestinal endoscopy.
Medscape: Your second recommendation is: Don't continue treatment for hepatic encephalopathy indefinitely after an initial episode with an identifiable precipitant.
Dr Merriman: This reflects a recommendation made in the recently published practice guideline on hepatic encephalopathy, which was jointly developed by the AASLD with the European Association for the Study of the Liver.
Patients may have episodes of hepatic encephalopathy with precipitating factors that can be identified and controlled, such as recurrent infections or variceal hemorrhage. In those circumstances where the precipitating factors are clearly identified and well controlled, the treatment of hepatic encephalopathy may not necessarily be indefinite and indeed could be discontinued.
This is important because in the past, it has been common practice to continue the prophylactic treatment of hepatic encephalopathy indefinitely after it was initiated, even though there was little basis to actually support that. So this recommendation has significant implications to reduce unnecessary use of therapeutics to prevent recurrent hepatic encephalopathy.
Medscape: Your third recommendation is: Don't repeat hepatitis C viral load testing outside of antiviral therapy.
Dr Merriman: This is an important, topical, and relevant recommendation, particularly in the context of the transformative changes occurring in the field of hepatitis C therapeutics with the imminent availability of a whole host of new, highly effective hepatitis C antiviral agents that are curing hepatitis C.
Highly sensitive serum assays of hepatitis C RNA are expensive. Performing these assays is appropriate at the time of diagnosis of hepatitis C and as part of antiviral therapy, typically at the beginning of and possibly during therapy, and also after therapy is completed. Outside of these circumstances, there is little benefit to measuring the hepatitis C viral RNA load, as it typically does not affect either the clinical management or outcomes.
This recommendation is of particular relevance to patients because, oftentimes, there is a mistaken patient perception that the testing is needed, that there is significance to quite modest changes in the hepatitis C viral load, and that it actually affects clinical outcomes. Therefore, this recommendation will prompt a discussion that should hopefully reduce the need for unnecessary virologic testing.
Medscape: Your fourth recommendation is: Don't perform CT or MRI routinely to monitor benign focal lesions in the liver unless there is a major change in clinical findings or symptoms.
Dr Merriman: Many patients have focal liver lesions detected by imaging—often incidentally—who don't have underlying liver disease and that are determined to be benign. Those who demonstrate both clinical and radiologic stability do not need repeated imaging as the likelihood of evolving into neoplastic lesions is very low (with the exception of hepatocellular adenoma). Clinical stability implies the absence of any new symptoms related to these focal liver lesions. This recommendation stems from a common perception that even after clinical and radiologic stability of the benign focal lesions has been demonstrated, that imaging needs to be repeated indefinitely. This recommendation provides guidance to support discontinuing serial imaging in these patients.
Because these lesions are often found incidentally and frequently in younger people, the additional implication of this recommendation is that we can reduce and avoid both unnecessary imaging and, in the case of CT scanning, unnecessary radiation exposure in this patient population.
Medscape: You mentioned the exception to this recommendation being hepatocellular adenoma.
Dr Merriman: Yes; this recommendation does not apply to those with hepatocellular adenoma. Patients with radiologic evidence of hepatocellular adenoma may have a risk of the lesion potentially transforming into a more neoplastic variant. These patients are typically monitored more closely, often depending in part upon the size of the lesion. However, it is important to remember that this represents a very small proportion of the total number of benign focal liver lesions.
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.