Pathology-related Choosing Wisely recommendations
2018 Recommendations
1. Avoid unnecessary duplicate genetic testing for inherited variants
Evidence/guidance
- Approximately 0.8% of all genetic test requests received for germline mutations were unnecessary duplicate samples from patients who had already been successfully tested (Miller CE et al. Genetic counsellor review of genetic test orders in a reference laboratory reduces unnecessary testing. Am J Med Genet A 2014;164A:1094–1101).
- Adverse effects from venepuncture include vasovagal reactions, pain and bruising, and direct and indirect nerve damage (Stevenson M et al. Appendix 8 Diagnostic venepuncture: systematic review of adverse events. Health Technology Assessment 2012;16:4; Kohn D, Bush A, Kessler I. Risk of venepuncture. Br Med J 1976;2:1133).
Patient information/decision aids
Genetic testing can help identify a disease risk or inherited condition. The results can help your doctor decide:
- Which additional tests, if any, are required
- Help to confirm a suspected diagnosis from previous tests undertaken
- Choose ways to prevent or treat a condition.
Genetic testing may also tell you which family members are at risk.
However, sometimes a genetic test is not the best way to identify a disease risk or inherited condition. A routine blood test or procedure might be just as good. Therefore, it is important you discuss and understand the reasons for a genetic test with your doctor before agreeing to have a sample taken for testing.
Repeat testing
Usually you don’t need to repeat a genetic test.
Your genetic information generally doesn’t change over your lifetime. Your doctor should check with you directly to confirm whether you have previously had the test. There is usually no reason to repeat a genetic test unless:
- Your doctor thinks an error may have been made in the laboratory performing the test.
- A new, more accurate test is available
2. Don’t give a patient a blood transfusion without informing them about the risks and benefits (although do not delay emergency transfusions)
Evidence/guidance
There is a lack of high-quality research in this field with largely observational data available. The evidence suggests that patients have a limited understanding of many aspects of transfusion, but that they do want to be part of an informed decision-making process. The evidence also indicates that patients are reassured by the provision of written information.
- NICE Guidance: Blood transfusion November 2015
- NICE Quality Standard: Blood Transfusion December 2016
Patient information\decision aids
A number of patient information materials are available through the NHSBT website:
3. Don’t transfuse red cells for iron deficiency anaemia without haemodynamic instability
Evidence\guidance
- NICE Guidance: Blood transfusion November 2015
- Lidder PG, et al. Pre-operative oral iron supplementation reduces blood transfusion in colorectal surgery – a prospective, randomised, controlled trial. Annals of the Royal College of Surgeons of England. 2007;89(4):418-421;
- Luporsi E, et al. Evaluation of cost savings with ferric carboxymaltose in anemia treatment through its impact on erythropoiesis-stimulating agents and blood transfusion: French healthcare payer perspective. Journal of Medical Economics. 2012;15(2):225-232.
- NICE Quality Standard: Blood Transfusion December 2016
Patient information\decision aids
- Leaflets are available through the NHSBT website
- Anaemia patient Information leaflet October 2016
- Iron in your diet
4. Use statins in appropriate patients
Evidence\guidance
- NICE Guidance: Cardiovascular disease: risk assessment and reduction, including lipid modification
- SIGN 149: Risk estimation and the prevention of cardiovascular disease.
- Collins R et al. Interpretation of the evidence for the efficacy and safety of stain therapy. Lancet 2016;388:2532–2561
- Mancini GB et al. Diagnosis, Prevention, and Management of Statin Adverse Effects and Intolerance: Canadian Consensus Working Group Update. Can J Cardiol 2016;32:S35–65.
Patient information\decision aids
2016 Recommendations
1. Unless a patient is at increased risk of prostate cancer because of race or family history, PSA testing does not necessarily lead to a longer life.
Patient information/decision aids
Evidence/guidance
- NICE Clinical Knowledge Summary: PSA testing
- Prostate Cancer UK information page on the PSA test
- Public Health England’s Prostate Cancer Risk Management Programme materials
2. Calcium testing is used when there are symptoms of kidney stones, bone disease or nerve-related disorders; but it is not necessary to test less than three months after the previous test except in acute conditions, during major surgery or in critically ill patients when tests should not be made more often than every 48 hours.
3. Only consider transfusing platelets for patients with chemotherapy-induced thrombocytopenia where the platelet count is < 10 x 109/L except when the patient has clinical significant bleeding or will be undergoing a procedure with a high risk of bleeding.
4. Use restrictive thresholds for patients needing red cell transfusions and give only one unit at a time except when the patient has active bleeding.
Evidence/guidance
- NICE Guidance: Blood transfusion
- Cochrane Review: Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion