ASN Quality and Patient Safety Task Force Outlines Top “Five Things” List for Choosing Wisely Campaign

The ABIM Foundation asked each partnering society to review its current practices and suggest five items that, based on the latest evidence on disease management and treatment, are overused or misused or could jeopardize patient safety and care. Each society submitted its list of Five Things Physicians and Patients Should Question.

ASN’s Five Things list includes tests or procedures regularly performed whose value should be weighed and discussed among patients and providers to determine whether they are appropriate for their individual care.

  1. Don’t perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms. Due to high mortality among end stage renal disease (ESRD) patients, routine cancer screening—including mammography, colonoscopy, prostate-specific antigen (PSA), and Pap smears—in dialysis patients with limited life expectancy, such as those who are not transplant candidates, is not cost effective and does not improve survival. False-positive tests can cause harm: unnecessary procedures, overtreatment, misdiagnosis, and increased stress. An individualized approach to cancer screening incorporating patients’ cancer risk factors, expected survival, and transplant status is required.
    • Sources: U.S. Renal Data System, American Society of Nephrology, American Society of Transplantation, Archives of Internal Medicine, Seminars in Dialysis.
  2. Don’t administer erythropoiesis-stimulating agents to chronic kidney disease patients with hemoglobin levels greater than or equal to 10 g/dL without symptoms of anemia. Administering erythropoiesis-stimulating agents (ESAs) to chronic kidney disease (CKD) patients with the goal of normalizing hemoglobin levels has no demonstrated survival or cardiovascular disease benefit, and may be harmful in comparison to a treatment regimen that delays ESA administration or sets relatively conservative targets (9–11 g/dL). ESAs should be prescribed to maintain hemoglobin at the lowest level that both minimizes transfusions and best meets individual patient needs.
    • Sources: U.S. Food and Drug Administration, The New England Journal of Medicine (multiple publications).
  3. Avoid nonsteroidal anti-inflammatory drugs in individuals with hypertension or heart failure or chronic kidney disease of all causes, including diabetes. The use of nonsteroidal anti-inflammatory drugs (NSAIDS), including cyclo-oxygenase type 2 (COX-2) inhibitors, for the pharmacological treatment of musculoskeletal pain can elevate blood pressure, make antihypertensive drugs less effective, cause fluid retention, and worsen kidney function in these individuals. Other agents such as acetaminophen, tramadol, or short-term use of narcotic analgesics may be safer than and as effective as NSAIDs.
    • Sources: National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines for Chronic Kidney Disease; Chronic Kidney Disease in Adults: UK Guidelines for Identification, Management and Referral; American Heart Association; Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; Scottish Intercollegiate Guidelines Network on Management of Chronic Heart Failure.
  4. Don’t place peripherally inserted central catheters in stage III–V chronic kidney disease patients without consulting nephrology. Venous preservation is critical for stage III–V chronic kidney disease patients. Arteriovenous fistulas (AVF) are the best hemodialysis access, with fewer complications and lower patient mortality, versus grafts or catheters. Excessive venous puncture damages veins, destroying potential AVF sites. Peripherally inserted central catheter (PICC) lines and subclavian vein puncture can cause venous thrombosis and central vein stenosis. Early nephrology consultation increases AVF use at hemodialysis initiation and may avoid unnecessary PICC lines or central/peripheral vein puncture.
    • Sources: Fistula First Breakthrough Initiative–National Coalition Recommendation for the Minimal Use of PICC Lines; American Society of Diagnostic and interventional Nephrology: Guidelines for Venous Access in Patients with Chronic Kidney Disease; Seminars in Dialysis; National Kidney Foundation Clinical Practice Guidelines for Vascular Access; The Renal Network, Inc. PICC Line Resource Toolkit; Clinical and Experimental Nephrology.
  5. Don’t initiate chronic dialysis without ensuring a shared decision-making process among patients, their families, and their physicians. The decision to initiate chronic dialysis should be part of an individualized, shared decision-making process among patients, their families, and their physicians. This process includes eliciting individual patient goals and preferences and providing information on prognosis and expected benefits and harms of dialysis within the context of these goals and preferences. Limited observational data suggest that survival may not differ substantially for older adults with a high burden of comorbidity who initiate chronic dialysis versus those managed conservatively.
    • Sources: Renal Physicians Association End-of-Life Care Guidelines, Pediatric Nephrology, Clinical Journal of the American Society of Nephrology, Journal of Pediatrics, Nephrology Dialysis Transplantation, Archives of Internal Medicine, The New England Journal of Medicine, Palliative Medicine.