Multicenter initiative to standardize management of pediatric immune thrombocytopenia improves adherence to guidelines

Practice variation exists in the management of newly diagnosed pediatric immune thrombocytopenia (ITP) despite availability of evidence-based treatment guidelines. The American Society of Hematology (ASH) ITP guidelines recommend that initial treatment of children should be based on assessment of clinical symptoms rather than the degree of thrombocytopenia and that short courses of corticosteroids should be prescribed to children requiring initial medication treatment. Retrospective review evaluating treatment of newly diagnosed children with ITP has demonstrated that management continues to be based on the platelet count with high use of intravenous immunoglobulin, which results in overuse of medications and high rates of inpatient hospitalizations and medical visits for administration and management of side effects. To improve adherence to ASH guidelines, the ITP Consortium of North America implemented a clinical care pathway as a multicenter quality improvement initiative. Retrospective data (11 centers, n=284) were collected prior to implementation and compared to post-implementation data (12 centers, n=266). With implementation of the clinical pathway, documentation of a bleeding score for children at diagnosis increased from 1% (3/284) to 95% (253/266). At diagnosis, initial treatment with ITP-directed medications decreased in children with no or mild bleeding symptoms (62% (177/284) vs. 31% (83/266), p<0.0001). Intravenous immunoglobulin use reduced from 51% (145/284) to 15% (41/266), p<0.0001. With implementation of the pathway, clinical outcomes were comparable with no increase in inpatient hospitalizations or bleeding events. Implementation of a clinical care pathway for a rare condition increases adherence to evidence-based guidelines and is feasible to implement across multiple centers.