The New ASH ITP-Guideline Recommendations - Marching Separately, Beating Together

Background:Immune thrombocytopenia (ITP) is rare. The 1996 American Society of Hematology (ASH) ITP-Guideline for many years set the standards of ITP-care. In 2019 ASH published a new ITP guideline. We wanted to assess the acceptance of these new guideline recommendations by German physicians.

Methods:This is a cross-sectional survey presenting ten recommendations on adult ITP from the new ASH ITP guideline to German hematologist, internists and other specialists at 4 medical educational activities on ITP between September 2019 and January 2020. We asked the physicians to express their preference for each recommendation on a 5-point scale. Numeric values were assigned to the degrees of agreement or disagreement. The numeric values of the responses were summed and divided by the number of respondents to create an average score. This was compared with the degree of support ASH experts expressed for each of their recommendation.

Results:One hundred thirty questionnaires were distributed and 56 were retrieved (43%). There was consensus in 7 of 10 management issues but there were obvious differences in 3. (1) German physicians were less likely to give corticosteroids in newly diagnosed but asymptomatic or only mildly symptomatic patients, but (2) in case corticosteroids were given, German physicians were more likely to prescribe longer corticosteroid treatment, and (3) German physicians clearly prefer 2nd line thrombopoietin receptor agonists (TPO-RAs) over splenectomy. The different approach may be explained by easier access to medical care for patients (higher hospital- and physician-density than in the US), universal coverage in a publicly funded health care system, and a less developed medicolegal network pushing malpractice claims in Germany.

Conclusion: The example of the recent ASH ITP guideline shows that recommendations must not be separated from the context in which they are produced. They cannot define a universal standard of care. Instead they need to be adapted and individualized, respecting the traditions of each health care system, physicians' experiences, patients' preferences, and health literacy. Guideline recommendations do not define a 'best treatment' or any universal standard of care, all they do is providing guidance to the physician in daily practice. Th. Jefferson's sentence still holds that all human beings are created equal, but this does not mean that all patients must be treated equally.