As part of the multi-year "Choosing Wisely" campaign sponsored by the ABIM (American Board of Internal Medicine) Foundation, the American College of Rheumatology has published a Top 5 List of Things Physicians and Patients Should Question.
In this brief recorded interview, Jinoos Yazdany MD, who co-chaired the ACR's "Top Five" task force along with rheumatology Charles King MD of Tupelo MS, describes some of the revelations and challenges in the process of choosing the five procedures to target as questionable, and some of the implications of the choice.
Dr. Yazdany is assistant professor of medicine in the Department of Rheumatology at the University of California San Francisco School of Medicine.
|Behind ACR's Challenge to Choose Tests Wisely|
Behind ACR's Challenge to Choose Tests Wisely
• You've listed five tests and procedures that may be unjustified in many circumstances ...
• What were the strongest areas of disagreement in this process?
• Which issues didn't (quite) make it, which were numbers 6-10 on the list?
• Two of the five items include tests for rheumatoid arthritis -- MRI for peripheral joints and sub-serologies after an ANA test has come up positive. Judging from your survey, how often are those procedures actually done by rheumatologists?
"Rheumatology is a relatively complex medical specialty ... We were expecting that some of these topics might be thorny or might lead to a lot of debate ... Because we actually went to the effort of sending out an email survey to the entire US rheumatology workforce ... in fact there was far more agreement than there was disagreement."
|What to Question: Items 6 - 10|
|6. Do not perform serial antinuclear antibody (ANA), rheumatoid factor (RF) or anti-cyclic citrullinated protein antibody (anti-CCP) testing in patients who already have a documented positive test and a connective tissue disease diagnosis. |
7. Do not order an HLA-B27 unless spondyloarthritis is suspected (i.e., inflammatory back pain, lower extremity monoarticular or oligoarticular synovitis, dactylitis, uveitis, or enthesitis).
8. Do not perform imaging for low back pain within 6 weeks of onset, unless red flags are present.
9. Do not order MRI before ordering plain radiographs for non-traumatic knee or shoulder pain.
10. Do not perform plain radiographs, CT scans, or MRIs in the evaluation of musculoskeletal pain until after an appropriate history and physical examination.
"Do we really know the prevalence of these items that were proposed on the ACR list? The answer is that we actually don't."
"Many of the things that were identified as areas of overuse actually occur before a patient reaches a specialist or in moments of transition ... if we can get a lot of this information out in an accessible format to patients before they reach the physician, that will be a huge step forward."
The Top Five Things Physicians and Patients Should Question
The ACR task force engaged a panel of practicing rheumatologists to identified questionable procedures, then whittled this of list more than 100 down to five (although numbers six through ten are also published in the report). Candidates for the Top Five list were distributed to all 6,188 members of the ACR, with intensive followup among a representative subsample of 390 to assure generalizability of the results. These responses were used to identify common themes and categories that were included along with the medical evidence in selecting the Top Five (and top ten) lists.
The Top Five procedures not to undertake without question and discussion, in brief:
1. Don’t test ANA sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.
2. Don’t test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings.
3. Don’t perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.
4. Don’t prescribe biologics for rheumatoid arthritis before a trial of methotrexate(Drug information on methotrexate) (or other conventional non-biologic DMARDs).
5. Don’t routinely repeat DXA scans more often than once every two years.
For further reference:
Yazdany Y, Schmajuk G, Robbins M et al, Choosing Wisely: The American College of Rheumatology’s Top 5 List of Things Physicians and Patients Should Question
Arthritis Care & Research (2013) 65:329-339