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From: The Rheumatologist, March 2013

Rheumatology Chooses Wisely

by Kurt Ullman

In 2010 Howard Brody, MD, wrote an article in the New England Journal of Medicine calling on professional societies to help limit healthcare costs by creating lists of things in their specialties that were of limited use. The ACR, working in conjunction with the American Board of Internal Medicine Foundation and Consumer Reports, recently released its five suggestions as part of the Choosing Wisely campaign.

ACR’s Top Five Things

  1. Do not test antinuclear antibody (ANA) subserologies without a positive ANA and clinical suspicion of immune-mediated disease. Tests for anti-nuclear antibody (ANA) sub-serologies (including antibodies to double-stranded DNA, Smith, RNP, SSA, SSB, Scl-70, centromere) are usually negative if the ANA is negative. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA, in the setting of lupus or Sjögren’s syndrome. Broad testing of autoantibodies should be avoided; instead the choice of autoantibodies should be guided by the specific disease under consideration.
  2. Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings. The musculoskeletal manifestations of Lyme disease include brief attacks of arthralgia or intermittent or persistent episodes of arthritis in one or a few large joints at a time, especially the knee. Lyme testing in the absence of these features increases the likelihood of false positive results and may lead to unnecessary follow-up and therapy. Diffuse arthralgias, myalgias or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.
  3. Do not perform MRI of the peripheral joints to routinely monitor inflammatory arthritis. Data evaluating MRI for the diagnosis and prognosis of rheumatoid arthritis are currently inadequate to justify widespread use of this technology for these purposes in clinical practice. Although bone edema assessed by MRI on a single occasion may be predictive of progression in certain RA populations, using MRI routinely is not cost-effective compared with the current standard of care, which includes clinical disease activity assessments and plain film radiography.
  4. Do not prescribe biologics for rheumatoid arthritis before a trial of methotrexate (or other conventional nonbiologic disease modifying antirheumatic drug). High quality evidence suggests that methotrexate and other conventional nonbiologic disease modifying antirheumatic drugs (DMARD) are effective in many patients with rheumatoid arthritis (RA). Initial therapy for RA should be a conventional non-biologic DMARDs unless these are contraindicated. If a patient has had an inadequate response to methotrexate with or without other non-biologic DMARDs during an initial three-month trial, then biologic therapy can be considered. Exceptions include patients with high disease activity and poor prognostic features (functional limitations, disease outside the joints, seropositivity or bony damage), where biologic therapy may be appropriate first-line treatment.
  5. Do not routinely repeat DXA scans more often than once every two years. Initial screening for osteoporosis should be performed according to National Osteoporosis Foundation recommendations. The optimal interval for repeating Dual-energy X-ray Absorptiometry (DXA) scans is uncertain, but because changes in bone density over short intervals are often smaller than the measurement error of most DXA scanners, frequent testing (e.g., less than two years) is unnecessary in most patients. Even in high-risk patients receiving drug therapy for osteoporosis, DXA changes do not always correlate with probability of fracture. Therefore, DXAs should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected. Recent evidence also suggests that healthy women age 67 and older with normal bone mass may not need additional DXA testing for up to ten years provided osteoporosis risk factors do not significantly change.

More details about the ACR’s Top Five Things List are available on the ACR website.

This list identifies the top five tests and treatments that should lead to careful discussions between rheumatologists and their patients to be sure decisions are being made that ensure high-quality patient care while also conserving healthcare resources.

“If we are going to build a healthcare system that provides high-quality care without wasting resources, it is absolutely critical that physicians demonstrate leadership,” says Jinoos Yazdany, MD, MPH, co-chair of the ACR task force that selected rheumatology’s top-five list and assistant professor at the University of California at San Francisco. “Providers know which cuts are likely or unlikely to hurt our patients. It is an ethical imperative that we lead the way while protecting the clinical needs of our patients.”

Task Force Commissioned

The eight-member task force was formed to oversee the multistage process that led to the final recommendations. The group was co-chaired by Dr. Yazdany and Charles M. King II, MD, who also chairs the ACR Committee on Rheumatologic Care.

“We thought it was very important that we go to the source to generate this list,” says Dr. Yazdany. “We asked rheumatologists who spend their lives caring for patients to think about waste they see in their communities and practices. We wanted suggestions from clinicians about ways to safely reduce costs without harming patients.”

A core membership group of about 20 practicing physicians was given the task of generating the first cut of the list. This initial round resulted in 105 unique items for further consideration.

“The core group was carefully selected to reflect the diversity of the College,” says Dr. King, who is also senior rheumatologist with Northern Mississippi Health Systems in Tupelo. “It was important that, to the extent possible, [the core group] reflected the age, gender, geographic distribution, and practice type of the general ACR membership with an emphasis on rheumatologists in clinical practice.”

Soliciting Input from Entire Membership

The core group went through three Delphi rounds where participants ranked the items based on their agreement with content of the suggestion, prevalence of the item in their community, and highest impact on costs. At the end, 22 items were included in the next phase of the project, sending a survey to the entire ACR membership and asking them for input.

“I don’t know what we expected in the way of feedback, but the response was nothing short of phenomenal,” Dr. Yazdany says. “We were pleasantly surprised by how engaged the membership was … nearly one in every five rheumatologists [who were contacted to take the survey] took the time to give their input.”

Literature Analysis in Final Cut

This resulted in a list of 10 items that was referred back to the task force. A targeted literature review helped the task force select the final five items.

“We performed a … thoughtful analysis of the available scientific literature for each of the remaining items,” says Dr. King. “We omitted a few of the higher-scoring items because robust evidence was lacking.”

There were other criteria that went into the discussions of what would make the list. The relevance of the items to rheumatology practice and the potential downstream harms of overuse were considered, as was cost.

“We looked at some tests for which false positive results can be misleading,” says Audrey B. Uknis, MD, ACR president and professor of medicine and senior associate dean for admissions and strategy at Temple University in Philadelphia. “Pretest probability is critical. We don’t want to send doctors on a wild goose chase looking for diseases that don’t really exist, especially if inappropriate treatments are given as a result.”

Dr. Yazdany noted that the task force members were expecting it to be much tougher than it was to narrow the options down to only five.

“Because we had gone through the process of asking clinicians to generate ideas, doing all the surveys, and then a review of the literature, it was very apparent which concerns were the most important to rheumatologists,” she says. “Where they saw waste, and areas that had good evidence supporting our statements, these were the areas that needed to be examined closely.”

Not Prescriptive List

All three rheumatologists interviewed here stress that this is not a list of things providers cannot do. This is meant to open a dialogue between providers and patients in an effort to curb waste and unnecessary spending while still ensuring high quality patient care.

“This is not a prescriptive list of what providers have to do, as there is no substitute for experience and clinical judgment,” says Dr. King. “The list is based on the best available current evidence and is not immutable. As the research matures, changes will be made as needed.”

Although the main audience for the list is rheumatologists and rheumatology patients, it can also serve as guidance for physicians in the general community who take care of patients with rheumatic diseases.

“These are the kinds of things that are the bread and butter of rheumatology, the things we know best,” says Dr. Uknis. “This is our attempt to share our knowledge and best practices.”


Kurt Ullman is a freelance writer based in Indiana.
 

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