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From: The Rheumatologist, November 2013

Choosing Wisely’s Treatments,Tests that Pediatric Rheumatologists and Patients Should Question

by Kurt Ullman

A Wise Choice for Kids

The ACR and the ABIM Foundation have teamed up to release five suggestions for pediatric rheumatologists in the Choosing Wisely campaign (visit www.rheumatology.org/fivethings for more information). This is a follow-up to the adult Top Five list for rheumatologists released by the ACR this March. (Read about the adult Top Five list online at www.The-Rheumatologist.org or in the March issue.)

ACR leadership had already participated in the Choosing Wisely campaign by developing an adult Top Five, and wanted to extend that to pediatric rheumatology, says Stacy P. Ardoin, MD, MHS, assistant professor in the division of rheumatology and immunology at Ohio State University in Columbus. “The Special Committee on Pediatric Rheumatology was charged with producing a list of five treatments or tests that were common, expensive, could cause harm, and where the evidence did not suggest they improved care.”

Focus Sparks Conversations

The focus of the Choosing Wisely campaign is to spark conversations between physicians and their patients about medical tests and procedures. To accomplish this, specialty and subspecialty societies have worked to create and disseminate lists of “Things Physicians and Patients Should Question.” It is hoped that these evidence-based recommendations will help decision making about appropriate kinds of care for individual patients.

Since the first three lists were published in 2012, more than 50 societies have developed lists specific to their specialties. In addition, Consumer Reports has developed more than 40 patient-friendly materials that help explain the science, outline options, and describe the risks and benefits of the various parts of the lists.

The pediatric rheumatology Top Five core group was made up of 18 individuals carefully chosen to represent providers across North America and those in various sized practices. The work of this group was overseen by Dr. Ardoin; Kelly Rouster-Stevens, MD, MSc, assistant professor of pediatrics at Emory University in Atlanta; and Special Committee Chair Polly Ferguson, MD, director of pediatric rheumatology at the University of Iowa Carver College of Medicine in Iowa City.

Stacy P. Ardoin, MD, MHS

The Special Committee on Pediatric Rheumatology was charged with producing a list of five treatments or tests that were common, expensive, could cause harm, and where the evidence did not suggest they improved care.

—Stacy P. Ardoin, MD, MHS

List Development Process

“First, we briefed participants on the purpose of [the Choosing Wisely campaign and] the Top Five lists and instructed them that we were looking for commonly ordered tests or procedures that may not improve patient care and ultimately increased costs,” says Dr. Rouster-Stevens. “The first round of surveys resulted in 121 items being suggested.” Two more rounds cut the list to 28 items. This lineup was sent via email to 1,198 physicians on the ACR membership list who had indicated they worked with pediatric patients. They got responses from 397, or roughly one in three. About half of those responding identified themselves as practicing primarily in pediatric rheumatology.

“After looking over the results, we settled on 10 items that were designated for an in-depth literature review,” says Dr. Ardoin. “From this, five were sent to the ACR board of directors for their input and approval. At their suggestion, two of the five were combined and another highly ranked item was added.”

The ACR’s Top Five list for pediatric rheumatologists as part of the ABIM Foundation’s Choosing Wisely campaign is:

1. Don’t order autoantibody panels unless the patient has a positive antinuclear antibody test (ANA) and evidence of rheumatic disease.

“These panels are expensive and, where there are no indications in the history and physical of rheumatic disease, there is no evidence that they add to the management of the patient,” says Dr. Rouster-Stevens. “The high levels of false positives with this test might unnecessarily instill anxiety in the patient and family, as well as triggering another round of unneeded testing.”

2. Don’t test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings.

“Lyme disease has received a lot of press recently, so rheumatologists get a lot of pressure from patients to test for it,” notes Dr. Ardoin. “It is important that physicians only test when there are symptoms and exam findings suggestive of [Lyme disease]. This would not only avoid wasting money, but also overuse of antibiotics that can lead to increased bacterial resistance.”

3. Don’t routinely perform surveillance joint radiographs to monitor juvenile idiopathic arthritis (JIA) disease activity.

“Of all the Top Five suggestions, the data on this one was the toughest to sort through,” says Dr. Rouster-Stevens. “But when we looked in depth, there was really no evidence supporting the idea that [radiographs] improved outcomes. In addition to the costs, there were concerns voiced about radiation exposure that could be avoided.”

4. Don’t perform methotrexate toxicity labs more often than every 12 weeks on stable doses.

“Fortunately, in children with rheumatic conditions, the frequency of liver or other abnormal values during methotrexate use is very low,” says Dr. Ardoin. “When a child is on a stable dose, there is little reason to test more often, unless they are at higher risk related to concomitant medications or comorbid conditions. Less testing reduces not only costs, but also anxiety and pain for the child.”

5. Don’t repeat a confirmed positive ANA in patients with established JIA or systemic lupus erythematous (SLE).

“Once the ANA is positive, it very likely to remain positive,” notes Dr. Ardoin. “Current evidence doesn’t suggest that changes in ANA or titer over time reflect an individual patient’s disease activity or course. It is not useful, and very costly, to serially test ANA.”

Kelly Rouster-Stevens, MD, MSc

Lyme disease has received a lot of press recently, so rheumatologists get a lot of pressure from patients to test for it. It is important that physicians only test when there are symptoms and exam findings suggestive of [Lyme disease].

—Kelly Rouster-Stevens, MD, MSc

Synergies with Adult List

The ACR adult and the pediatrics Top Five lists share some similarities. They both suggest against ordering ANA panels and testing for Lyme disease without evidence of disease from examination and history.

Dr. Rouster-Stevens doesn’t think that the overlap is surprising. “There are definitely differences in how you treat adults and kids,” she says. “But I think that many of the overarching themes of rheumatology are similar.”

The pediatric rheumatology Top Five recommendations are not to be viewed as a list of things physicians have to do, and it does not substitute for a rheumatologist’s experience and clinical judgment.

Although it was developed for rheumatologists under the auspices and direction of the ABIM Foundation’s Choosing Wisely campaign, the list is also geared as a way to communicate with other specialties.

“A big part of our effort is talking to physicians outside of rheumatology and giving them a sense of what we think are the important issues for all physicians to think about,” says Dr. Rouster-Stevens. “We hope to inform the practices of other specialties when there is an overlap.”


Kurt Ullman is a freelance writer based in Indiana.

Pediatric Rheumatology: Top Five Things Physicians and Patients Should Question

1. Don’t order autoantibody panels unless positive antinuclear antibody test (ANA) and evidence of rheumatic disease.

Up to 50% of children develop musculoskeletal pain. There is no evidence that autoantibody panel testing in the absence of history or physical exam evidence of a rheumatologic disease enhances the diagnosis of children with isolated musculoskeletal pain. Autoantibody panels are expensive; evidence has demonstrated cost reduction by limiting autoantibody panel testing. Thus, autoantibody panels should be ordered following confirmed ANA positivity or clinical suspicion that a rheumatologic disease is present in the child.

2. Don’t 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. Don’t routinely perform surveillance joint radiographs to monitor juvenile idiopathic arthritis (JIA) disease activity.

There are no available data to suggest that routinely obtaining surveillance joint radiographs to monitor for the development or progression of erosive changes in children with JIA improves outcomes. Radiation exposure and cost are potential risks. In the absence of data to support clear benefit, radiographs should be obtained by the pediatric rheumatologist only when history and physical exam raise clinical concern about joint damage or decline in function.

4. Don’t perform methotrexate toxicity labs more often than every 12 weeks on stable doses.

Laboratory abnormalities in JIA patients taking methotrexate are usually mild and rarely prompt significant changes in management. Screening low-risk children every one to two months may lead to unnecessary interruptions in treatment. More frequent monitoring may be required in the first six months after methotrexate initiation or dose escalation and in patients with risk factors for toxicity, including obesity, diabetes, renal disease, psoriasis, systemic JIA, Down syndrome, and use of alcohol or other hepatotoxic or myelosuppressive medications.

5. Don’t repeat a confirmed positive ANA in patients with established JIA or SLE.

ANA is important in the diagnosis of SLE and positivity guides more frequent slit lamp examination for detection of uveitis in children with JIA. Beyond this, there is no evidence that ANA is valuable in the ongoing management of SLE or JIA. It is recommended that, following diagnosis of SLE or JIA, ANA should not be repeated unless a child with JIA has evolution of symptoms suggestive of an autoimmune connective tissue disease.

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