“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.”