Objective: In 2013, the American College of Rheumatology (ACR) participated in the Choosing Wisely campaign and devised a recommendation to avoid testing antinuclear antibody (ANA) subserologies without a positive ANA and clinical suspicion of disease. The goals of our study were to describe ANA and subserology ordering practices and predictors of ordering concurrent ANA and subserologies in a safety-net hospital.Methods: We identified ANA and subserologies (dsDNA, Sm, RNP, SSA, SSB, Scl-70 and centromere) completed at Denver Health between 1/1/2005 and 12/31/2011. Variables included demographics, primary insurance, service, and setting from which the test was ordered. We performed multivariable logistic regression to determine predictors of concurrent ordering of ANA and subserologies.Results: During seven years, 3221 ANA were performed in 2771 individuals and 211 (6.6%) were performed concurrently with at least one subserology. The most common concurrent subserologies were dsDNA (21.8%), SSA (20.8%), and SSB (19.7%). In the multivariable logistic analysis, significant predictors of concurrent ANA and subserologies were the labs being ordered from subspecialty care (OR 8.12, 95% CI 5.27-12.50, p-value <0.0001) or from urgent/inpatient care (OR 3.86, 95% CI 1.78-8.38, p-value 0.001). A significant predictor of decreased odds was male gender (OR 0.32, 95% CI 0.21-0.49, p-value <0.0001). Five individuals (2.2% of the negative ANA with subserologies ordered) had a negative ANA but positive subserologies.Conclusion: Of 3221 ANA, 6.6% were performed concurrently with subserologies, and subspecialists were more likely to order concurrent tests. A negative ANA predicted negative subserologies with rare exceptions, which validates the ACR’s recommendations.

In the not-too-distant past, most physicians were paid by one of two ways: a fixed salary or by collecting fee-forservice charges. The former payment system was typical for physicians employed at academic health centers, larger integrated health care systems, commercial laboratories, and public hospitals, and for many hospital-based physicians. The latter payment system was typical of private practice groups, independent laboratories, and some hospital-based physicians. As the structure of health care reimbursement changed from 1980 to 2000, many physicians began changing to systems characterized by a guaranteed base salary with one or more variable salary components such as incentive, supplement, or bonus payments. Because the variable salary components were often used as incentives to modify physician behavior (eg, utilization of health care resources) or to increase productivity, there arose a need for the development and implementation of systems to track and analyze behaviors and productivity.Because of the structure of reimbursement systems at that time, this approach was primarily aligned with billable charges. The most widely used of these productivity measurements was the relative value unit (RVU) system, which attempted to assign units of productivity based on "relative values" of specific activities. Early on, this system made intuitive sense: most reimbursement during that era was based on fee-for-service systems, so increased productivity was directly related to increased charges and payments. Not surprisingly, important flaws in these systems quickly became evident: the incentive was to do as many procedures and perform as many tests as possible to maximize reimbursement, increasing utilization was a constant risk (even for unnecessary procedures and tests), and development of standardized approaches to account for nonbillable activities lagged behind. Moreover, because there was no incentive for physicians to do things that did not generate charges, not surprisingly these activities received less emphasis.As time passed, a number of changes in health care delivery occurred, all of which have the net outcome of driving utilization of tests and services downward. These included the emergence of managed care programs, growing awareness that keeping populations healthy through preventive measures resulted in decreased costs, adoption of best models of health care delivery around the world, and the growing use of evidence-based medicine. Through time, as these factors have matured and become widely adopted throughout health care, it has become apparent that the traditional approach of assessing productivity linked to billable services is fundamentally at variance with the concept of decreased utilization as part of contemporary health care.For pathology, as in many other medical specialties, the recent past has been characterized by important changes in practice. In many academic medical centers, large private practices, and reference laboratories, services increasingly are aligned with the need for sub...

A 45-year-old Liberian woman was referred by her primary care physician for left arm pain and drainage from a fistulous tract on the posterior aspect of the left deltoid muscle. The arm pain began 3 years prior, and the patient initially sought attention in her home country. Although medical records from Liberia were not available, she reported undergoing bone débridement twice in the first year of illness. The drainage ceased after the second débridement. The patient had lived in the capital city of Liberia until she immigrated to the United States 2 years after onset. Shortly thereafter, she again had a draining fistulous tract develop although she waited another year before presenting to the orthopaedic clinic.Review of systems revealed a 1-month history of lowgrade fevers and night sweats. She denied exposure to tuberculosis or contact with animals. Physical examination revealed an oblique, deltopectoral healed incision with a small punctuate area that drained purulent fluid. There was an additional small, healed incision on the posterior aspect of the left deltoid. She had 20°flexion and 20°abduction of the humerus. Laboratory values included a normal complete blood count, a negative HIV ELISA, and a negative tuberculin skin test. Erythrocyte sedimentation rate (ESR) was 51 mmol/L and C-reactive protein (CRP) was 51 mg/L. Imaging studies, including plain radiographs (Fig. 1) and MRI (Figs. 2, 3), were performed.Based on the history, physical examination, laboratory tests, and imaging studies, what is the differential diagnosis? Imaging InterpretationPlain film evaluation of the left shoulder (Fig. 1) revealed a postsurgical appearance to the proximal left humerus withThe institution of the author (HY) has received funding from the Larrk Foundation. The remaining authors (ST, AS, TJ) certify that he or she has no commercial associations that might pose a conflict of interest in connection with the submitted article. Each author certifies that his or her institution waived or does not require approval for the reporting of this case and that all investigations were conducted in conformity with ethical principles of research.