Choosing Wisely in Daily Practice: An Intervention Study on Antinuclear Antibody Testing by Rheumatologists

Abstract

Objective. To assess the effect of a simple intervention on antinuclear antibody (ANA) test overuse by rheumatologists. Methods. This was an explorative, pragmatic, before-and-after, controlled implementation study among rheumatologists working at 3 rheumatology departments in secondary and tertiary care centers in The Netherlands. The intervention was given in all study centers separately and combined education with feedback. Six outcome measures describe the intervention effects: the ANA/new patient ratio (APR), difference with the target APR, percentage of positive ANA tests, percentage of repeated ANA testing, percentage of ANA-associated diseases, and APR variation between rheumatologists. Outcomes were compared between the pre-and postintervention period (both 12 months) using (multilevel) logistic regression or F testing. Results are reported together for centers 1 and 2, and separately for center 3, because ANA tests could not be linked to an individual rheumatologist in center 3. Results. The APR decreased from 0.37 to 0.11 after the intervention in centers 1 and 2 (odds ratio [OR] 0.19, 95% confidence interval [95% CI] 0.17-0.22, P < 0.001) and from 0.45 to 0.30 in center 3 (OR 0.53, 95% CI 0.45-0.62, P < 0.001). The percentage of repeated ANA requests in all centers and the APR variation for centers 1 and 2 decreased significantly. Only in center 3 did the percentage of ANA-associated diseases increase significantly. Conclusion. A simple intervention resulted in a relevant and significant decrease in the numbers of ANA tests requested by rheumatologists, together with an improvement on 3 other outcome measures.

Choosing Wisely in Pediatric Hospital Medicine: 5 New Recommendations to Improve Value

“…1,2 In 2013, the Society of Hospital Medicine (SHM) participated in the campaign, contributing a list of 5 pediatric hospital medicine (PHM) tests and treatments to be questioned by patients and doctors. 3 Since initial publication, the CW lists have inspired numerous improvement initiatives, [4][5][6][7][8][9][10] including many in PHM. [11][12][13][14][15][16] CW recommendations also informed the creation of benchmarks, guidelines, 17,18 and studies to better define and measure value.…”

Frequency of Repeating Antinuclear Antibody Testing: When Less Is More

“…When, in 2012, the American Board of Internal Medicine Foundation launched the campaign Choosing Wisely®: Next Steps in Improving Healthcare Value to encourage delivering evidence-based medicine among specialties and reduce cost and harm associated with unnecessary and unsupported use of investigations and treatments, ANA testing appeared at the top of the five items on which rheumatologists internationally agreed their practices needed to be questioned [16,17]. Since then and all over the globe, multiple studies have been carried out to investigate the landscape of ANA testing: out of all ANA tests, how many are ordered appropriately; which specialties order most of the tests; how much unnecessary ANA tests represent of HCE; and what interventions can be used to reduce the inappropriate ordering of ANA tests [18][19][20].…”

Frequency of repeat antinuclear antibody testing in Ontario: a population-based descriptive study

“…27 However, the proportion of potentially redundant repeat tests in our sample is higher than in previous studies. 27,31,33 Potential explanations for this may be our ability to capture most tests performed across settings in Ontario and the publicly funded health care system in which this study was performed (i.e., patients not required to pay out of pocket for testing).…”

“…5 Targeted strategies are effective in improving the appropriateness of testing. 33 Multiple linked interventions coupled with computerized order set modifications can effect lasting change in ordering behaviours. 36 It is difficult to extrapolate costs associated with repeat testing.…”