Canadian Rheumatologists Create Their List of Tests to "Choose Wisely"

February 13, 2015

Antinuclear antibody testing and DEXA both appear on a new Canadian list of rheumatology tests to avoid and on a similar 2013 list from the American College of Rheumatology. There are interesting differences in the other 3 choices.

Chow SL, Thorne JC, Bell MJ, et al., Choosing Wisely: The Canadian Rheumatology Association’s List of 5 Items Physicians and Patients Should Question.J Rheumatol. 2015. First Release Feb 1 2015; doi:10.3899/jrheum.141140.

Antinuclear antibody (ANA) testing tops a list of 5 procedures that physicians and patients should question, as drafted by a team of rheumatologists on behalf of the Canadian Rheumatology Association’s “Choosing Wisely” committee.

Modeled on a successful effort in the US backed by more than 60 American specialty medical societies, including the American College of Rheumatology (ACR) which has developed its own "top 5 list", this is part of a nationwide effort in Canada to curb unnecessary healthcare spending and encourage smarter choices in medical care.

Although ANA testing and dual energy x-ray absorptiometry (DEXA) appear on both lists, the other items differ.

CRAACR
ANA testingANA subserologies
HLAB27 testingLyme disease testing
DEXA bone scansMRI of peripheral joints
Bisphosphonate monotherapyBiologic agents
Full-body bone scansRoutinely repeated

The Canadian report says that:

•    ANA testing should not be usedto screen adults who lack symptoms of systemic lupus erythematosus (SLE) such as malar rash and photosensitivity. Otherwise “can be misleading and may precipitate further unnecessary testing, erroneous diagnosis, or even inappropriate therapy.”
•    HLA-B27 testing is not useful on its own to diagnose patients with low back pain absent signs or symptoms of spondyloarthropathy (SpA) such as inflammatory back pain lasting more than 3 months and enthesitis or dactylitis, because there’s “low probability” that they have SpA.
•    Dual energy X-ray absorptiometry (DEXA) bone scans repeated every 2 years are not a good predictor of fracture risk in people with stable bone mineral density (BMD). Every 5-10 years may suffice. BMD changes themselves don’t correlate well with clinical outcomes.
•    Bisphosphonate treatment used alone does not appear to reduce fracture risk in patients with low bone mass, and is not cost-effective. Although up to 40% of US physicians say they recommend treatment for women with mild bone loss, the Canadians advise a more personalized approach.
•   Full body bone scans (e.g., scintigraphy) are not specific enough to screen for peripheral and axial inflammatory arthritis in adults and have limited clinical utility. An appropriate history and physical are usually good enough for diagnosis, and avoid the radiation risk (equivalent to that from 40 routine chest X-rays).