Think Before You Order: Choose Wisely Save

Early in medical training, we are taught diagnoses are made 90% of the time based only on the history and physical exam of the patient; laboratory tests play a minor role. When ordered, tests are used as evidence to support the diagnosis already made by the physician. However, over time, whether it is related to time constraints, laziness, demands by the patient, or conflicts of interests, we are over-ordering tests and becoming too reliant on the results. Sometimes, we cling to the hope that the repeat test will yield a different result. Here are several abstracts from the American College of Rheumatology 2022 Convergence Meeting showing waste, futility and costs of repeat testing.    We need to do better together to reduce healthcare costs. 

Abstract #1278 is a population-based study examining the trends of anti-nuclear antibody (ANA) testing in the Upper Midwest of the United States from 2000-2019. 72,2795 unique individuals underwent 134,098 ANA tests. 46% of total tests were repeated tests.  The mean time between repeat testing was 2.7 years. Women were twice more likely to have repeat testing than men (incidence 12/100 person-years in women vs. 6.43/100 person-years in men). 

Commentary: Don’t repeat the ANA. To reduce healthcare expenditures and medical waste, the American College of Rheumatology and Canadian Rheumatology Association partnered with The Choosing Wisely Initiative and came up with this recommendation: "With rare exceptions, repeat ANA testing  repeat ANA and/or ANA subserology adds little if any clinical value to patient management such as monitoring disease activity, confirming remission or predicting disease flares." (1)

Abstract #0725 In this retrospective study conducted in Melbourne, Australia, the authors reviewed all extractable nuclear antigen (ENA) tests that were performed. Over 23,000 ENA tests resulted from 19,603 patients from 2013 to 2020. The majority of the tests were negative (89.2%). Of the positive tests (n=2305), 51% were due to anti-Ro52 antibodies. 2636 ENA were repeated tests, and 95.7% had no change in the results compared to the first test. The ENA result change from negative to positive in 53 patients, but only 5 had a new ANA-associated rheumatic disease (AARD). The authors concluded ENA test results rarely change or result in a new diagnosis of an AARD

Commentary: Don't repeat the ENA panel.

Abstract #0228 details the survey results of Medicine Residents on ANA ordering. 46 residents responded when the survey was conducted in May 2022. Most residents (60.9%) will order both ANA and ENA panel when evaluating a patient for possible connective tissue disease (CTD), 17.3% will order only an ANA initially. 73.95% of residents would not repeat an ANA in a patient with known AARD.  59% would order an ANA for nonspecific symptoms as back pain, fatigue and myalgias. 89% were not aware of any recommendations for appropriate use of ANA testing.

Commentary:  We need to do a better job training medical students, residents about appropriate ANA and ENA testing and to avoid repeat ANA testing on someone with a known AARD. The Choosing Wisely initiative noted “Do not test antinuclear antibody (ANA) subserologies without a positive ANA and clinical suspicion of immune-mediated disease.” (1)

Abstract #0058 shares a quality improvement project that resulted in $26,000 saved over 3 months when Lehigh Valley Health Network (LVHN) instituted hospital order sets for reflex testing to ENA only if the ANA is positive (>1:80 titer) rather than allowing medical providers to order both ANA and ENA panels for suspected rheumatologic disorders. The intervention was directed towards departments inappropriately ordering more ENA panels including orthopedicis, internal medicine, family medicine, and neurology and resulted in substantial healthcare savings.

Commentary:  We need to do a better job training other specialties about appropriate ANA and ENA testing and implement restrictions on when to order an ENA panel.

References 

1. Fritzler MJ. Choosing wisely: Review and commentary on anti-nuclear antibody (ANA) testing. Autoimmun Rev. 2016 Mar;15(3):272-80. doi: 10.1016/j.autrev.2015.12.002. Epub 2015 Dec 11. PMID: 26687321.