ACR Creates New "Don't" List of Questionable Procedures

The American College of Rheumatology (ACR) has published its entry in the national multispecialty "Choosing Wisely" campaign spearheaded by the ABIM (American Board of Internal Medicine) Foundation and intended to reduce unnecessary and expensive medical procedures. Now appearing in the journal Arthritis Care and Research is the ACR's list of the top five procedures in rheumatology that deserve careful thought and discussion before proceeding, along with a description of the process and details about and exceptions to the items on the list.

Chosen from a list of more than 100 suggestions by a group of practicing rheumatologists, and vetted after a survey sent to the entire 6000+ membership of the ACR (to which older male rheumatologists in clinical practice were most likely to respond), the list contains five suggestions that all begin with the word "Don't." However, it is not meant to be a set of "Never's," says task force co-chair Jinoos Yazdany MD, who is assistant professor of medicine at the University of California San Francisco School of Medicine. Rather, the list is meant to inspire conversations on these subjects between patients and all of the doctors involved in the care of their rheumatologic conditions.

 Podcast with Dr. Yazdany:

 Behind ACR's Challenge to Choose Tests Wisely

 Learn what the Top Five list means for you and  your patients.

The Top Five list includes:

1. Don’t test ANA sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease. Sub-serologies are usually negative if the ANA test is negative, says the report. Exceptions are anti-Jo1 in some forms of myositis or sometimes anti-SSA in lupus or Sjogren's syndrome.

2. Don’t test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings. Lyme disease causes brief attacks of arthralgia or episodes of arthritis in one or a few large joints, especially the knee. Diffuse arthralgias are likely to produce false positive results.

3. Don’t perform MRI of the peripheral joints to routinely monitor inflammatory arthritis. This is usually not cost-effective. Prefer assessing disease activity and using plain film radiography.

4. Don’t prescribe biologics for rheumatoid arthritis before a trial of methotrexate (or other conventional non-biologic DMARDs). In most cases, at least a 3-month initial trial of a non-biologic DMARD is appropriate. Exceptions: patients with high disease activity and poor prognostic features.

5. Don’t routinely repeat DXA scans more often than once every two years. The optimal interval isn't clear, but bone density changes over short intervals are smaller than the measurement error of many DXA scanners and changes often don't correlate with fracture risk in any case. For women over 67, intervals of a decade may be sufficient.