Implementation of a simple intervention was associated with a significant reduction in the number of requested antinuclear antibody (ANA) laboratory tests in a cohort of rheumatologists. The decrease in the number of ANA tests ordered was also accompanied by less repeat ANA requisitions and less ANA/new patient ratio (APR) variation, according to research published in Arthritis Care & Research. 

“Rational use of diagnostic tests is very important as inappropriate testing leads to a higher patient burden due to uncertainty. additional testing, higher false-positive rates, and higher costs,” said study author Nienke Lesuis, MD, of Sint Maartenskliniek, Nijmegen, the Netherlands in an email interview with Rheumatology Advisor.

Supported by the American College of Rheumatology, the Choosing Wisely campaign was designed to decrease inappropriate laboratory testing. The campaign identified ANA testing as leading contributor to unnecessary testing. The ACR recommends testing for ANA subserologies after a clinical suspicion of an immune disorder and a positive ANA.

To evaluate the effects of the Choosing Wisely intervention on ANA antibody testing orders by rheumatologists, Dr Lesuis and colleagues conducted an explorative, controlled implementation study in 7 rheumatology departments in 3 hospitals in the Netherlands.


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The intervention included a 1-hour group session covering ANA testing, use in daily practice, and feedback. A 1-hour booster session was scheduled 6 months later to review the information again.

The cohort included 3 hospitals and 29 rheumatologists. There was one loss to followup and 2 rheumatologists did not attend the intervention sessions. The rheumatologists included in the study were an average of 40.2 years, 48.8 years, and 46.8 years of age at Centers 1, 2, and 3, respectively. The participants average practice experience was 4.7 years, 12.2 years, and 12.3 years, respectively.  

Overall the information sessions were associated with a significant decrease in the APR. Centers 1 and 2 saw a decrease in APR from 0.37 to 0.11 (OR: 0.19, 95% CI: 0.17 to 0.22, P<.01). Center 3 saw a decrease in APR from 0.45 to 0.30 (OR: 0.53, 95% CI: 0.45 to 0.62, P<.01).

There was also a significant decrease in the number of repeated ANA requests in both Centers 1 and 2 (6.9 to 1.3, OR: 0.15, 95% CI: 0.07 to 0.35, P<.01) and Center 3 (9.0 to 3.7, OR: 0.38, 95% CI: 0.20 to 0.73, P<.01).  However, there were no significant changes in the number of positive ANA tests after the intervention in both Centers 1 and 2 (24.6 to 24.4, P=.69) and Center 3 (37.0 to 37.7, P=.84). 

All three centers showed improvement, but no center reached the target calculated APR.

“Our report shows that it is possible to reduce test overuse with a relative simple intervention. We hope that other clinicians take our study as an example to assess their own test use, and decrease test overuse” Dr Lesuis indicated.

Summary and Clinical Applicability

Overuse of unnecessary laboratory testing contributes to increased healthcare costs and false-positive test results.  In this study, a straight-forward and low cost intervention let to a sizable decrease in ANA test requests. The decrease in volume of ANA test requisitions was accompanied by less repeat ANA requests and less APR variation between rheumatologists. 

“We greatly support [the Choosing Wisely] campaign and we hope that more studies will be done on effective ways to decrease unnecessary tests, treatments and procedures. This might help many more physicians to avoid doing unnecessary tests and to choose even more wisely”, Dr Lesuis told Rheumatology Advisor. 

These results could be clinically impactful due to potential lower costs, less false-positive results, and less subsequent testing. 

“Although both the Choosing Wisely advice and this study were aimed at rheumatologists, decreasing ANA test overuse can also be relevant for other specialties, such as internal medicine, neurology, and primary care”, the authors concluded.

Limitations and Disclosures

Limitations of the study included an inability to link a specific rheumatologist to an ANA request, thus preventing individual feedback. Additionally, the study did not include chart reviews to assess whether the test was correctly ordered.   The voluntary participation of centers in the study could have introduced selection bias.   A cost-analysis should be done to estimate the savings associated with reduced inappropriate testing as compared to the cost of running the intervention.

It is important to note that this study did not show a causal relationship between education intervention and the indicated changes in laboratory testing.

Reference

1.       Lesuis N, Hulscher ME, Piek E, et al. Choosing Wisely in Daily Practice: An Intervention Study on Antinuclear Antibody Testing by Rheumatologists. Arthritis Care Res (Hoboken). 2016;68(4):562-9.