Karmela K. Chan

The U.S.A. is a big spender when it comes to medical care. Many estimates show medical spending in this country to be about twice as much per person as in other developed countries, without much additional benefit.

Choosing Wisely is an initiative of the American Board of Internal Medicine Foundation, in cooperation with Consumer Reports, designed to limit unnecessary testing. The idea is blindingly simple: They asked nine medical societies to each come up with their own list of five commonly performed tests or procedures the value of which should be questioned and discussed based on current evidence. A few of my favorites include a recommendation from the American College of Physicians to hold off on imaging nonspecific low back pain, and from the American Academy of Allergy, Asthma and Immunology to avoid routine diagnostic testing for chronic urticaria.

The American College of Rheumatology is one of the eight subspecialty groups that are slated to publish their list in the fall of this year. To that end, ACR sent out a survey on this topic to its members in mid-June.

Of course, this work involves a formal process with committees and a structured review of evidence, but I can certainly come up with my own list of five tests that are ordered too much or too little. I’ll bet you can come up with your own and that there will be overlap between yours and mine.

• I’ve heard talk of a "rheumatoid panel" in the nether world of primary care. This often includes a uric acid level, antinuclear antibodies, rheumatoid factor (RF), and Lyme testing. I understand that the poor primary care physicians are bombarded with complaints, and in the same 15-minute visit that you and I have to address a single problem, PCPs have to discuss their patient’s angina, constipation, hypertension, diabetes, asthma, and pain. But I think perhaps a little bit more thought can eliminate some components of this wasteful battery of tests. Since when did doctors stop ordering simple imaging tests in lieu of serologic tests? I saw a patient whose vertebral fracture went undiagnosed but came to see me because her ANA, which was performed because she complained of back pain, was 1:80.

• The HLA-B27 is sometimes included in this so-called "rheumatoid panel." Of patients who are HLA-B27 positive, less than 5% will have spondylitis. In my opinion, this test does not add much more than can be gathered from a good history and physical exam. When I suspect sacroiliitis, I get more information from an MRI of the sacroiliac joints than from a positive HLA-B27. Whether or not someone has an HLA-B27 does not change my management of the patient with uveitis and sacroiliitis or syndesmophytes or dactylitis.

• Not all ankle swelling is arthritis. Sometimes it’s edema, and a simple urinalysis would have saved the patient a subspecialist copay. Or it’s the wrong specialist’s copay anyway.

• This is not an original thought, since the American College of Physicians has already said it, but it bears repeating: Not all low back pain needs to be imaged. This is perhaps one of the few areas in which I find myself not in complete opposition to the obstructionist procedures of insurance companies. Frequently, we forget that physical therapy for low back pain can be very, very effective.

• The new IGRA (Interferon-Gamma Release Assay) tests for tuberculosis (for example, T-Spot and QuantiFERON Gold) may be useful to make a diagnosis of TB, and that’s exactly how I use these tests, when TB is on my differential for something else, such as a positive RF or a septic arthritis. For purposes of screening patients prior to starting a biologic DMARD though, especially in a population with low endemicity, the tuberculin skin testing is more cost effective.

I am excited to find out in the fall what recommendations the ACR makes. What recommendations would you make?

 Dr. Chan is in practice in Pawtucket, R.I.

The U.S.A. is a big spender when it comes to medical care. Many estimates show medical spending in this country to be about twice as much per person as in other developed countries, without much additional benefit.

Choosing Wisely is an initiative of the American Board of Internal Medicine Foundation, in cooperation with Consumer Reports, designed to limit unnecessary testing. The idea is blindingly simple: They asked nine medical societies to each come up with their own list of five commonly performed tests or procedures the value of which should be questioned and discussed based on current evidence. A few of my favorites include a recommendation from the American College of Physicians to hold off on imaging nonspecific low back pain, and from the American Academy of Allergy, Asthma and Immunology to avoid routine diagnostic testing for chronic urticaria.

The American College of Rheumatology is one of the eight subspecialty groups that are slated to publish their list in the fall of this year. To that end, ACR sent out a survey on this topic to its members in mid-June.

Of course, this work involves a formal process with committees and a structured review of evidence, but I can certainly come up with my own list of five tests that are ordered too much or too little. I’ll bet you can come up with your own and that there will be overlap between yours and mine.

• I’ve heard talk of a "rheumatoid panel" in the nether world of primary care. This often includes a uric acid level, antinuclear antibodies, rheumatoid factor (RF), and Lyme testing. I understand that the poor primary care physicians are bombarded with complaints, and in the same 15-minute visit that you and I have to address a single problem, PCPs have to discuss their patient’s angina, constipation, hypertension, diabetes, asthma, and pain. But I think perhaps a little bit more thought can eliminate some components of this wasteful battery of tests. Since when did doctors stop ordering simple imaging tests in lieu of serologic tests? I saw a patient whose vertebral fracture went undiagnosed but came to see me because her ANA, which was performed because she complained of back pain, was 1:80.

• The HLA-B27 is sometimes included in this so-called "rheumatoid panel." Of patients who are HLA-B27 positive, less than 5% will have spondylitis. In my opinion, this test does not add much more than can be gathered from a good history and physical exam. When I suspect sacroiliitis, I get more information from an MRI of the sacroiliac joints than from a positive HLA-B27. Whether or not someone has an HLA-B27 does not change my management of the patient with uveitis and sacroiliitis or syndesmophytes or dactylitis.

• Not all ankle swelling is arthritis. Sometimes it’s edema, and a simple urinalysis would have saved the patient a subspecialist copay. Or it’s the wrong specialist’s copay anyway.

• This is not an original thought, since the American College of Physicians has already said it, but it bears repeating: Not all low back pain needs to be imaged. This is perhaps one of the few areas in which I find myself not in complete opposition to the obstructionist procedures of insurance companies. Frequently, we forget that physical therapy for low back pain can be very, very effective.

• The new IGRA (Interferon-Gamma Release Assay) tests for tuberculosis (for example, T-Spot and QuantiFERON Gold) may be useful to make a diagnosis of TB, and that’s exactly how I use these tests, when TB is on my differential for something else, such as a positive RF or a septic arthritis. For purposes of screening patients prior to starting a biologic DMARD though, especially in a population with low endemicity, the tuberculin skin testing is more cost effective.

I am excited to find out in the fall what recommendations the ACR makes. What recommendations would you make?

 Dr. Chan is in practice in Pawtucket, R.I.

The U.S.A. is a big spender when it comes to medical care. Many estimates show medical spending in this country to be about twice as much per person as in other developed countries, without much additional benefit.

Choosing Wisely is an initiative of the American Board of Internal Medicine Foundation, in cooperation with Consumer Reports, designed to limit unnecessary testing. The idea is blindingly simple: They asked nine medical societies to each come up with their own list of five commonly performed tests or procedures the value of which should be questioned and discussed based on current evidence. A few of my favorites include a recommendation from the American College of Physicians to hold off on imaging nonspecific low back pain, and from the American Academy of Allergy, Asthma and Immunology to avoid routine diagnostic testing for chronic urticaria.

The American College of Rheumatology is one of the eight subspecialty groups that are slated to publish their list in the fall of this year. To that end, ACR sent out a survey on this topic to its members in mid-June.

Of course, this work involves a formal process with committees and a structured review of evidence, but I can certainly come up with my own list of five tests that are ordered too much or too little. I’ll bet you can come up with your own and that there will be overlap between yours and mine.

• I’ve heard talk of a "rheumatoid panel" in the nether world of primary care. This often includes a uric acid level, antinuclear antibodies, rheumatoid factor (RF), and Lyme testing. I understand that the poor primary care physicians are bombarded with complaints, and in the same 15-minute visit that you and I have to address a single problem, PCPs have to discuss their patient’s angina, constipation, hypertension, diabetes, asthma, and pain. But I think perhaps a little bit more thought can eliminate some components of this wasteful battery of tests. Since when did doctors stop ordering simple imaging tests in lieu of serologic tests? I saw a patient whose vertebral fracture went undiagnosed but came to see me because her ANA, which was performed because she complained of back pain, was 1:80.

• The HLA-B27 is sometimes included in this so-called "rheumatoid panel." Of patients who are HLA-B27 positive, less than 5% will have spondylitis. In my opinion, this test does not add much more than can be gathered from a good history and physical exam. When I suspect sacroiliitis, I get more information from an MRI of the sacroiliac joints than from a positive HLA-B27. Whether or not someone has an HLA-B27 does not change my management of the patient with uveitis and sacroiliitis or syndesmophytes or dactylitis.

• Not all ankle swelling is arthritis. Sometimes it’s edema, and a simple urinalysis would have saved the patient a subspecialist copay. Or it’s the wrong specialist’s copay anyway.

• This is not an original thought, since the American College of Physicians has already said it, but it bears repeating: Not all low back pain needs to be imaged. This is perhaps one of the few areas in which I find myself not in complete opposition to the obstructionist procedures of insurance companies. Frequently, we forget that physical therapy for low back pain can be very, very effective.

• The new IGRA (Interferon-Gamma Release Assay) tests for tuberculosis (for example, T-Spot and QuantiFERON Gold) may be useful to make a diagnosis of TB, and that’s exactly how I use these tests, when TB is on my differential for something else, such as a positive RF or a septic arthritis. For purposes of screening patients prior to starting a biologic DMARD though, especially in a population with low endemicity, the tuberculin skin testing is more cost effective.

I am excited to find out in the fall what recommendations the ACR makes. What recommendations would you make?

 Dr. Chan is in practice in Pawtucket, R.I.