‘Choosing Wisely’: Canada vs. U.S.

In 2011, the American Board of Internal Medicine started the Choosing Wisely campaign, a subtly subversive call to curb health care spending. As part of that campaign, the American College of Rheumatology published its own list of five “tests, treatments, or services … whose necessity or value should be questioned” in March 2013.

As it turns out, Canada has also started a Choosing Wisely Canada campaign, and in February of this year the Canadian Rheumatology Association published their list of five. Though the methodology for coming up with the list was the same in these two very similar populations, there is surprisingly little overlap between the two lists. It is likely that the differences are partly explained by how medicine is practiced and paid for in the two countries. How invested physicians are in their respective professional societies may play a role, too. As part of the methodology, surveys were sent out to membership: At the time of the study the ACR had 6,188 members and a 17% response rate, while the CRA had a membership of 484 and a 35% response rate.

The ACR publication reminds us that the initiative is in part a response to a physician charter for medical professionalism, drafted in 2002 by a collaboration of physician organizations, including the ABIM Foundation and the American College of Physicians, outlining principles of professionalism, “including patient welfare, patient autonomy, and social justice” (Ann. Intern. Med. 2002;136:143-6).

Social justice, according to the ACR, “calls on the profession to promote a fair distribution of health care resources and to engage in collective efforts to improve the health care system for the welfare of society.” I wonder if the gap between the survey response rates of the American and the Canadian groups reflects greater indifference to societal welfare, but I certainly hope not.

In any event, I would like to devote some space to reviewing these two lists. They are worth revisiting often. I’ve included some clarifying statements from each publication that I thought were helpful.

The ACR list (Arthritis Care Res. 2013;65:329-39)

• Do not test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA in the setting of lupus or Sjögren syndrome.

• Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate examination findings. Diffuse arthralgias, myalgias, or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.

• Do not perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.

• Do not prescribe biologic agents for RA before a trial of methotrexate (or another conventional nonbiologic DMARD)

• Do not routinely repeat DXA scans more often than once every 2 years. DXA scans should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected.

The CRA list (J. Rheumatol. 2015;42:682-9)

• Do not order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus or other connective tissue disease. At one center in Canada, ANA testing was positive only 15% of the time and cost more than $800,000 over 3 years when combined with ENA and anti-dsDNA. … An ANA test should be ordered only if the clinician feels there is reasonable clinical suspicion of SLE or CTD based on historical information, physical findings and results of other laboratory tests.

• Do not order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms. There is no clinical utility to ordering an HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.

• Do not repeat DXA scans more often than every 2 years. If BMD are stable and/or individuals are at low risk of fracture, then less frequent monitoring up to an interval of 5-10 years can be considered.

• Do not prescribe bisphosphonates for patients at low risk of fracture.

• Do not perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adult population.

Dr. Chan practices rheumatology in Pawtucket, R.I.

In 2011, the American Board of Internal Medicine started the Choosing Wisely campaign, a subtly subversive call to curb health care spending. As part of that campaign, the American College of Rheumatology published its own list of five “tests, treatments, or services … whose necessity or value should be questioned” in March 2013.

As it turns out, Canada has also started a Choosing Wisely Canada campaign, and in February of this year the Canadian Rheumatology Association published their list of five. Though the methodology for coming up with the list was the same in these two very similar populations, there is surprisingly little overlap between the two lists. It is likely that the differences are partly explained by how medicine is practiced and paid for in the two countries. How invested physicians are in their respective professional societies may play a role, too. As part of the methodology, surveys were sent out to membership: At the time of the study the ACR had 6,188 members and a 17% response rate, while the CRA had a membership of 484 and a 35% response rate.

The ACR publication reminds us that the initiative is in part a response to a physician charter for medical professionalism, drafted in 2002 by a collaboration of physician organizations, including the ABIM Foundation and the American College of Physicians, outlining principles of professionalism, “including patient welfare, patient autonomy, and social justice” (Ann. Intern. Med. 2002;136:143-6).

Social justice, according to the ACR, “calls on the profession to promote a fair distribution of health care resources and to engage in collective efforts to improve the health care system for the welfare of society.” I wonder if the gap between the survey response rates of the American and the Canadian groups reflects greater indifference to societal welfare, but I certainly hope not.

In any event, I would like to devote some space to reviewing these two lists. They are worth revisiting often. I’ve included some clarifying statements from each publication that I thought were helpful.

The ACR list (Arthritis Care Res. 2013;65:329-39)

• Do not test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA in the setting of lupus or Sjögren syndrome.

• Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate examination findings. Diffuse arthralgias, myalgias, or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.

• Do not perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.

• Do not prescribe biologic agents for RA before a trial of methotrexate (or another conventional nonbiologic DMARD)

• Do not routinely repeat DXA scans more often than once every 2 years. DXA scans should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected.

The CRA list (J. Rheumatol. 2015;42:682-9)

• Do not order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus or other connective tissue disease. At one center in Canada, ANA testing was positive only 15% of the time and cost more than $800,000 over 3 years when combined with ENA and anti-dsDNA. … An ANA test should be ordered only if the clinician feels there is reasonable clinical suspicion of SLE or CTD based on historical information, physical findings and results of other laboratory tests.

• Do not order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms. There is no clinical utility to ordering an HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.

• Do not repeat DXA scans more often than every 2 years. If BMD are stable and/or individuals are at low risk of fracture, then less frequent monitoring up to an interval of 5-10 years can be considered.

• Do not prescribe bisphosphonates for patients at low risk of fracture.

• Do not perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adult population.

Dr. Chan practices rheumatology in Pawtucket, R.I.

In 2011, the American Board of Internal Medicine started the Choosing Wisely campaign, a subtly subversive call to curb health care spending. As part of that campaign, the American College of Rheumatology published its own list of five “tests, treatments, or services … whose necessity or value should be questioned” in March 2013.

As it turns out, Canada has also started a Choosing Wisely Canada campaign, and in February of this year the Canadian Rheumatology Association published their list of five. Though the methodology for coming up with the list was the same in these two very similar populations, there is surprisingly little overlap between the two lists. It is likely that the differences are partly explained by how medicine is practiced and paid for in the two countries. How invested physicians are in their respective professional societies may play a role, too. As part of the methodology, surveys were sent out to membership: At the time of the study the ACR had 6,188 members and a 17% response rate, while the CRA had a membership of 484 and a 35% response rate.

The ACR publication reminds us that the initiative is in part a response to a physician charter for medical professionalism, drafted in 2002 by a collaboration of physician organizations, including the ABIM Foundation and the American College of Physicians, outlining principles of professionalism, “including patient welfare, patient autonomy, and social justice” (Ann. Intern. Med. 2002;136:143-6).

Social justice, according to the ACR, “calls on the profession to promote a fair distribution of health care resources and to engage in collective efforts to improve the health care system for the welfare of society.” I wonder if the gap between the survey response rates of the American and the Canadian groups reflects greater indifference to societal welfare, but I certainly hope not.

In any event, I would like to devote some space to reviewing these two lists. They are worth revisiting often. I’ve included some clarifying statements from each publication that I thought were helpful.

The ACR list (Arthritis Care Res. 2013;65:329-39)

• Do not test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA in the setting of lupus or Sjögren syndrome.

• Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate examination findings. Diffuse arthralgias, myalgias, or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.

• Do not perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.

• Do not prescribe biologic agents for RA before a trial of methotrexate (or another conventional nonbiologic DMARD)

• Do not routinely repeat DXA scans more often than once every 2 years. DXA scans should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected.

The CRA list (J. Rheumatol. 2015;42:682-9)

• Do not order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus or other connective tissue disease. At one center in Canada, ANA testing was positive only 15% of the time and cost more than $800,000 over 3 years when combined with ENA and anti-dsDNA. … An ANA test should be ordered only if the clinician feels there is reasonable clinical suspicion of SLE or CTD based on historical information, physical findings and results of other laboratory tests.

• Do not order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms. There is no clinical utility to ordering an HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.

• Do not repeat DXA scans more often than every 2 years. If BMD are stable and/or individuals are at low risk of fracture, then less frequent monitoring up to an interval of 5-10 years can be considered.

• Do not prescribe bisphosphonates for patients at low risk of fracture.

• Do not perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adult population.

Dr. Chan practices rheumatology in Pawtucket, R.I.