“We performed a … thoughtful analysis of the available scientific literature for each of the remaining items,” says Dr. King. “We omitted a few of the higher-scoring items because robust evidence was lacking.”
There were other criteria that went into the discussions of what would make the list. The relevance of the items to rheumatology practice and the potential downstream harms of overuse were considered, as was cost.
“We looked at some tests for which false positive results can be misleading,” says Audrey B. Uknis, MD, ACR president and professor of medicine and senior associate dean for admissions and strategy at Temple University in Philadelphia. “Pretest probability is critical. We don’t want to send doctors on a wild goose chase looking for diseases that don’t really exist, especially if inappropriate treatments are given as a result.”
Dr. Yazdany noted that the task force members were expecting it to be much tougher than it was to narrow the options down to only five.
“Because we had gone through the process of asking clinicians to generate ideas, doing all the surveys, and then a review of the literature, it was very apparent which concerns were the most important to rheumatologists,” she says. “Where they saw waste, and areas that had good evidence supporting our statements, these were the areas that needed to be examined closely.”
Not Prescriptive List
All three rheumatologists interviewed here stress that this is not a list of things providers cannot do. This is meant to open a dialogue between providers and patients in an effort to curb waste and unnecessary spending while still ensuring high quality patient care.
“This is not a prescriptive list of what providers have to do, as there is no substitute for experience and clinical judgment,” says Dr. King. “The list is based on the best available current evidence and is not immutable. As the research matures, changes will be made as needed.”
Although the main audience for the list is rheumatologists and rheumatology patients, it can also serve as guidance for physicians in the general community who take care of patients with rheumatic diseases.
“These are the kinds of things that are the bread and butter of rheumatology, the things we know best,” says Dr. Uknis. “This is our attempt to share our knowledge and best practices.”
Kurt Ullman is a freelance writer based in Indiana.