Background/Purpose: In March 2013, the American College of Rheumatology published its Top 5 List of Things Physicians and Patients Should Question as part of the American Board of Internal Medicine’s Choosing Wisely campaign. First on the list was “Don’t test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease.” Previously, we examined positive subserologies when the ANA was negative, and were surprised to find that rheumatologists were frequently ordering subserologies when the ANA was negative. The present study was undertaken to elucidate the extent of this ordering pattern and understand the providers’ rationales. The ultimate goal is to develop a quality improvement program to support cost effective utilization of subserologies.

Methods: We conducted a retrospective study of the Geisinger Health System that includes 2198 providers; 342 in primary care and 14 in rheumatology.  We looked at the incidence of subserologies ordered simultaneously with an ELISA ANA when the ANA result was normal.  Data from 2011-2012 was collected via the Sunquest lab system and EPIC electronic health record. Subserologies included were ELISA dsDNA, Anti-Smith/RNP, SSA/SSB, SCL70 and JO1 antibodies.  Since anti-Smith/RNP, SCL70, and dsDNA should be negative when the ANA screen is negative, those testing instances represent unnecessary utilization. A six question survey was sent to providers who ordered ANA negative subserologies more than twice in an attempt to determine the providers’ ordering rationale and to ascertain if they had quality improvement educational preferences.  Finally, a cost analysis was done totaling the allowed reimbursement of unnecessary subserology tests based on the Medicare fee schedule. 

Results: 22596 ANA tests were ordered from 2011-2012.  2246 ANA’s were ordered at the same time as subserologies when all tests were negative (9.4%).  32.8% were ordered by Rheumatologists. 

Out of 440 unique ordering providers, 183 ordered testing more than twice.  130 were sent the survey and 47 completed it.  The primary reasons for ordering ANA’s in conjunction with subserologies were an unclear diagnosis based on history and physical (16) and patient convenience (7).  Providers were asked about opportunities for quality improvement. 10 preferred monetary incentives, 18 were interested in educational materials, 28 favored reflex testing, and 10 would want training through the EHR.

In our cost analysis we found that, excluding SSA/SSB and Jo-1, the estimated total cost of subserologies ordered with a negative ANA from 2011-2012 was $39,091.

Conclusion: In the Geisinger Integrated Health System, Rheumatologists frequently did not choose subserologies wisely.  No specialty was immune from ordering ANA’s and subserologies simultaneously.  Responding physicians were most receptive to educational materials and reflex testing to help eliminate superfluous subserologies.  If reflex testing had been available in 2011-2012, Geisinger would have saved close to $40,000 in unnecessary tests.  We will be implementing an ANA/reflex subserology option combined with directed provider education about ordering patterns to improve utilization.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/choosing-subserologies-wisely-an-opportunity-for-rheumatologic-healthcare-resource-savings/