Background/Purpose:

The ACR in 2013 and the Canadian Rheumatology Association (CRA) in 2015 published their respective Choosing Wisely recommendations to promote evidence-based care and reduce medical services that may have questionable value. HLA-B27 testing was #7 in ACR’s and #2 in CRA’s Choosing Wisely list of recommendations. HLA-B27 testing is not to be ordered unless features suggestive of a SpA are present. We sought to assess adherence to CRA’s Choosing Wisely recommendations (presence of 2 or more features or 1 feature with radiographic sacroiliitis) by primary care physicians (PCP) ordering HLA-B27 within a large integrated healthcare system and to identify additional areas for quality improvement.

Methods:

Retrospective analysis of all patients who had HLA-B27 testing at Regions Hospital/Health Partners, a large academic vertically and horizontally integrated healthcare system, from 1/1/2014 – 7/1/2015. Chart review identified features of SpA (defined as inflammatory back pain > 3 months with onset < 45 years old, peripheral synovitis, enthesitis, dactylitis, psoriasis, or uveitis) at the time of HLA-B27 testing. We assessed if any imaging (Xray, CT, or MRI) identifying sacroiliitis +/- 6 months from HLA-B27 order was present, the presence of inflammatory markers (ESR or CRP) +/- 1 month from the HLA-B27 order, and if an eventual diagnosis of SpA was made. Data were analyzed to generate descriptive information regarding frequency, demographics, as well as a cost analysis.

Results:

During the 18 months, a total of 627 tests were ordered; 336 by Rheumatologists, 68 by Ophthalmology, and 223 by PCPs. Age ranged from 1 to 92 years. We focused on PCP ordered HLA-B27 testing habits. Applying Choosing Wisely recommendations, only 31 of 223 tests (13.9%) were ordered correctly; 20 (9%) had two or more features, and 11 (4.9%) had one feature with a positive imaging result. Even if ONE feature alone was allowed to be an indication for testing (as opposed to the CRA recommended TWO), only 38.1% of tests were ordered correctly. In comparison, 80% of tests ordered by rheumatologists had one feature and 35% had at least two. The average cost of HLA-B27 test within our payer system is $70-100. Thus, a cost savings of $15,000-20,000 would have occurred if ordered correctly. This does not include secondary costs of referrals to specialists for positive results.

Conclusion:

Improperly ordered HLA-B27 tests occurred nearly 86% of the time from PCPs within our large integrated healthcare system resulting in a cost of $15,000-20,000. EMR educational implementation plans have been shown to be effective for quality improvement. We are planning on utilizing EMR ordering alerts to aid HLA-B27 ordering that is more consistent with Choosing Wisely recommendations which promote evidence-based care.

Table 1. Demographics and features in HLA-B27 testing between 1/2014 and 7/2015 in a large integrated healthcare system.