rheumatology
Medicines

Five ‘do-not-do’ recommendations for rheumatology


Over enthusiasm for arthroscopy, some imaging and antibody testing have been called out in the Australian Rheumatology Association’s (ARA) top five list of investigations or interventions delivering low value.

As part of the EVOLVE initiative, 179 rheumatologists and 19 trainees helped identify the top five do-not-do’ statements from a preliminary list of evidence-based recommendations developed by an ARA working group.

ARA president Professor Rachelle Buchbinder said the focus was on reducing potential harm to patients and unnecessary cost to the health system.

“The recommendations were directed at our own activities but we also felt responsibility as experts in arthritis and musculoskeletal conditions that we didn’t want our patients treated in this way.”

“For example, we shouldn’t be offering arthroscopy to people with knee osteoarthritis ourselves and we would recommend GPs don’t offer it either.”

The top recommendation was to avoid arthroscopy for knee osteoarthritis or degenerative meniscal tears – which in 2015 cost almost $27.1 million.

“It’s consistent with the Australian clinical care standard for management of knee osteoarthritis and consistent with Australian and international guidelines,” she said.

“High quality evidence from randomised controlled trials show arthroscopy is no better than placebo and there are potential risks both peri-and post-operatively, and some suggestion that it might hasten joint replacement especially in older people.”

Professor Buchbinder told the limbic they also recommended against imaging for acute low back pain in the absence of worrying clinical features for the risk of doing more harm than good.

MBS-funded imaging for low back pain has increased consistently since 2004 primarily due to increased numbers of CT and MRI scans which cost $99.08 million in 2015.

“Again, imaging for acute onset back pain should be reserved only for people that you are worried might have a serious underlying condition such as malignancy or infection.”

She said age-related abnormalities were exceedingly common and potentially harmful downstream effects included patient worry, more imaging and unnecessary treatment.

Rheumatologists were also concerned about the increase in expensive ultrasound-guided injections and use of ultrasound to investigate shoulder pain, which may also detect age-related changes unrelated to the patient’s problem.

“For many parts of the body – knee and shoulder – it’s very easy to know where you are and to accurately place the needle using landmarks.  For some joints like these, there is evidence that imaging doesn’t make it any more effective.”

Other recommendations were to avoid anti-nuclear antibody (ANA) testing without symptoms of systemic rheumatic disease and anti-ds DNA antibody testing in people with a negative ANA and without a high degree of suspicion for lupus.

“A positive ANA in low titres is not uncommon in the general population so don’t order the test unless someone has clinical features that suggest the possibility of an autoimmune systemic disease.”

“If the ANA is negative and patients don’t have suspicious signs or symptoms of lupus, we shouldn’t request an anti-ds DNA as it is highly unlikely it will be elevated.”


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