Public health

Kiwi rheumatologists add three more “do-not-do” low value activities

Rheumatologists across the Tasman have released a top five list of ‘low value activities’ to be avoided that adds three more on top of Australian EVOLVE recommendations.

The New Zealand Rheumatology Association’s top five ‘do not do’ activities for the RACP initiative include:

  • Do not prescribe more than the minimum effective dose of glucocoricosteroid therapy (10-20mg daily) for initial treatment of polymyalgia rheumatica;
  • Do not order extractable nuclear antibodies ENA testing in patients with negative antinuclear antibodies;
  • Do not repeat DEXA scans for diagnosis of osteoporosis more than every five years for patients in good health, with no risk factors for accelerated bone loss or fracture with T scores greater than -2.00.

Their list also includes two recommendations previously made by the Australian Rheumatology Association (ARA) on its EVOLVE list:

  • Do not perform arthroscopy with lavage and/or debridement or partial meniscectomy for patients with symptomatic osteoarthritis of the knee and/or degenerate meniscal tear;
  • Do not order anti-double stranded DNA antibodies in antinuclear antibody (ANA) negative patients unless clinical suspicion of systemic lupus erythematosus remains high.

The ARA also made recommendations against ordering ANA testing without symptoms and/or signs suggestive of a systemic rheumatic disease; against imaging for low back pain in patients without indications of a serious underlying condition and against ultrasound guidance to perform injections into the subacromial space as it provides no additional benefit in comparison to landmark-guided injection.

Dr Rebecca Grainger, a rheumatologist and senior lecturer at the University of Otago, said it was unnecessary to routinely order of ENA and anti-dsDNA antibodies tests for patients who have already tested negative for a more general ANA test. The practice can lead to false positive results, cause anxiety in patients and waste precious health resources.

“There are some specific exceptions to this rule. ENA testing in patients who have already tested negative for antinuclear antibodies could be warranted where the doctor has a high clinical suspicion of an autoimmune condition,” she said.

The new recommendations are consistent with international guidelines and could lead to a 10% reduction in these kinds of tests each year, which in the city of Wellington would mean at least 650 fewer tests, she concluded.

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