ABSTRACT

In 2012, the American Board of Internal Medicine Foundation launched a health initiative campaign named “Choosing Wisely” to advance a national dialog on avoiding unnecessary medical tests, treatments, and procedures. Each specialty society, including the American College of Rheumatology, developed evidence-based recommendation lists about tests and treatments that were overused and did not provide meaningful benefit to patients. In Turkey, only the Turkish Society of Internal Medicine published their recommendations within the scope of this campaign. The Turkish Society for Rheumatology should also publish its Choosing Wisely recommendations.

Dear Editor,

The American Board of Internal Medicine Foundation launched a health initiative campaign named “Choosing Wisely” in 2012 to advance a national dialog on avoiding unnecessary medical tests, treatments, and procedures. Then, each specialty society developed lists of evidence-based recommendations about overused tests and treatments that did not provide benefits. Currently, the Choosing Wisely campaign has partnered with more than 70 societies involving more than one million clinicians^[1] in the US, Canada, Australia and Europe. In Turkey, the Turkish Society of Internal Medicine has been working with the European Federation of Internal Medicine within the frame of the Choosing Wisely Project since 2017.^[2]

It is always important to perform appropriate diagnostic autoantibody tests in rheumatology practice. In a study to evaluate the serological and clinical features of patients referred through a central triage system because of a positive anti-nuclear antibody (ANA), approximately 15% of referrals had only antibodies to DFS70, the vast majority of which did not have clinical evidence for an ANA associated rheumatic disease.^[3] Unnecessarily studied positive test results encourage inappropriate referrals from primary and secondary care physicians to tertiary care specialists.

There is clear common ground with efforts to optimize autoantibody tests using and Choosing Wisely campaign. The starting point is to define the most common wrong practices in terms of overuse -and of course underuse could also be a problem- of diagnostics and therapeutic interventions to choose wisely, especially in the post-pandemic world.

The American College of Rheumatology had five recommendations for physicians and patients should question below;^[4]

1. Don’t test ANA sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.

2. Don’t test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings.

3. Don’t perform magnetic resonance imaging of the peripheral joints to routinely monitor inflammatory arthritis.

4. Don’t prescribe biologics for rheumatoid arthritis before a trial of methotrexate (or other conventional non-biologic disease-modifying antirheumatic drugs).

5. Don’t routinely repeat dual energy X-ray absorptiometry scans more often than once every two years.

The top 5 issues may change according to time, health policies of countries, socio-cultural and economic conditions. This viable solution requires active and organized efforts, and the most important and leading of these organizations are professional societies such as the Turkish Society for Rheumatology. Are the recommendations by The American College of Rheumatology applicable to even in Turkey?

The coronavirus disease-2019 (COVID-19) pandemic has changed the socio-cultural and economic balances worldwide. Countries with the strongest economies in the world were helpless against the pandemic, and the pandemic led them to revise and question their health systems. Additionally, it reminded us once again how vital the rational management of existing resources is, such as avoiding unnecessary tests. As an example, the evidence of elevated false-positive autoantibody levels following severe acute respiratory syndrome coronavirus 2 infection should be a warning to avoid unnecessary testing.^[5]

In the post-COVID-19 era, the Choosing Wisely philosophy will be much more meaningful and these recommendations may need to be revised.

I believe that it is time to start an awareness for Choosing Wisely campaign in the field of Rheumatology in Turkey. The Rheumatology Societies should take the initiative to launch a Choosing Wisely campaign in Rheumatology. I want to start the discussion of this topic with a question: What are the top 5 problems/recommendations in the field of rheumatology in Turkey?

Ethic

Peer-review: Externally peer-reviewed.

Conflict of Interest: No conflict of interest was declared by the author.

Financial Disclosure: The author declare that they have no relevant financial disclosures.