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Review Diagnostic tests for rheumatic disease: clinical utility revisited. 2005
Shmerling RH. · Division of Rheumatology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston MA, USA. · South Med J. · Pubmed #16108239 No free full text.
Abstract: Establishing a diagnosis of systemic rheumatic disease requires an integration of a patient's symptoms, physical examination findings, and the results of diagnostic testing. There is often a temptation by clinicians to rely heavily on objective measures such as the presence or absence of an autoantibody. Medical textbooks and the medical literature may overestimate the diagnostic utility of many commonly ordered tests for rheumatic disease because the tests are usually analyzed among patients with established rheumatic disease rather than among patients with an uncertain cause of symptoms as is common in practice. Few diagnostic tests are highly sensitive, though the antinuclear antibody in systemic lupus erythematosus (SLE) and the erythrocyte sedimentation rate in temporal arteritis are notable exceptions. Conversely, few diagnostic tests are highly specific; anti-proteinase-3 and antimyeloperoxidase antibodies (types of antineutrophilic cytoplasmic antibodies) among patients with Wegener granulomatosis (and related vasculitides) and anti-double-stranded and anti-Smith antibodies among patients with SLE may be particularly helpful in the proper clinical settings due to their high specificity. Anticitrullinated cyclic protein (anti-CCP), a newly described autoantibody that may be highly specific for rheumatoid arthritis, requires additional study as its utility in clinical practice is uncertain.
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Article A computer based intervention to reduce unnecessary serologic testing. 1999
Solomon DH, Shmerling RH, Schur PH, Lew R, Fiskio J, Bates DW. · Robert B. Brigham Multipurpose Arthritis and Musculoskeletal Diseases Center, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA. · J Rheumatol. · Pubmed #10606365 No free full text.
Abstract: OBJECTIVE: Laboratory testing is important in the evaluation of patients with possible systemic rheumatic disease, but uncritical use of any test may result in misleading information and unnecessary costs. We attempted to reduce the number of unnecessary antinuclear antibody, rheumatoid factor, and complement level tests ordered by house officers at a large teaching hospital, where inpatient orders are written through a computer based order entry system. METHODS: We conducted a prospective cohort study of an interactive test ordering program. The intervention consisted of displaying post-test probability estimates during the usual physician order entry session. These estimates were based on pretest probabilities entered by the ordering physician and sensitivities and specificities derived from a literature review. Another group of test orders did not prompt the intervention and were considered controls. The outcome of interest was the percentage of tests canceled in the intervention group versus the control group. RESULTS: Eleven percent (11/99) of intervention orders were canceled, versus only one order among 236 controls (p = 0.001). However, there was no association between the physicians' pretest probability estimates and whether test orders were canceled (p = 0.59). Additionally, 43 of the 335 orders (13%) yielded positive tests, but only 4 patients (1%) were given new diagnoses of rheumatic disease. CONCLUSION: The computer based intervention significantly reduced orders for antinuclear antibody and rheumatoid factor levels by 10%. Further reductions without clinical harm are probably possible, since the yield of testing for new rheumatic diseases was low.
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