Unnecessary Lab Tests for Systemic Lupus Erythematosus?

VBCR - December 2015, Volume 4, No 6 - Lupus
Alice Goodman

It appears that unnecessary and avoidable serial routine laboratory tests are ordered for about 11% of patients with systemic lupus erythematosus (SLE) at each office visit, according to a recent survey of medical practices that treat these patients.

“There is room for quality improvement efforts to reduce the healthcare utilization cost for SLE patients. These unnecessary serial tests identified in this survey may underestimate the burden of the problem, which is inherent in the design of a self-reported survey. We need larger studies to explore this issue,” said lead author Aman Kugasia, MD, John H. Stroger, Jr Hospital of Cook County, Chicago, IL.

The 13-item survey designed by the Lupus Society of Illinois was conducted online for physicians, mainly rheumatologists, who treat patients with SLE. Each recipient received a cover letter explaining the purpose of the study, which was to improve patient care, as well as an electronic link to the survey.

Eighty-six physicians completed the survey; 97% were rheumatologists, 46 MDs practiced in an academic setting, 27 practiced in a private setting, and the remaining 13 practiced in both types of setting. Mean age of respondents was 55 years.

At baseline, demographics, training, and medical certification status were well-balanced according to type of practice setting. However, private practitioners had a greater workload than academic physicians: 96% versus 46%, respectively, worked more than 20 hours a week (P <.001).

Also, no significant differences were observed in the number of patients with SLE seen per month or the time intervals between patients’ longitudinal visits. About 54% of all physicians see more than 20 patients with SLE per month. The majority (81%) of respondents see their patients every 3 to 4 months.

Most physicians performed antinuclear antibody (ANA) testing by indirect fluorescent antibody (IFA) assay rather than by enzyme-linked immunosorbent assay (ELISA): 70% versus 28%, respectively (P = .01). More academics used IFA (83%), whereas 44% of private practice physicians used ELISA.

Among all MDs, 77% ordered anti-dsDNA and 82% ordered C3/C4 testing. In addition, 40% to 60% ordered erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) tests, and over 90% ordered a urinalysis at each SLE patient visit. ESR and CRP were ordered more frequently by private practitioners than by academicians (P = .007 and P <.001, respectively, for each test).

The authors speculate that among private practice physicians, gaps in knowledge or practice patterns may be responsible for greater use of some serial laboratory tests that are unnecessary.

They recommend that physician education, targeting private practice physicians, should include indications and lack of prognostic utility for serial routine testing of ANA, ENA (extractable nuclear antigens), and SSA/SSB (Sjögren syndrome type A/B antigens) autoantibodies at each follow-up visit.

A limitation of this study is its small sample size.

Reference

Kugasia A, Jolly M, Sequeira W, et al. Physician patterns of patient care in systemic lupus erythematosus: are we ordering unnecessary tests? Presented at: 2015 American College of Rheumatology Annual Meeting; November 7-11, 2015; San Francisco, CA. Abstract 136.

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