Australian Rheumatology Association
Evolve Top-5 Recommendations on low-value practices

The Australian Rheumatology Association (ARA) is an association of rheumatologists in Australia that is a specialty society of the Royal Australasian College of Physicians (RACP). Rheumatologists are specialist physicians with particular expertise in the diagnosis and holistic management of diseases that affect joints, muscles, tendons and bones. They treat all forms of arthritis, autoimmune connective tissue disease, spinal and soft tissue disorders and certain metabolic bone disorders, such as osteoporosis and chronic musculoskeletal pain syndromes.

Download the Australian Rheumatology Association Top 5 List

1

Do not perform arthroscopy with lavage and/or debridement or partial meniscectomy in patients with symptomatic osteoarthritis of the knee and/or degenerate meniscal tear

Rationale

There is consistent evidence to indicate that arthroscopic lavage and/or debridement to treat people for symptomatic knee osteoarthritis, and/or partial meniscectomy for patients with a degenerate meniscal tear (with or without underlying osteoarthritis), is no more effective than placebo surgery or non-operative alternatives.

There appears to be a high rate of conversion from knee arthroscopy to total knee arthroplasty, which rises with increased age, further suggesting arthroscopic surgery should be avoided in people over the age of 50 years. Additionally, arthroscopy is associated with peri and post-operative risks and considerable cost.

Evidence

Buchbinder R, Richards B, Harris I. Knee osteoarthritis and role for surgical intervention: lessons learned from randomized clinical trials and population-based cohorts. Curr Opin Rheumatol 2014; 26: 138-144.

Fedorka CJ, Cerynik DL, Tauberg B, Toossi N, Johanson NA. The relationship between knee arthroscopy and arthroplasty in patients under 65 years of age. J Arthroplasty 2014; 29: 335-338.

Khan M, Evaniew N, Bedi A, Ayeni OR, Bhandari M. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ 2014; 186: 1057-1064.

Katz JN, Brophy RH, Chaisson CE, de Chaves L, Cole BJ, Dahm DL, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med 2013; 368: 1675-1684.

Sihvonen R, Paavola M, Malmivaara A, Itala A, Joukainen A, Nurmi H, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013; 369: 2515-2524.

Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ 2015, 350: h2747.

Wai EK, Kreder HJ, Williams JI. Arthroscopic débridement of the knee for osteoarthritis in patients fifty years of age or older: utilization and outcomes in the Province of Ontario. J Bone Joint Surg Am 2002; 84-A: 17-22.
2

Do not order antinuclear antibody (ANA) testing without symptoms and/or signs suggestive of a systemic rheumatic disease

Rationale

Antinuclear antibodies (ANAs) are present in healthy individuals and ANA testing is only useful in patients with symptoms and/ or signs of a rheumatic disease where it can aid in the confirmation or exclusion of systemic connective tissues diseases. ANA testing has a very high negative predictive value for excluding connective tissue diseases as a cause for patients’ symptoms. However, a positive ANA result does not have a high positive predictive value for diagnosing these conditions in isolation, and further sub-serology testing is needed to accurately diagnose and classify these conditions.

Evidence

Agmon-Levin N, Damoiseaux J, Kallenberg C, Sack U, Witte T, Herold M, et al. International recommendations for the assessment of autoantibodies to cellular antigens referred to as anti-nuclear antibodies. Ann Rheum Dis 2014; 73: 17-23.

British Columbia Guidelines: Antinuclear Antibody (ANA) Testing for Connective Tissue Disease [homepage on the Internet] British Columbia: Ministry of Health [updated 1 June 2013; cited 18 Sept 2017]. Available at: http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bcguidelines/ana-testing

Solomon DH, Kavanaugh AJ, Schur PH. Evidence-based guidelines for the use of immunologic tests: antinuclear antibody testing. Arthritis Rheum 2002; 47: 434-444.
3

Do not undertake imaging for low back pain in patients without indications of a serious underlying condition

Rationale

Most episodes of low back pain (~90%) do not require imaging. Imaging may identify irrelevant incidental findings and increase the risk of exposure to unnecessary, and sometimes invasive treatment, in addition to increasing costs. For patients with low back pain and no suggestion of serious underlying conditions there are no significant differences in pain or disability outcomes between immediate imaging as compared with usual care without imaging.

Evidence

Graves JM, Fulton-Kehoe D, Martin DP, Jarvik JG, Franklin GM. Factors associated with early magnetic resonance imaging utilization for acute occupational low back pain: a population-based study from Washington State workers' compensation. Spine 2012; 37: 1708-1718.

Jarvik JG, Gold LS, Comstock BA, Heagerty PJ, Rundell SD, Turner JA, et al. Association of early imaging for back pain with clinical outcomes in older adults. JAMA 2015; 313: 1143-1153.

Suri P, Boyko EJ, Goldberg J, Forsberg CW, Jarvik JG. Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or radicular symptoms: retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (LAIDBACK). BMC Musculoskel Dis 2014, 15: 152.

Webster BS, Bauer AZ, Choi Y, Cifuentes M, Pransky GS. Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine 2013; 38: 1939-1946.
4

Do not use ultrasound guidance to perform injections into the subacromial space as it provides no additional benefit in comparison to landmark-guided injection

Rationale

Currently there is no high-quality evidence to support the superiority of ultrasound-guided subacromial injections compared with injections guided by landmarks alone. Based upon moderate quality evidence from five trials, a Cochrane review was unable to find any advantage (in terms of pain, function, range of motion or adverse events) of ultrasound-guided injection over either landmark-guided or intramuscular injection. These results are consistent with a more recent trial. In view of the currently available data and the significant added cost, there is little clinical justification in using ultrasound to guide injections for shoulder pain.

Evidence

Bloom JE, Rischin A, Johnston RV, Buchbinder R. Image-guided versus blind glucocorticoid injection for shoulder pain. Cochrane Database System Rev 2012; 8: CD009147.

Dogu B, Yucel SD, Sag SY, Bankaoglu M, Kuran B. Blind or ultrasound-guided corticosteroid injections and short-term response in subacromial impingement syndrome: a randomized, double-blind, prospective study. Am J Phys Med Rehabil 2012; 91: 658-665.
5

Do not order anti-double standard (ds) DNA antibodies in ANA negative patients unless clinical suspicion of systemic lupus erythematosus (SLE) remains high

Rationale

International recommendations advise testing for anti-dsDNA antibodies only after detecting a positive ANA in patients with symptoms consistent with systemic lupus erythematosus. In patients who are ANA negative, anti-dsDNA should only be ordered in clinical situations where the pre-test probability of SLE is very high. Where positive, repeating anti-dsDNA antibodies titres is a useful test for monitoring disease activity, especially in lupus nephritis.

Evidence

Agmon-Levin N, Damoiseaux J, Kallenberg C, Sack U, Witte T, Herold M, et al. International recommendations for the assessment of autoantibodies to cellular antigens referred to as anti-nuclear antibodies. Ann Rheum Dis 2014; 73: 17-23.

Kavanaugh AF, Solomon DH. Guidelines for immunologic laboratory testing in the rheumatic diseases: anti-DNA antibody tests. Arthritis Rheum 2002; 47: 546-555.

Linnik MD, Hu JZ, Heilbrunn KR, Strand V, Hurley FL, Joh T. Relationship between anti-double-stranded DNA antibodies and exacerbation of renal disease in patients with systemic lupus erythematosus. Arthritis Rheum 2005; 52: 1129-1137.

How this list was developed

An ARA Evolve working group comprising of 19 rheumatologists and 3 advanced rheumatology trainees was established after a call for interest. The group agreed that items should be included if they were either primarily a rheumatologist issue or an issue that rheumatologists should advocate for on behalf of their patients. A preliminary list of low-value clinical practices was created based upon the working group’s clinical experiences, as well as consideration of potentially relevant items identified from a review of other lists generated. This list was refined into 12 items and small teams for each topic were formed to review the evidence pertaining to these items and their relevance to Australian healthcare. Brief summaries of the evidence were written based on NHMRC evidence review standards. An anonymous online survey was created based on these summaries and all ordinary (356 rheumatologists) and associate (72 rheumatology trainees) ARA members were invited to participate. Survey participants were asked to select the five recommendations for which they considered the evidence to be the strongest. The survey attracted a 50% response rate and based on its results, the ARA top five recommendations were formulated.

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