American College of physicians ACP high value care recommendations in rheumatology part 1 diagnosis Ahmed Yehia Ismaeel, MD Beni-Suef University

1. ACP HVC (High
value care)
recommendation
s
Ahmed Yehia, MD

2. High Value Care
Recommendations
for the Rheumatology
section of MKSAP 19.

3. •The American College of Physicians,
in collaboration with multiple other
organizations, is engaged in a
worldwide initiative to promote the
practice of High Value Care (HVC).

4. The goals of the HVC initiative are to
•improve health care outcomes
by
• providing care of proven
benefit
•reducing costs by avoiding
unnecessary & even harmful
interventions.

5. The concept of health care value
clinical
benefit costs & harms
For a given intervention
"
‫نفعهما‬ ‫من‬ ‫أكبر‬ ‫وإثمهما‬
"

6. High Value Care
Recommendation
A recommendation to
choose diagnostic &
management strategies for
patients in specific clinical
situations that balance
clinical benefit with cost &
harms with the goal of
improving patient outcomes.

7. Postulation1
Rheumatic diseases can be
diagnosed only after investigations.

8. Case
•This 30-year-old lady
presents with recurrent
orogenital ulcers.
•What is your diagnosis?
•What are the
investigations needed for
this diagnosis
confirmation?

10. ICBD
Ocular lesions 2
Genital aphthosis 2
Oral aphthosis 2
Skin lesions 1
Neurological symptoms 1
Vascular manifestations 1
+ve Pathergy test
*
1
*
*Pathergy test is optional and the primary scoring system does not include pathergy testing. However, where
pathergy testing is conducted one extra point may be assigned for a positive result.
OGO (2) - BPCC (1)
All criteria are clinical.

11. What about HLA- B51?

12. HLA-B51 is more prevalent in
BD than the general population.
Due to low specificity & a
variable prevalence among
ethnicities, it is not considered
a diagnostic criterion in the
ICBD.
However, among BD patients in
this study, a significantly higher
percentage were positive for
HLA-B51 than patients in whom
BD was ruled out. This was not
the case for HLA-B5 and HLA-
B27.

13. •Because of the absence of specific biological criteria, the
diagnosis is essentially clinical. The diagnostic criteria make
it possible to establish the diagnosis with good sensitivity &
specificity.

14. •HLA-B51 does not confirm or
invalidate a diagnosis of Behçet’s
disease.

15. HVC
RECOMMENDATION 1
• An accurate history & a thorough musculoskeletal physical
examination are essential to diagnose & differentiate
inflammatory & noninflammatory symptoms & can help to
avoid unnecessary testing.

16. A good clinician is a
good observer.
A careful history provides 80% of the
diagnostic information.
Physical examination adds another 15%.
While Imaging & laboratory together
contribute only 5%.

17. Although immunologic
laboratory tests can have
great utility in the diagnosis
& management of patients
with rheumatic diseases,
they can be misused.
• Improper application of these tests can
result in
• Misdiagnosis
• inappropriate therapy
• unnecessary health care expenses.

18. So, postulation 1 is wrong.
Rheumatic diseases can be
diagnosed only after
investigations.

19. Case
Her GP requested her labs which revealed the
following:
CBC,
chemistry:
normal.
ESR: 8.
ANA, +ve,
1/40.
How to
assess?
A 40-year-old female patient presents with a 2
weeks history of diffuse bony pains. No other
signs or symptoms.

20. •Her physician requested S.
C3, C4, anti-dsDNA which all
came unremarkable.
•So, he requested ENAs.

21. +ve ENA , -ve ANA

22. Postulation 2
ANA = CTD.
ANA = SLE.

23. HVC
RECOMMENDATION 3
•Antinuclear antibody testing
should not be performed in a
patient with nonspecific
symptoms & normal findings on
clinical examination because it
does not establish the diagnosis of
a connective tissue disease.

24. ARA choosing wisely recommendation 2
•Do not order antinuclear antibody (ANA)
testing without symptoms and/or signs
suggestive of a systemic rheumatic disease.

25. ARA choosing wisely
recommendation 2
justification
•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.

26. Recommendation 1
•Don’t order ANA as a screening test in patients
without specific signs or symptoms of SLE or
another connective tissue disease (CTD).
Canadian Rheumatology Association, September 30, 2022

27. ANA reactivity is present in
Diseased
• Rheumatic
• Non-rheumatic
• Infectious
• Non-infectious
Healthy non-diseased (up to 20%)

28. Conditions associated
with positive ANA
• Condition % ANA-positive
• SLE 95-98
• Healthy relatives of SLE patients 15-25
• Rheumatoid arthritis 15-30
• Mixed connective tissue disease (MCTD) 95 -100
• Progressive systemic sclerosis 95
• Polymyositis 80
• Sjögren's syndrome 75-90
• Cirrhosis (all causes) 15
• Autoimmune liver disease (autoimmune hepatitis 60-90
• primary biliary cirrhosis
• Chronic HCV infection 10 - 30
• Normals 3 - 5
• Normal elderly (>70 yr.) 20 - 40
• Neoplasia 15-25

29. • Extensive laboratory studies (e.g., ANA testing) should also not be performed unless other specific
diagnoses are suspected. Positive ANA test results, particularly at low titers, are nonspecific & have
a low positive predictive value. Positive findings on ANA screening are highly prevalent in both the
general population & patients with fibromyalgia.
• In addition to ANA positivity driving unnecessary additional testing, patients with fibromyalgia &
positive ANA results are often incorrectly diagnosed with a connective tissue disease and given
inappropriate and potentially harmful therapy.

30. Pretest probability
•ANA in
• A 30-year-old female with this
rash, recurrent oral ulcers &
polyarthritis.
• A 70-year-old man with diffuse
pains & fatigue.

31. Unnecessary investigation= false positive

32. ANA testing should be used exclusively to
confirm the presence of a clinically suspected
connective tissue disease.
False (+) prevalence in the general population
is 5%.
Prevalence of SLE is 0.1% (PM = 0.05%, PSS =
0.03%)
Only 1 in 50 subjects with +ANA (1:80) in
unscreened population would have SLE
Qaseem A, Alguire P, Dallas P, et al. Appropriate use of
screening and diagnostic tests to foster high value, cost
conscious care. Ann Intern Med. 156:147-9, 2012

33. Because of limited specificity, results of
these tests should be
• always interpreted in the context of the clinical history & physical examination
• applied with great caution, if at all, in the setting of low pretest probability.

34. Case
• A 28-year-old lady presented
with 2 months history of LBP.
• It is aggravated by exertion & is
relieved by rest.
• She had unremarkable labs
apart from mildly elevated CRP.

35. What is the most
likely diagnosis?

36. Would you request HLA-B27?
No, low pretest probability.
•mechanical in character
•Duration < 3 months.
This LBP

37. Causes of low
back pain
• Lumbar spondylosis
• Disk herniation
• Spondylolisthesis
• Spinal stenosis
• Fracture (mostly osteoporotic)
• Nonspecific (idiopathic)
Mechanical
• Primary
• Metastatic
Neoplastic
• Spondyloarthritis
Inflammatory

38. Causes of low back pain
Infectious
• Vertebral
osteomyelitis
• Epidural
abscess
• Septic diskitis
• Herpes zoster
Metabolic
• Osteoporotic
compression
fractures
• Paget disease
Referred pain to
spine
• From major
viscera,
retroperitoneal
structures,
urogenital
system, aorta,
or hip

39. 80% of individuals have
a LBP episode at some
point throughout life.
• The incidence of SpA varies,
depending on the examined
populations, from 0.2% to 1.9%.
Mechanical
LBP
IBP
Uncommon presentation of a
common disease is more
common than a common
presentation of an uncommon
disease
Epidemiology

40. Recommendation 2
•Don’t order an HLA-B27 unless
spondyloarthritis is suspected based on specific
signs or symptoms.
Canadian Rheumatology Association, September 30, 2022

41. Recommendation 2
• HLA-B27 testing is not useful as a single diagnostic test in a patient with LBP without further SpA signs
or symptoms (e.g., IBP: 3 months duration with age of onset <45 years, peripheral synovitis, enthesitis,
dactylitis, psoriasis or uveitis) because the diagnosis of SPA in these patients is of low probability.
• If HLA-B27 is used, at least two SpA signs or symptoms, or the presence of positive imaging findings,
need to be present to classify a patient as having axial SpA. There is no clinical utility to ordering an
HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.
Canadian Rheumatology Association, September 30, 2022

43. SpA features
(Ahmed Yehia
mnemonics)
•Arthritis
•Psoriasis
•CRP ++
•Crohn’s / Colitis
•Dactylitis
•Enthesitis
•Eye (uveitis)
•Family history of SpA
•Good response to NSAIDs
•HLA B27
•Inflammatory back pain

44. Case: CSA
A 40-year-old female presents with 2-year bilateral knee
arthralgia with morning stiffness of 15 minutes. Other
joints are asymptomatic.
Musculoskeletal examination including the knees is
normal.
ESR: 12 mm (1st hour)
CRP: -ve
Rheumatoid factor came +ve, 16 (Reference < 8)
Anti-CCP is –ve.
How to proceed?

46. Recommendation 9
Don’t order Rheumatoid factor (RF) & Anti-
Citrullinated Protein Antibody (ACPA) unless patients
have clinically suspicious arthralgia (CSA) or arthritis
on exam.
Canadian Rheumatology Association, September 30, 2022

47. EULAR defined
characteristics
describing arthralgia at
risk for RA
• To be used in patients with
arthralgia without clinical
arthritis & without other
diagnosis or other explanation
for the arthralgia.

48. EULAR defined
characteristics
describing
arthralgia at
risk for RA
• Joint symptoms of recent onset (duration
<1 year)
• Symptoms located in MCP joints
• Duration of morning stiffness ≥60 min
• Most severe symptoms present in the early
morning
• Presence of a first-degree relative with RA
History taking
• Difficulty with making a fist
• Positive squeeze test of MCP joints
Physical examination

49. Recommendation 9
justification
Avoid ordering these autoantibodies in patients with arthralgia who do not meet
the CSA criteria or have arthritis (>1 swollen joint) on physical exam.
EULAR defines CSA at risk for developing RA as having 3 or more parameters.
Even in CSA with positive RF & ACPA, > 30%-60% of patients will not develop RA
over the next 2 years.
Most musculoskeletal pain causing global disability is not related to RA.
Inappropriate testing of RF serology in patients with low likelihood of RA is
associated with low positive predictive value (PPV) & increased cost.
Canadian Rheumatology Association, September 30, 2022

51. • In the absence of clinical involvement of small joints of hands, one
should be extremely reluctant to make a diagnosis of RA.

52. Rheumatic Conditions Infections Pulmonary Disease Miscellineous
RA (70-80%) SBE Silicosis Aging
SLE (15-35%)
MCTD (50-60%)
TB
Leprosy
Sarcoidosis Leukemia
Sjogren’s Syndrome
(75-95%)
Syphilis IPF Colon Cancer
Systemic Sclerosis Viral
infections
Asbestosis Cirrhosis- Hep C/PBC
Cryoglobulinemia
(40-100%)
Parasitic
Disease
Sarcoidosis
RF positive disease states

53. RF Positivity & Aging
Frequency of a positive RF increases with
age
•Age 20-60: 2-4%
•Age 60-70: 5%
•Age >70: 10-25%

54. HVC
RECOMMENDATION 4
•Antinuclear antibody (ANA)
subserology testing should not
be performed routinely, even in
the setting of a positive ANA
result, without strong clinical
suspicion of an underlying
connective tissue disease.

55. The American College of
Rheumatology's top 5 list for
choosing wisely
Do not test anti-nuclear antibody
(ANA) subserologies without
•a positive ANA &
•clinical suspicion of immune-
mediated disease.

56. An ENA panel will not be ordered when a
person has a negative ANA test.
The ANA test evaluates the
presence or absence of
autoantibodies.
The ENA panel aims to
determine to what
proteins in the cell
nucleus these
autoantibodies (anas)
react.

57. If an ANA is negative, then the
person is extremely unlikely to test
positive for a specific antinuclear
antibody (which is what the ENA
panel tests).

58. The pattern of positive & negative ENA panel is evaluated in the
context of the person’s clinical findings (signs & symptoms).
If someone has clinical findings that suggest a specific
autoimmune disorder and the corresponding ENA autoantibody
is positive, then it is likely that the person has that condition.
If an individual has symptoms but the autoantibody is not
present, it may mean that symptoms are due to another
condition.

59. Clinical Associations of ANA sub‐serologies and Connective
Tissue Disease

60. Anti-dsDNA
The sensitivity in the diagnosis of
SLE is only about 60%, while the
specificityis very high (>99%).
It should not be used as a screening
test for the diagnosis of SLE.
The major utility is in confirmation
of the diagnosis of lupus in ANA-
positive individuals.

61. • Unlike ANA, dsDNA levels
generally correlate with
disease activity, especially in
lupus nephritis.
• In some patients, the dsDNA
levels may not parallel disease
activity, the so-called “clinico-
serologic discordance.”

63. Case
A 30-year-old gentleman presented
with low back pain for 3 week.
His comprehensive history &
examination are unremarkable.
What is the best imaging modality?

64. First., let’s classify his back pain.
•Acute
< 4 weeks
•Subacute
4 : 12 weeks
•Chronic
> 12 weeks

65. Let’s revise
guidelines

66. American College of
Radiology ACR
Appropriateness Criteria
Low Back Pain

67. Variant 1: Acute LBP
with or without
radiculopathy.
No red flags.
No prior management
Initial imaging

68. He neglected
management &
came 2 weeks later
with the same pain.
What is the best
imaging modality?

69. First., let’s classify his back pain.
•Acute
< 4 weeks
•Subacute
4 : 12 weeks
•Chronic
> 12 weeks

70. Subacute or
chronic LBP with
or without
radiculopathy.
No red flags.
No prior
management
Initial imaging

71. You started conservative therapy.
In the absence of red flags, first-line treatment for chronic LBP
remains conservative therapy with both pharmacologic & non-
pharmacologic (e.g. exercise, remaining active) therapy.
ACR recommendations

72. AAFP recommendations (2017 guidelines) for LBP
Nonpharmacologic treatment, including superficial heat, massage,
acupuncture, or spinal manipulation, should be used initially for
most patients with acute or subacute low back pain, as they will
improve over time regardless of treatment.
When pharmacologic treatment is desired, NSAIDs or
skeletal muscle relaxants should be used.

73. AAFP recommendations (2017 guidelines) for LBP
Nonpharmacologic treatment, including exercise,
multidisciplinary rehabilitation, acupuncture,
mindfulness-based stress reduction, tai chi, yoga, motor
control exercise, progressive relaxation, biofeedback,
low-level laser therapy, cognitive behavioural therapy, or
spinal manipulation, should be used initially for most
patients who have chronic low back pain.

74. For patients who have chronic LBP &
do not respond to nonpharmacologic
therapy, NSAIDs should be used.
Tramadol or duloxetine should be
considered for those patients who do
not respond to or do not tolerate
NSAIDs.
Opioids should only be considered if
other treatments are unsuccessful &
when the potential benefits outweigh
the risks for an individual patient.
Opioids (Consider risk & benefits)
Tramadol or duloxetine
NSAIDs
Non-pharmacologic therapy
Chronic LBP
AAFP recommendations (2017 guidelines)

75. ARA choosing wisely recommendation 4
•Do not undertake imaging for low back pain
(LBP) in patients without indications of a
serious underlying condition.

76. ARA choosing wisely recommendation 4 justification
•Most episodes of LBP (~90%) do not require imaging. Imaging
may identify irrelevant incidental findings & increase the risk
of exposure to unnecessary & sometimes invasive treatment
& increasing costs. For patients with LBP & 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.

77. The imaging modality of choice for the
initial evaluation of most rheumatic
conditions is
Conventional
Radiography
MRI CT
MSUS Bone scan.

78. HVC RECOMMENDATION 5: Radiography is usually the first
imaging test ordered in the evaluation of rheumatologic diseases
because it is
readily available
Inexpensive
exposes patients to only a low level of
ionizing radiation
useful in monitoring arthritis progression.

79. HVC RECOMMENDATION 6: Ultrasonography is an
inexpensive means to
assess soft-tissue abnormalities
assess disease activity
assist with tendon or joint injections.

80. • An international movement that
began in USA & has since
spread around the world.
• Launched in 2012 by
the American Board of Internal
Medicine (ABIM) Foundation to
advance a national dialogue on
how to avoid unnecessary
medical tests, treatments &
procedures.

82. ‫خيرين‬ ‫دايما‬ ‫مش‬ ‫الخير‬ ‫زيادة‬
.

83. Overprescription of
antibiotics has important
consequences
•increasing
antimicrobial-resistant
bacteria
•Dangerous
hypersensitivity
reactions
Inappropriate use of
surgery — common in
high-income countries —
•puts patients at risk of
surgical complications.

86. ‫حقنة‬
‫هتلر‬
‫لقتل‬
‫في‬
‫روس‬
‫اإلنفلونزا‬
‫قصدي‬
‫لق‬
‫تل‬
‫اإلنسان‬
!!
.1
‫فولتارينن‬
.2
‫ديكساميثازون‬
.3
‫سيفترياكسو‬
‫ن‬

87. No Egyptian
Recommendations

88. The American College of
Rheumatology's top 5 list for
choosing wisely
• 1. Do not test ANA subserologies without a positive ANA & clinical
suspicion of immune-mediated disease.
• 2. Do not test for Lyme disease as a cause of musculoskeletal symptoms
without an exposure history & appropriate examination findings.
• 3. Do not perform MRI of the peripheral joints to routinely monitor
inflammatory arthritis.
• 4. Do not prescribe biologic agents for RA before a trial of methotrexate
(or other conventional non-biologic disease-modifying anti-rheumatic
drug).
• 5. Do not routinely repeat dual x-ray absorptiometry scans more often
than once every 2 years.

89. ‫جزاكم‬
‫هللا‬
‫خيرا‬
‫رب‬ ‫هلل‬ ‫والحمد‬
‫العالمين‬