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Utilization & predictive value of laboratory tests in patients referred to rheumatologists by primary care physicians

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By Suarez-Almazor ME, Gonzalez-Lopez L, Gamez-Nava JI, Belseck E, Kendall CJ, Davis P • • October 15, 1998

OBJECTIVE: Antinuclear antibodies (ANA), rheumatoid factors
(RF), and erythrocyte sedimentation rate (ESR) are among the
most frequently requested tests in the diagnosis and
investigation of connective tissue diseases (CTD). We evaluate
the utilization patterns and predictive value of these tests
in patients referred to rheumatologists by primary care
METHODS: We reviewed the records of all new
patients referred by primary care physicians in 1994 to 2
rheumatologists practicing at the University of Alberta. Data
extracted from the records included diagnostic tests requested
by referring primary care physicians, signs and symptoms at
the initial rheumatology consult, and followup diagnoses.
RESULTS: Seven hundred eleven new patients had been referred
by over 300 primary care physicians: RF had been requested in
25%, ANA in 21%, and ESR in 29%. One hundred nine (15%) of the
711 patients had a CTD, 45 (6%) had rheumatoid arthritis (RA),
and 8 (1%) systemic lupus erythematosus (SLE). The predictive
values of positive tests for the diagnosis of CTD were low:
49% for RF, 29% for ANA, and 35% for ESR. For RA, the positive
predictive values were 44% for RF, 8% for ANA, 17% for ESR;
for SLE, 2, 12, and 3%, respectively. Diffuse musculoskeletal
pain and fatigue were significantly associated with test
utilization, although most patients with these symptoms had
fibromyalgia or localized soft tissue rheumatism.
Primary care physicians frequently requested autoantibodies in
patients referred to rheumatologists. Most tests were
negative, and were often requested in patients without CTD,
resulting in low positive predictive values and questionable
clinical utility. These findings suggest inappropriate overuse
and lack of understanding of the use of autoantibody tests in
diagnosing rheumatic diseases. A decrease in inappropriate use
could be achieved by emphasizing that fatigue and diffuse
musculoskeletal pain are not indicative of CTD in the absence
of other features such as joint swelling, typical rash, or
organ involvement.

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