Choosing wisely: the American College of Rheumatology's Top 5 list of things physicians and patients should question

Abstract

Objective: We sought to develop a list of 5 tests, treatments, or services commonly used in rheumatology practice whose necessity or value should be questioned and discussed by physicians and patients.

Methods: We used a multistage process combining consensus methodology and literature reviews to arrive at the American College of Rheumatology's (ACR) Top 5 list. Rheumatologists from diverse practice settings generated items using the Delphi method. Items with high content agreement and perceived high prevalence advanced to a survey of ACR members, who comprise >90% of the US rheumatology workforce. To increase the response rate, a nested random sample of 390 rheumatologists received more intensive survey followup. The samples were combined and weighting procedures were applied to ensure generalizability. Items with high ratings underwent literature review. Final items were then selected and formulated by the task force.

Results: One hundred five unique items were proposed and narrowed down to 22 items during the Delphi rounds. A total of 1,052 rheumatologists (17% of those contacted) participated in the member-wide survey, whereas 33% of those in the nested random sample participated; respondent characteristics were similar in both samples. Based on survey results and available scientific evidence, 5 items (relating to antinuclear antibodies, Lyme disease, magnetic resonance imaging, bone absorptiometry, and biologic therapy for rheumatoid arthritis) were selected for inclusion.

Conclusion: The ACR Top 5 list is intended to promote discussions between physicians and patients about health care practices in rheumatology whose use should be questioned and to assist rheumatologists in providing high-value care.

Figure 1

Flow diagram showing methods for developing the American College of Rheumatology (ACR) Top 5 list. n = candidate items for the Top 5 list considered at each phase of the project.

Figure 2

Summary of themes that emerged from qualitative analysis of the American College of Rheumatology (ACR) Top 5 List survey. ACR members were asked to provide comments on either the individual candidate items proposed for the Top 5 list or any aspect of the overall project. Free-text survey responses were analyzed using qualitative analysis to identify major themes and subthemes. For additional details, please see Supplementary Table 2 and Table 3 (available in the online version of this article at http://onlinelibrary.wiley.com/.doi/10.1002/acr.21930/abstract).