Choosing wisely in daily practice: a mixed methods study on determinants of antinuclear antibody testing by rheumatologists

Scand J Rheumatol. 2017 May;46(3):241-246. doi: 10.1080/03009742.2016.1190983. Epub 2016 Jul 29.


Objectives: To explore the relationship between antinuclear antibody (ANA) overuse and rheumatologist-related factors before and after an intervention aimed at reducing ANA overuse.

Method: In this mixed methods study we performed surveys among rheumatologists (n = 20) before and after the ANA intervention (education and feedback). We identified clinician-related determinants of ANA overuse (demographic characteristics, cognitive bias, numeracy, personality, thinking styles, and knowledge) by multivariate analysis. Two focus group meetings with rheumatologists were held 6 months after the intervention to explore self-reported determinants.

Results: Questionnaires were completed by all rheumatologists and eight participated in the focus groups. Rheumatologists with more work experience and a less extravert personality ordered more ANA tests before the intervention [β = 0.01, 95% confidence interval (CI) 0.003 to 0.02, p = 0.01 and β = -0.11, 95% CI -0.21 to -0.01, p = 0.04, respectively; R2 = 47%]. After the intervention, female rheumatologists changed less than their male colleagues with regard to the number of ANA tests ordered (β = 0.15, 95% CI 0.03-0.26, p = 0.02; R2 = 25%). During the focus groups, seven themes were identified that influenced improvement in ANA overuse: determinants related to the intervention and the study, individual health professionals, patients, professional interactions, incentives and resources, capacity for organizational change, and social, political, and legal factors.

Conclusions: We identified several determinants that together explained a sizable part of the variance observed in the ANA outcomes at baseline and in the change in ANA outcomes afterwards. Furthermore, the focus groups yielded additional factors suggesting a complex interplay of determinants influencing rheumatologists' ANA ordering behaviour.

Publication types

  • Pragmatic Clinical Trial

MeSH terms

  • Adult
  • Antibodies, Antinuclear*
  • Clinical Competence*
  • Cognition
  • Controlled Before-After Studies
  • Education, Medical, Continuing
  • Extraversion, Psychological
  • Feedback
  • Female
  • Focus Groups
  • Humans
  • Male
  • Medical Overuse / prevention & control
  • Medical Overuse / statistics & numerical data*
  • Middle Aged
  • Multivariate Analysis
  • Personality
  • Practice Patterns, Physicians' / statistics & numerical data*
  • Qualitative Research
  • Rheumatologists / psychology
  • Rheumatologists / statistics & numerical data*
  • Serologic Tests / statistics & numerical data*
  • Surveys and Questionnaires


  • Antibodies, Antinuclear