Choosing Wisely: The Canadian Rheumatology Association Pediatric Committee's List of Items Physicians and Patients Should Question.

Abstract

To develop a list of tests or treatments frequently used in pediatric rheumatology practice which may be unnecessary based on existing evidence. A Choosing Wisely (CW) Working Group composed of 16 pediatric rheumatologists, one allied health practitioner, one parent, and one patient used the Delphi method to generate, rank, and refine a list of tests and treatments that may be unnecessary or harmful. The items with the highest content agreement and perceived impact were presented in a survey to all Canadian Rheumatology Association (CRA) physicians who practice pediatric rheumatology. Respondents were asked to rate their agreement, impact, and rank the items. Five items with the highest composite scores and two additional items selected by the CW Working Group were put forward for literature review. The initial Delphi procedure generated 80 items. After three rounds, the list was narrowed to 13 items. The survey was completed by 41/81 (51%) CRA pediatric members across Canada. Respondent characteristics were similar to the CRA pediatric membership for gender, geographical location, and career stage. The highest composite score items were anti-nuclear antibody testing, drug toxicity monitoring, human leukocyte antigen-B27 testing, rheumatoid factor/anti-cyclic citrullinated peptide testing, and Lyme serology testing. Two additional items (numerous or repeated intra-articular corticosteroid injections, and autoinflammatory diseases genetic testing) were also selected. Literature review was performed for these seven highest priority items. We have identified areas for quality improvement in the evaluation and treatment of rheumatic diseases in Canadian children.