Choosing wisely: Review and commentary on anti-nuclear antibody (ANA) testing

Choosing Wisely®: Next Steps in Improving Healthcare Value is an initiative of the American Board of Internal Medicine (ABIM) Foundation. The driving forces for the Choosing Wisely (CW) campaign include rising and unstainable health care expenditures and evidence that there is lack of fiscal stewardship of health care resources. The American College of Rheumatology and the Canadian Rheumatology Association published their top five Choosing Wisely recommendations, the first of which pertained to antinuclear antibodies (ANA) and ANA subserology testing. Concerns about the wasteful use of these tests prompted an analysis of the expenditures attributable to ANA testing as a proportion of total health care expenditures and based on a financial model was in the range of 0.00125%. It is suggested that if the sole use of ANA testing is to add evidence to support a diagnosis when the pre-test probability is high, then the ANA test has limited clinical value. Accordingly, the goal of ANA testing needs to be reconsidered and expanded beyond an approach to simply confirming a diagnosis with 'intention to treat' to a goal of case finding of 'pre- or early disease' with an 'intent to prevent' disease. This an area where more significant inroads can be made in preventing end organ disease and thereby reducing health care expenditures HCE. One CW recommendation that bears emphasizing is that, with a few possible exceptions, repeat ANA or ANA subserology testing has little clinical value in monitoring disease activity or predicting a flare.