title: Choosing wisely: the Canadian Rheumatology Association's list of 5 items physicians and patients should question.
abstract: OBJECTIVE
  To develop a list of 5 tests or treatments used in rheumatology that have evidence indicating that they may be unnecessary and thus should be reevaluated by rheumatology healthcare providers and patients.
  
  
  METHODS
  Using the Delphi method, a committee of 16 rheumatologists from across Canada and an allied health professional generated a list of tests, procedures, or treatments in rheumatology that may be unnecessary, nonspecific, or insensitive. Items with high content agreement and perceived relevance advanced to a survey of Canadian Rheumatology Association (CRA) members. CRA members ranked these top items based on content agreement, effect, and item ranking. A methodology subcommittee discussed the items in light of their relevance to rheumatology, potential effect on patients, and the member survey results. Five candidate items selected were then subjected to a literature review. A group of patient collaborators with rheumatic diseases also reviewed these items.
  
  
  RESULTS
  Sixty-four unique items were proposed and after 3 Delphi rounds, this list was narrowed down to 13 items. In the member-wide survey, 172 rheumatologists responded (36% of those contacted). The respondent characteristics were similar to the membership at large in terms of sex and geographical distribution. Five topics (antinuclear antibodies testing, HLA-B27 testing, bone density testing, bone scans, and bisphosphonate use) with high ratings on agreement and effect were chosen for literature review.
  
  
  CONCLUSIONS
  The list of 5 items has identified starting points to promote discussion about practices that should be questioned to assist rheumatology healthcare providers in delivering high-quality care.
authors: From the Division of Rheumatology, Department of Medicine, University of Toronto, Toronto; Southlake Regional Health Centre, Newmarket; Division of Rheumatology, Department of Medicine, Western University, London; Division of Rheumatology, Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Medicine and Department of Rheumatic Diseases, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.S.L. Chow, MD; M.J. Bell, MD; Z. Bagheri, MD; D. Frackowiak, MD; B. Kuriya, MD, Division of Rheumatology, Department of Medicine, University of Toronto; J.C. Thorne, MD, Southlake Regional Health Centre; R. Ferrari, MD, Department of Medicine and Department of Rheumatic Diseases, University of Alberta; T. Boyd, MD; M. Jung, MD, Division of Rheumatology, Department of Medicine, Western University; A.M. Colwill, MD, Division of Rheumatology, Department of Medicine, University of British Columbia; G.S. Hazlewood, MD, Division of Rheumatology, Department of Medicine, University of Calgary; P. Tugwell, MD, Division of Rheumatology, Department of Medicine, University of Ottawa. Shirley.Chow@sunnybrook.ca.
authors: Shirley L
authors: SL
authors: Chow
authors: From the Division of Rheumatology, Department of Medicine, University of Toronto, Toronto; Southlake Regional Health Centre, Newmarket; Division of Rheumatology, Department of Medicine, Western University, London; Division of Rheumatology, Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Medicine and Department of Rheumatic Diseases, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.S.L. Chow, MD; M.J. Bell, MD; Z. Bagheri, MD; D. Frackowiak, MD; B. Kuriya, MD, Division of Rheumatology, Department of Medicine, University of Toronto; J.C. Thorne, MD, Southlake Regional Health Centre; R. Ferrari, MD, Department of Medicine and Department of Rheumatic Diseases, University of Alberta; T. Boyd, MD; M. Jung, MD, Division of Rheumatology, Department of Medicine, Western University; A.M. Colwill, MD, Division of Rheumatology, Department of Medicine, University of British Columbia; G.S. Hazlewood, MD, Division of Rheumatology, Department of Medicine, University of Calgary; P. Tugwell, MD, Division of Rheumatology, Department of Medicine, University of Ottawa.
authors: J
authors: J
authors: Carter Thorne
authors: From the Division of Rheumatology, Department of Medicine, University of Toronto, Toronto; Southlake Regional Health Centre, Newmarket; Division of Rheumatology, Department of Medicine, Western University, London; Division of Rheumatology, Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Medicine and Department of Rheumatic Diseases, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.S.L. Chow, MD; M.J. Bell, MD; Z. Bagheri, MD; D. Frackowiak, MD; B. Kuriya, MD, Division of Rheumatology, Department of Medicine, University of Toronto; J.C. Thorne, MD, Southlake Regional Health Centre; R. Ferrari, MD, Department of Medicine and Department of Rheumatic Diseases, University of Alberta; T. Boyd, MD; M. Jung, MD, Division of Rheumatology, Department of Medicine, Western University; A.M. Colwill, MD, Division of Rheumatology, Department of Medicine, University of British Columbia; G.S. Hazlewood, MD, Division of Rheumatology, Department of Medicine, University of Calgary; P. Tugwell, MD, Division of Rheumatology, Department of Medicine, University of Ottawa.
authors: Mary J
authors: MJ
authors: Bell
authors: From the Division of Rheumatology, Department of Medicine, University of Toronto, Toronto; Southlake Regional Health Centre, Newmarket; Division of Rheumatology, Department of Medicine, Western University, London; Division of Rheumatology, Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Medicine and Department of Rheumatic Diseases, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.S.L. Chow, MD; M.J. Bell, MD; Z. Bagheri, MD; D. Frackowiak, MD; B. Kuriya, MD, Division of Rheumatology, Department of Medicine, University of Toronto; J.C. Thorne, MD, Southlake Regional Health Centre; R. Ferrari, MD, Department of Medicine and Department of Rheumatic Diseases, University of Alberta; T. Boyd, MD; M. Jung, MD, Division of Rheumatology, Department of Medicine, Western University; A.M. Colwill, MD, Division of Rheumatology, Department of Medicine, University of British Columbia; G.S. Hazlewood, MD, Division of Rheumatology, Department of Medicine, University of Calgary; P. Tugwell, MD, Division of Rheumatology, Department of Medicine, University of Ottawa.
authors: Robert
authors: R
authors: Ferrari
authors: From the Division of Rheumatology, Department of Medicine, University of Toronto, Toronto; Southlake Regional Health Centre, Newmarket; Division of Rheumatology, Department of Medicine, Western University, London; Division of Rheumatology, Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Medicine and Department of Rheumatic Diseases, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.S.L. Chow, MD; M.J. Bell, MD; Z. Bagheri, MD; D. Frackowiak, MD; B. Kuriya, MD, Division of Rheumatology, Department of Medicine, University of Toronto; J.C. Thorne, MD, Southlake Regional Health Centre; R. Ferrari, MD, Department of Medicine and Department of Rheumatic Diseases, University of Alberta; T. Boyd, MD; M. Jung, MD, Division of Rheumatology, Department of Medicine, Western University; A.M. Colwill, MD, Division of Rheumatology, Department of Medicine, University of British Columbia; G.S. Hazlewood, MD, Division of Rheumatology, Department of Medicine, University of Calgary; P. Tugwell, MD, Division of Rheumatology, Department of Medicine, University of Ottawa.
authors: Zarnaz
authors: Z
authors: Bagheri
authors: From the Division of Rheumatology, Department of Medicine, University of Toronto, Toronto; Southlake Regional Health Centre, Newmarket; Division of Rheumatology, Department of Medicine, Western University, London; Division of Rheumatology, Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Medicine and Department of Rheumatic Diseases, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.S.L. Chow, MD; M.J. Bell, MD; Z. Bagheri, MD; D. Frackowiak, MD; B. Kuriya, MD, Division of Rheumatology, Department of Medicine, University of Toronto; J.C. Thorne, MD, Southlake Regional Health Centre; R. Ferrari, MD, Department of Medicine and Department of Rheumatic Diseases, University of Alberta; T. Boyd, MD; M. Jung, MD, Division of Rheumatology, Department of Medicine, Western University; A.M. Colwill, MD, Division of Rheumatology, Department of Medicine, University of British Columbia; G.S. Hazlewood, MD, Division of Rheumatology, Department of Medicine, University of Calgary; P. Tugwell, MD, Division of Rheumatology, Department of Medicine, University of Ottawa.
authors: Tristan
authors: T
authors: Boyd
authors: From the Division of Rheumatology, Department of Medicine, University of Toronto, Toronto; Southlake Regional Health Centre, Newmarket; Division of Rheumatology, Department of Medicine, Western University, London; Division of Rheumatology, Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Medicine and Department of Rheumatic Diseases, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.S.L. Chow, MD; M.J. Bell, MD; Z. Bagheri, MD; D. Frackowiak, MD; B. Kuriya, MD, Division of Rheumatology, Department of Medicine, University of Toronto; J.C. Thorne, MD, Southlake Regional Health Centre; R. Ferrari, MD, Department of Medicine and Department of Rheumatic Diseases, University of Alberta; T. Boyd, MD; M. Jung, MD, Division of Rheumatology, Department of Medicine, Western University; A.M. Colwill, MD, Division of Rheumatology, Department of Medicine, University of British Columbia; G.S. Hazlewood, MD, Division of Rheumatology, Department of Medicine, University of Calgary; P. Tugwell, MD, Division of Rheumatology, Department of Medicine, University of Ottawa.
authors: Ann Marie
authors: AM
authors: Colwill
authors: From the Division of Rheumatology, Department of Medicine, University of Toronto, Toronto; Southlake Regional Health Centre, Newmarket; Division of Rheumatology, Department of Medicine, Western University, London; Division of Rheumatology, Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Medicine and Department of Rheumatic Diseases, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.S.L. Chow, MD; M.J. Bell, MD; Z. Bagheri, MD; D. Frackowiak, MD; B. Kuriya, MD, Division of Rheumatology, Department of Medicine, University of Toronto; J.C. Thorne, MD, Southlake Regional Health Centre; R. Ferrari, MD, Department of Medicine and Department of Rheumatic Diseases, University of Alberta; T. Boyd, MD; M. Jung, MD, Division of Rheumatology, Department of Medicine, Western University; A.M. Colwill, MD, Division of Rheumatology, Department of Medicine, University of British Columbia; G.S. Hazlewood, MD, Division of Rheumatology, Department of Medicine, University of Calgary; P. Tugwell, MD, Division of Rheumatology, Department of Medicine, University of Ottawa.
authors: Michelle
authors: M
authors: Jung
authors: From the Division of Rheumatology, Department of Medicine, University of Toronto, Toronto; Southlake Regional Health Centre, Newmarket; Division of Rheumatology, Department of Medicine, Western University, London; Division of Rheumatology, Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Medicine and Department of Rheumatic Diseases, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.S.L. Chow, MD; M.J. Bell, MD; Z. Bagheri, MD; D. Frackowiak, MD; B. Kuriya, MD, Division of Rheumatology, Department of Medicine, University of Toronto; J.C. Thorne, MD, Southlake Regional Health Centre; R. Ferrari, MD, Department of Medicine and Department of Rheumatic Diseases, University of Alberta; T. Boyd, MD; M. Jung, MD, Division of Rheumatology, Department of Medicine, Western University; A.M. Colwill, MD, Division of Rheumatology, Department of Medicine, University of British Columbia; G.S. Hazlewood, MD, Division of Rheumatology, Department of Medicine, University of Calgary; P. Tugwell, MD, Division of Rheumatology, Department of Medicine, University of Ottawa.
authors: Damian
authors: D
authors: Frackowiak
authors: From the Division of Rheumatology, Department of Medicine, University of Toronto, Toronto; Southlake Regional Health Centre, Newmarket; Division of Rheumatology, Department of Medicine, Western University, London; Division of Rheumatology, Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Medicine and Department of Rheumatic Diseases, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.S.L. Chow, MD; M.J. Bell, MD; Z. Bagheri, MD; D. Frackowiak, MD; B. Kuriya, MD, Division of Rheumatology, Department of Medicine, University of Toronto; J.C. Thorne, MD, Southlake Regional Health Centre; R. Ferrari, MD, Department of Medicine and Department of Rheumatic Diseases, University of Alberta; T. Boyd, MD; M. Jung, MD, Division of Rheumatology, Department of Medicine, Western University; A.M. Colwill, MD, Division of Rheumatology, Department of Medicine, University of British Columbia; G.S. Hazlewood, MD, Division of Rheumatology, Department of Medicine, University of Calgary; P. Tugwell, MD, Division of Rheumatology, Department of Medicine, University of Ottawa.
authors: Glen S
authors: GS
authors: Hazlewood
authors: From the Division of Rheumatology, Department of Medicine, University of Toronto, Toronto; Southlake Regional Health Centre, Newmarket; Division of Rheumatology, Department of Medicine, Western University, London; Division of Rheumatology, Department of Medicine, University of Ottawa, Ottawa, Ontario; Department of Medicine and Department of Rheumatic Diseases, University of Alberta, Edmonton; Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.S.L. Chow, MD; M.J. Bell, MD; Z. Bagheri, MD; D. Frackowiak, MD; B. Kuriya, MD, Division of Rheumatology, Department of Medicine, University of Toronto; J.C. Thorne, MD, Southlake Regional Health Centre; R. Ferrari, MD, Department of Medicine and Department of Rheumatic Diseases, University of Alberta; T. Boyd, MD; M. Jung, MD, Division of Rheumatology, Department of Medicine, Western University; A.M. Colwill, MD, Division of Rheumatology, Department of Medicine, University of British Columbia; G.S. Hazlewood, MD, Division of Rheumatology, Department of Medicine, University of Calgary; P. Tugwell, MD, Division of Rheumatology, Department of Medicine, University of Ottawa.
authors: Bindee
authors: B
authors: Kuriya
authors: Peter
authors: P
authors: Tugwell
mesh_terms: D002170:Canada; D003362:Cost-Benefit Analysis; D003955:Diagnostic Tests, Routine / Q000191:economics*; D006801:Humans; D012216:Rheumatic Diseases / Q000175:diagnosis* / Q000191:economics; D012219:Rheumatology / Q000191:economics*
keywords: CLINICAL PRACTICE GUIDELINE; COST-BENEFIT ANALYSIS; COST-EFFECTIVENESS; RHEUMATOLOGY