title: Choosing wisely in daily practice: a mixed methods study on determinants of antinuclear antibody testing by rheumatologists.
abstract: OBJECTIVE
  To explore the relationship between antinuclear antibody (ANA) overuse and rheumatologist-related factors before and after an intervention aimed at reducing ANA overuse.
  
  
  METHODS
  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.
authors.affiliation: a Department of Rheumatology , Sint Maartenskliniek , Nijmegen , The Netherlands.
authors.forename: N
authors.initials: N
authors.lastname: Lesuis
authors.affiliation: a Department of Rheumatology , Sint Maartenskliniek , Nijmegen , The Netherlands.
authors.forename: A A
authors.initials: AA
authors.lastname: den Broeder
authors.affiliation: b Unit for Clinical Therapy Research, Inflammatory Diseases (ClinTRID) , Karolinska Institute , Stockholm , Sweden.
authors.forename: R F
authors.initials: RF
authors.lastname: van Vollenhoven
authors.affiliation: a Department of Rheumatology , Sint Maartenskliniek , Nijmegen , The Netherlands.
authors.forename: J E
authors.initials: JE
authors.lastname: Vriezekolk
authors.affiliation: c Institute for Health Sciences, IQ Healthcare , Radboud University Medical Centre , Radboud , Nijmegen , The Netherlands.
authors.forename: Mejl
authors.initials: M
authors.lastname: Hulscher
mesh_terms: D000328:Adult; D000974:Antibodies, Antinuclear; D002983:Clinical Competence; D003071:Cognition; D065187:Controlled Before-After Studies; D004502:Education, Medical, Continuing; D005120:Extraversion, Psychological; D005246:Feedback; D005260:Female; D017144:Focus Groups; D006801:Humans; D008297:Male; D000069342:Medical Overuse / Q000517:prevention & control / Q000706:statistics & numerical data*; D008875:Middle Aged; D015999:Multivariate Analysis; D010551:Personality; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D036301:Qualitative Research; D000072140:Rheumatologists / Q000523:psychology / Q000706:statistics & numerical data*; D012698:Serologic Tests / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires
chemical_list: D000974:Antibodies, Antinuclear