Background due to our daily clinical and laboratory practice, we realized that primary care physicians of Cyprus (public & private sector), as well as other medical specialties, are not familiar with the clinical significance of autoantibodies used to diagnose autoimmune rheumatological diseases. This resulted to an increasing number of orders for autoantibodies, which were irrelevant to the person's condition, leading to a high expenditure for tests not clinically needed, whereas the laboratory was not able to respond to the demand with the available resources (human, hardware, economic).
Objectives (a) to persuade, through education, all the primary care physicians of Cyprus to order autoantibodies up to the point of the primary healthcare level and (b) to minimize the number of unneeded orders, as well as the expenditure, and save resources. To accomplish this target, we created an algorithm for ordering antinuclear antibodies (ANA). Mainly the primary care physicians should use the algorithm as a protocol.
Methods we searched the literature to find (a) existing algorithms for ordering the ANA, as well as other autoantibodies that should be performed if ANA is found positive and (b) the relevant scientific evidence to guide primary care physicians while ordering ANA. In addition, we planned educational lectures for all the primary care physicians (public & private sector). Our scope was to develop an algorithm that guides the primary care physician to order antinuclear antibodies only if the person's symptoms are relevant to an autoimmune rheumatological disease.
Results we found algorithms from different sources (university clinics, scientific societies [medical and laboratory], commercial companies producing autoantibody kits). Most of the algorithms found were focusing on the suspected disease, for which the relevant autoantibodies should be ordered. We established an algorithm targeting the primary care physicians: they should only order antinuclear antibodies if an autoimmune rheumatology disease is suspected; if ANA is negative, then an autoimmune disease does not exist and the test should never be repeated (unless there is an important reason); if ANA is positive, then the person should be sent for a consultation to a rheumatologist, who is responsible to take the medical history, examine clinically the person and decide if there is a need or not to order for any other autoantibodies, if an autoimmune rheumatology condition is still suspected. The developed algorithm was communicated (year 2014) to the primary care physicians through lectures in small teams (it was repeated in seven different teams, and captured almost all). The Cyprus Rheumatology Society acknowledged the algorithm, whereas the Health Insurance Organization, with the Ministry of Health, organized the educational part.
Conclusions the development and establishment (years 2015–2016) of the algorithm for the ordering of antinuclear antibodies by the primary care physicians, changed their attitude towards ordering nowadays with more scientific and evidenced based criteria. This was seen on the lower numbers of orders of antinuclear antibodies within these two years.
the developed algorithm, with the associated text and lecture (all in pdf format), can be viewed (greek language only) and/or downloaded from http://www.hio.org.cy/gr/kko_ergkon_eksetaseon_pfy.html.
Disclosure of Interest None declared