Applying Choosing Wisely: Antinuclear Antibody (ANA) and Sub-
Serology Testing in a Safety Net Hospital System
Lisa Anne Davis*, 1, 2, Barbara Goldstein1, 2, 3, Vivian Tran1, 2, Angela Keniston1, Jinoos Yazdany4, Joel Hirsh1, 2, Amy Storfa1, JoAnn Zell1, 2, 3
1 Denver Health and Hospital Authority, Denver, CO, USA
2 University of Colorado School of Medicine, Aurora, CO, USA
3 National Jewish Health, Denver, CO, USA
4 University of California San Francisco, San Francisco, CA, USA
In 2013, the American College of Rheumatology (ACR) participated in the Choosing Wisely
campaign and devised a recommendation to avoid testing antinuclear antibody (ANA) subserologies without a positive
ANA and clinical suspicion of disease. The goals of our study were to describe ANA and subserology ordering practices
and predictors of ordering concurrent ANA and subserologies in a safety-net hospital.
We identified ANA and subserologies (dsDNA, Sm, RNP, SSA, SSB, Scl-70 and centromere) completed at
Denver Health between 1/1/2005 and 12/31/2011. Variables included demographics, primary insurance, service, and
setting from which the test was ordered. We performed multivariable logistic regression to determine predictors of
concurrent ordering of ANA and subserologies.
During seven years, 3221 ANA were performed in 2771 individuals and 211 (6.6%) were performed concurrently
with at least one subserology. The most common concurrent subserologies were dsDNA (21.8%), SSA (20.8%), and SSB
(19.7%). In the multivariable logistic analysis, significant predictors of concurrent ANA and subserologies were the labs
being ordered from subspecialty care (OR 8.12, 95% CI 5.27-12.50, p-value <0.0001) or from urgent/inpatient care (OR
3.86, 95% CI 1.78-8.38, p-value 0.001). A significant predictor of decreased odds was male gender (OR 0.32, 95% CI
0.21-0.49, p-value <0.0001). Five individuals (2.2% of the negative ANA with subserologies ordered) had a negative
ANA but positive subserologies.
Of 3221 ANA, 6.6% were performed concurrently with subserologies, and subspecialists were more likely to
order concurrent tests. A negative ANA predicted negative subserologies with rare exceptions, which validates the ACR’s
Keywords: Antinuclear antibody (ANA), choosing wisely, ordering practices, quality of care, quality indicators, resource
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* Address correspondence to this author at the Denver Health and Hospital
Authority, 777 Bannock St. MC 4000, Denver, Colorado 80204-4507, USA;
Tel: (303) 602-5037; Fax: (303) 602-5055; E-mail: