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AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care

Topic Suggestion Description

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Date submitted: January 30, 2009

Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.
Population: Children < 18 years of age:

1. What are the incidences and prevalences of non-inflammatory pain syndromes (e.g., benign hypermobility syndrome, patellofemoral stress syndrome, fibromyalgia, and growing pain) in children and adolescents?

2. What is the natural history of non inflammatory pain syndromes in children and adolescents?

3. a) What is the diagnostic accuracy of antinuclear antibody (ANA) and rheumatoid factor (RF) for children < 18 years of age?

? With respect to the following conditions (including but not limited to):

• Juvenile Idiopathic Arthritis/Juvenile Rheumatoid Arthritis
• Systemic Lupus erythematosus
• Non inflammatory pain syndromes (e.g. fibromyalgia, patellofemoral stress syndrome, benign hyper motility syndrome, growing pains)


b) What is the evidence that that demographic and clinical factors modify accuracy?
• Gender
• Children with signs/symptoms of synovitis versus children with vague musculoskeletal complaints
• Age?
• Race/ethnicity?

? Accuracy can include:

• Sensitivity
• Specificity

4. What are the benefits and harms associated with obtaining ANA and RF for the conditions listed?

? Outcomes (including but not limited to):
• Patient referrals (i.e. to pediatric rheumatologists)
• Additional diagnostic testing (e.g. radiologic studies, laboratory testing, etc)
• Treatment
• Psychological (anxiety)
Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)
If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:
What is the diagnositic accuracy of ANA and Rheumatoid factor in children < 18 yo?
What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)
Children < 18 yo
Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)
• Children with signs/symptoms of synovitis versus children with vague musculoskeletal complaints
• Age?
• Race/ethnicity?
Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)
Interested in improved diagnosis of aforementioned condtions (e.g. SLE, RA, etc)
Describe any health-related risks, side effects, or harms that you are concerned about.
Anxiety, false positives?

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?
Which priority area(s) and population(s) does this topic apply to? (check all that apply)
EHC Priority Conditions (updated in 2008)
  • Arthritis and nontraumatic joint disorders
AHRQ Priority Populations
  • Children
Federal Health Care Program
  • Medicaid
  • State Children's Health Insurance Program (SCHIP)


Describe why this topic is important.
Rheumatic diseases are an important cause of disability in childhood, proper diagnosis and early agressive management can minimize morbidity.
Diagnosing these disease presents challenges, tests such as ANA are frequently used but are not always specific (one study noted that nearly 33% of healthy children had a positive ANA)
What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)
This topic was nominated by the AAP in developing their clinical guideline.
Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)
If yes, please explain:
When physicians are confronted with patients who have poorly characterized musculoskeletal complaints with or without historical or physical examination evidence of an inflammatory rheumatic disease, they frequently order a wide number of laboratory evaluations. Testing which may or may not be relevant or appropriate for the clinical situation. Not infrequently these are ordered as part of a “rheumatic disease” laboratory screening panel designed for adults. These practice patterns escalate the economic and social burden of medical care through their high rate of false positive test results, resulting in further testing and consultation, in addition to the anxiety experienced by the patient and family. As a result of misunderstanding the sensitivity and specificity of autoantibody testing for specific rheumatic diseases, physicians continue to use such testing indiscriminately.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?
The answer will help to inform clinical practice guidelines for autoantibody testing in children.
Describe the timeframe in which an answer to your question is needed.
Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

Nominator Information

Other Information About You: (optional)
Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)
  • Other
Are you making a suggestion as an individual or on behalf of an organization?
Organization - aap