Clinical Rheumatology

, Volume 32, Issue 5, pp 601–608

An evaluation of autoimmune antibody testing patterns in a Canadian health region and an evaluation of a laboratory algorithm aimed at reducing unnecessary testing

  • Ada Man
  • Kam Shojania
  • Carmen Phoon
  • Jason Pal
  • Monika Hudoba de Badyn
  • David Pi
  • Diane Lacaille
Original Article


Autoantibody tests are often ordered inappropriately. We aimed to evaluate the ordering patterns of these tests in our local health region and to develop a laboratory algorithm aimed at reducing unnecessary tests. Laboratory data including the number and sequence of tests, ordering physician specialties and results for antinuclear (ANA), extractable nuclear antigen (ENA) and anti-double stranded DNA (anti-dsDNA) antibody tests from 2007 to 2009 were evaluated. Based on this information and a clinical consensus meeting, an algorithm was developed and applied retrospectively to 1 year of inpatient laboratory data to simulate potential cost savings. We identified a large volume of these autoantibody tests performed, equating to testing costs of $862,706.72, where less than 17 % of each were positive. Repeated ANA tests were mostly ordered after a previously negative result, and 1 % of patients with negative results changed to ≥1:160 on repeat testing. Close to half of all ENA and anti-dsDNA tests that were ordered were done so simultaneously with ANA, suggesting their use as screening tests. This was done more frequently in the inpatient setting. An algorithm was developed where ENA and anti-dsDNA tests would be cancelled if ANA was negative in the same sample. ANA repeated within 1 year would be cancelled and the prior result provided. Application of the algorithm retrospectively simulated a 30 % cost savings. Repeat testing and simultaneous ordering of multiple tests contributed to the excessive ordering of autoantibody tests in our health region. Our proposed algorithm would reduce testing costs and should be accompanied by appropriate educational information for physicians.


Antibodies Antinuclear/analysis Autoantibodies/analysis Rheumatic diseases/diagnosis Serologic tests/utilization Unnecessary Procedures 

Supplementary material

10067_2012_2141_MOESM1_ESM.doc (58 kb)
ESM 1(DOC 58 kb)


  1. 1.
    Tan EM, Feltkamp TE, Smolen JS et al (1997) Range of antinuclear antibodies in “healthy” individuals. Arthritis Rheum 40(9):1601–1611PubMedCrossRefGoogle Scholar
  2. 2.
    Tampoia M, Brescia V, Fontana A et al (2007) Application of a combined protocol for rational request and utilization of antibody assays improves clinical diagnostic efficacy in autoimmune rheumatic disease. Arch Pathol Lab Med 131(1):112–116PubMedGoogle Scholar
  3. 3.
    Solomon DH, Shmerling RH, Schur PH et al (1999) A computer based intervention to reduce unnecessary serologic testing. J Rheumatol 26(12):2578–2584PubMedGoogle Scholar
  4. 4.
    Bonaguri C, Melegari A, Dall’Aglio P et al (2009) An Italian multicenter study for application of a diagnostic algorithm in autoantibody testing. Ann N Y Acad Sci 1173:124–129PubMedCrossRefGoogle Scholar
  5. 5.
    Wiik A, Cervera R, Haass M et al (2006) European attempts to set guidelines for improving diagnostics of autoimmune rheumatic disorders. Lupus 15(7):391–396PubMedCrossRefGoogle Scholar
  6. 6.
    Tozzoli R, Bizzaro N, Tonutti E et al (2002) Guidelines for the laboratory use of autoantibody tests in the diagnosis and monitoring of autoimmune rheumatic diseases. Am J Clin Pathol 117(2):316–324PubMedCrossRefGoogle Scholar
  7. 7.
    Stinton LM, Fritzler MJ (2007) A clinical approach to autoantibody testing in systemic autoimmune rheumatic disorders. Autoimmun Rev 7(1):77–84PubMedCrossRefGoogle Scholar
  8. 8.
    Kavanaugh A, Tomar R, Reveille J, Solomon DH, Homburger HA (2000) Guidelines for clinical use of the antinuclear antibody test and tests for specific autoantibodies to nuclear antigens. American College of Pathologists. Arch Pathol Lab Med 124(1):71–81PubMedGoogle Scholar
  9. 9.
    Shojania K (2000) Rheumatology: 2. What laboratory tests are needed? CMAJ 162(8):1157–1163PubMedGoogle Scholar
  10. 10.
    Bizzaro N, Wiik A (2004) Appropriateness in anti-nuclear antibody testing: from clinical request to strategic laboratory practice. Clin Exp Rheumatol 22(3):349–355PubMedGoogle Scholar
  11. 11.
    Anon. (2001) Guidelines and protocols advisory committee—antinuclear antibody (ANA) testing for connective tissue disease. Accessed June 4, 2012.
  12. 12.
    Solomon DH, Kavanaugh AJ, Schur PH (2002) Evidence-based guidelines for the use of immunologic tests: antinuclear antibody testing. Arthritis Rheum 47(4):434–444PubMedCrossRefGoogle Scholar
  13. 13.
    Avina-Zubieta JA, Sayre EC, Bernatsky S et al (2011) Adult Prevalence of Systemic Autoimmune Rheumatic Diseases (SARDs) in British Columbia. Can Arthritis Rheum 63(Suppl 10):1846Google Scholar
  14. 14.
    Anon. (2012) Population estimates, British Columbia and sub-provincial—BC stats. Accessed May 21, 2012.
  15. 15.
    Anon. (2012) Medical Services Plan home page. Accessed July 24, 2012.
  16. 16.
    Wiik AS (2005) Anti-nuclear autoantibodies: clinical utility for diagnosis, prognosis, monitoring, and planning of treatment strategy in systemic immunoinflammatory diseases. Scand J Rheumatol 34(4):260–268PubMedCrossRefGoogle Scholar
  17. 17.
    Dahle C, Skogh T, Aberg AK, Jalal A, Olcén P (2004) Methods of choice for diagnostic antinuclear antibody (ANA) screening: benefit of adding antigen-specific assays to immunofluorescence microscopy. J Autoimmun 22(3):241–248PubMedCrossRefGoogle Scholar
  18. 18.
    Peene I, Meheus L, Veys E, De Keyser F (2001) Detection and identification of antinuclear antibodies (ANA) in a large and consecutive cohort of serum samples referred for ANA testing. Ann Rheum Dis 60(12):1131–1136PubMedCrossRefGoogle Scholar
  19. 19.
    Damoiseaux JGMC, Tervaert JWC (2006) From ANA to ENA: how to proceed? Autoimmun Rev 5(1):10–17PubMedCrossRefGoogle Scholar
  20. 20.
    Fritzler MJ, Miller BJ (1995) Detection of autoantibodies to SS-A/Ro by indirect immunofluorescence using a transfected and overexpressed human 60 kD Ro autoantigen in HEp-2 cells. J Clin Lab Anal 9(3):218–224PubMedCrossRefGoogle Scholar
  21. 21.
    Fritzler MJ, Wiik A, Fritzler ML, Barr SG (2003) The use and abuse of commercial kits used to detect autoantibodies. Arthritis Res Ther 5(4):192–201PubMedCrossRefGoogle Scholar
  22. 22.
    Meroni PL, Schur PH (2010) ANA screening: an old test with new recommendations. Ann Rheum Dis 69(8):1420–1422PubMedCrossRefGoogle Scholar

Copyright information

© Clinical Rheumatology 2013

Authors and Affiliations

  • Ada Man
    • 1
    • 5
  • Kam Shojania
    • 2
    • 4
  • Carmen Phoon
    • 3
  • Jason Pal
    • 3
  • Monika Hudoba de Badyn
    • 3
  • David Pi
    • 3
  • Diane Lacaille
    • 2
    • 4
  1. 1.Section of RheumatologyBoston University School of MedicineBostonUSA
  2. 2.Division of RheumatologyUniversity of British ColumbiaVancouverCanada
  3. 3.Department of Pathology and Laboratory MedicineUniversity of British ColumbiaVancouverCanada
  4. 4.Arthritis Research Centre of CanadaVancouverCanada
  5. 5.Arthritis Center/RheumatologyBoston University School of MedicineBostonUSA

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