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Indications and diagnostic outcome of antineutrophil cytoplasmic antibody testing in hospital medicine: a pattern of over-screening

Abstract

Introduction/objective

Antineutrophil cytoplasmic antibodies (ANCA) serology can aid in the diagnosis and classification of ANCA-associated vasculitides (AAV). However, it is often ordered in patients without clinical manifestations of vasculitis. In this retrospective chart review, we aim to better understand the clinical practices on ANCA testing.

Methods

We retrospectively reviewed patients’ charts for the indications and diagnostic outcomes of ANCA tests. All ANCA tests ordered at two Canadian hospitals (a community hospital and an academic tertiary hospital) between January and December 2016 were included in the study. Descriptive statistics are used.

Results

A total of 302 ANCA tests were included. The majority (n = 198, 65.6%) were ordered without an indication for testing. For those patients with at least 1 clinical manifestation of AAV (n = 104), 25% were ANCA positive and 18.3% resulted in a diagnosis of AAV. In comparison, among those without a clinical manifestation of AAV (n = 198), only 1.5% were ANCA positive and none was diagnosed with AAV. All patients diagnosed with AAV had at least 1 indication for ANCA testing. The three most common clinical presentations in patients with a final diagnosis of AAV were glomerulonephritis (81.8%), pulmonary hemorrhage (45.5%), and multiple lung nodules (31.8%).

Conclusion

To our knowledge, this is the first study that evaluates patients with both positive and negative ANCA test results in an inpatient setting. We demonstrated a low rate of ANCA positivity and AAV diagnosis in patients without clinical manifestations of AAV. Overall, there is a high rate of ANCA testing without an indication at our academic institution. This over-testing may be curbed by strategies such as a gating policy, culture changes, and clinician education.

Key Points
AAV is a clinical-pathological diagnosis, and despite the usefulness of ANCA testing, it does not confirm nor rule out AAV.
ANCA testing for the diagnosis of AAV is generally only indicated when there is a clear manifestation of AAV.
Although patients with AAV may occasionally present without classic signs and symptoms, the diagnostic utility of ANCA serology in this setting is low, and testing is more likely to result in a false-positive or false-negative test.
If clinical suspicion remains high despite negative ANCA testing, clinicians should seek consultation with a rheumatologist.

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Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Code availability

Not applicable.

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Authors and Affiliations

Authors

Contributions

All the authors contributed to the study’s conception and design. Material preparation, data collection, and analysis were performed by Yanzhu Xu, Noren Khamis, Touraj Khosravi-Hafshejani, and Julia Tan. The first draft of the manuscript was written by Noren Khamis and Touraj Khosravi-Hafshejani, and all the authors commented on previous versions of the manuscript. All the authors read and approved the final manuscript.

Corresponding author

Correspondence to Natasha Dehghan.

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Ethics approval

Ethics approval was received from the University of British Columbia Clinical Research Ethics Board (H20-00215).

Consent to participate

A waiver of consent was approved as a standard for retrospective research of medical records based on minimal risk to the subjects, lack of adverse effect to subjects, and for the feasibility of achieving the study.

Consent for publication

A waiver of consent was approved as a standard for retrospective research of medical records based on minimal risk to the subjects, lack of adverse effect to subjects, and for the feasibility of achieving the study.

Conflict of interest

Dr. J.A. Avina-Zubieta is the BC Lupus Society Research Scholar and the Walter & Marilyn Booth Research Scholar. Other authors have no conflict of interest to disclose.

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Xu, Y., Khamis, N., Khosravi-Hafshejani, T. et al. Indications and diagnostic outcome of antineutrophil cytoplasmic antibody testing in hospital medicine: a pattern of over-screening . Clin Rheumatol 40, 4983–4991 (2021). https://doi.org/10.1007/s10067-021-05870-w

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Keywords

  • Antineutrophil cytoplasmic antibodies
  • Health care costs
  • Physician practice patterns
  • Quality improvement
  • Vasculitis