Poor Adherence to Indications for Anti-neutrophil Cytoplasmic Antibody Testing in a South African Tertiary Hospital

Ramona Govender, B. Hodkinson
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Abstract

Appropriate use of laboratory investigations is increasingly important in resource-constrained environments. In this study, we reviewed the anti-neutrophil cytoplasmic antibody (ANCA) testing practices in a tertiary hospital in South Africa. A retrospective file review was conducted, encompassing all ANCA tests ordered over 12 months, including both inpatients and outpatients. Sociodemographic and clinical details were extracted from the patient records. All requests were assessed against the International Consensus Statement of 1999, which provides clinical guidelines for the indications for ANCA testing. Of the 945 ANCA tests requested, 790 patient records were reviewed, while 155 records were found to be missing, and 62 patients had multiple tests. Only 193 patients (24.4%) had indications for ANCA testing that met the guidelines. The most common tests done outside guideline indications were critical limb ischemia (9.6%), stroke (7.3%), uveitis (5.7%), renal impairment (4.9%), and interstitial lung disease (4.4%). Among the patients, ten (1.3%) were diagnosed with ANCA-associated vasculitis (AAV), of whom nine had renal-limited vasculitis. Twenty-six patients tested positive for ANCA without any evidence of AAV. Of these false positives, 10 (38.4%) were human immunodeficiency virus (HIV) positive, 3 (11.5%) had tuberculosis (TB), and 3 (11.5%) had other autoimmune diseases. The annual cost of ANCA tests amounted to ZAR274,046, with ZAR17,490 spent on duplicate testing and ZAR208,275 on non-indicated clinical conditions. The study revealed that ANCA testing was performed outside standard guidelines in three-quarters of requests, and duplicate testing was common, resulting in large cost implications. Chronic infections, such as HIV and TB, and autoimmune conditions accounted for half of the false-positive tests. The findings suggest that training of clinicians is likely to reduce unnecessary tests.
南非一家三级医院抗中性粒细胞细胞质抗体检测的适应症依从性差
在资源有限的环境中,适当利用实验室调查越来越重要。在本研究中,我们回顾了抗中性粒细胞细胞质抗体(ANCA)在南非三级医院的检测实践。进行了回顾性档案审查,包括住院和门诊患者在12个月内订购的所有ANCA检查。从患者记录中提取社会人口学和临床细节。所有请求都是根据1999年国际共识声明进行评估的,该声明为ANCA检测的适应症提供了临床指南。在要求进行的945项ANCA检查中,审查了790项患者记录,发现155项记录缺失,62名患者进行了多次检查。只有193例(24.4%)患者的ANCA检测指征符合指南。指南适应症之外最常见的检查是严重肢体缺血(9.6%)、中风(7.3%)、葡萄膜炎(5.7%)、肾脏损害(4.9%)和肺间质性疾病(4.4%)。其中10例(1.3%)被诊断为anca相关性血管炎(AAV),其中9例为肾局限性血管炎。26例患者ANCA检测呈阳性,无AAV证据。在这些假阳性中,10例(38.4%)为人类免疫缺陷病毒(HIV)阳性,3例(11.5%)患有结核病,3例(11.5%)患有其他自身免疫性疾病。ANCA检测的年度费用为274,046扎拉姆,其中重复检测费用为17,490扎拉姆,非指征临床疾病检查费用为208,275扎拉姆。研究表明,在四分之三的请求中,ANCA测试是在标准指南之外进行的,重复测试很常见,导致巨大的成本影响。艾滋病毒和结核病等慢性感染以及自身免疫性疾病占假阳性检测的一半。研究结果表明,培训临床医生可能会减少不必要的检查。
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