Autoantibody Ordering Patterns Across a Tertiary Hospital: A Retrospective Audit

Autoantibody testing supports the diagnosis of systemic autoimmune diseases, but indiscriminate use in low pre-test probability settings can reduce test positivity and inflate direct laboratory costs. Hospital-wide audits of real-world ordering practices across specialties remain scarce and, to our knowledge, have not been reported in the Gulf region.

To describe the test positivity rate, direct laboratory cost, and departmental variation of hospital-wide autoantibody testing in a tertiary center in the Eastern Province of Saudi Arabia.

We conducted a retrospective hospital-wide audit of all autoantibody tests ordered across 15 clinical departments at King Fahd University Hospital between 1 January and 30 April 2024. Test volumes, positivity rates, and direct laboratory costs were summarized at departmental and subspecialty levels. Rheumatology was compared with all non-rheumatology services as a pre-specified inferential contrast using chi-square or Fisher exact tests with 95% Wilson confidence intervals and Benjamini-Hochberg adjustment across per-marker comparisons; the unit of analysis was the test order.

A total of 5973 autoantibody tests were performed in 1059 patients, with an overall test positivity rate of 16.3% (95% CI 15.4-17.2). Total direct laboratory expenditure was USD 509,136, of which 87% was attributable to negative results. Test positivity ranged from 26% in Pediatrics to ≤7% in Neurology and Neurosurgery. Rheumatology had a higher positivity rate (24.4%, 95% CI 22.2-26.8) than non-rheumatology services combined (13.9%, 95% CI 12.9-14.9; p<0.001), with the largest absolute differences for antinuclear antibodies (88.7% vs 35.7%; p<0.001) and SSA antibodies (27.9% vs 5.9%; p<0.001). Direct cost per positive result was USD 364 in Rheumatology versus USD 606 in non-rheumatology services.

In this single-center audit, autoantibody ordering practices clustered into two descriptive patterns: hypothesis-driven, higher-positivity testing within specialist care and broader, lower-positivity panel use in several non-specialist services. These differences were statistically significant and most plausibly reflect more disciplined application of pre-test probability by specialists, although referral filtering and case-mix differences contribute and cannot be fully separated from clinician-level reasoning in this dataset. These patterns suggest that targeted diagnostic stewardship-reflex-cascade algorithms, order-menu redesign, and indication-based gating-could concentrate autoantibody testing where pre-test probability is highest, improving positivity and reducing avoidable cost without restricting clinical access.