standardization: a bumpy but necessary path...s1 s2 s3 s4 s5 o5 ctnt o4 ast, ldh bilirubin k o3 o2...
TRANSCRIPT
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Centre forMetrological Traceabilityin Laboratory Medicine
(CIRME)
Director: Prof. Mauro Panteghini
site: http://users.unimi.it/cirme
Mauro PanteghiniMauro Panteghini
University of Milan Medical School University of Milan Medical School
Research Centre for Metrological Research Centre for Metrological
Traceability in Laboratory Medicine (CIRME)Traceability in Laboratory Medicine (CIRME)
Standardization: Standardization:
a bumpy but necessary patha bumpy but necessary path
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Drivers for global standardization in
laboratory medicine
• Clinical governance and guidelines (EBM)
• Laboratory accreditation, consolidation and
networking
• Advances in IT and electronic health records
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Appropriate test
in the right context
Appropriate test Appropriate test
in the right contextin the right context
Right sample
handling
Right sample Right sample
handlinghandling
Result equivalence and
harmonization of QC practice
Result equivalence andResult equivalence and
harmonization of QC practiceharmonization of QC practice
Uniform
communication
Uniform Uniform
communicationcommunication
Result utilization
and intervention
Result utilization Result utilization
and interventionand intervention
Plebani M & Panteghini M.
Biochim Clin 2015;39:12
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“Wrongs” anywhere compromisetest result quality and patient safety!
Lab-related causes of diagnostic mistakes
Vignette from Lippi G & Simundic AM. CCLM 2018;56:1660
Inappropriate test orderedAppropriate test not ordered
Appropriate test result inaccurate
Appropriate test result not used properly
Appropriate test result delayed/missed
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Key preanalytical steps identified as the most
critical and in need of immediate standardization
Michael P Cornes et al. Ann Clin Biochem 2016;53:539-547
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The right test choice
With the right advice as to what to do next with the result
With the right
interpretation
The triad of elements of value in laboratory information
Ferraro S & Panteghini M. Clinical Biochemistry 50 (2017) 555–561
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Atlas of Diagnostic Variation
• 72-fold difference in PSA requesting
between most and least requesting groups
of GPs
• 89-fold difference in BNP requesting
• 106-fold difference in annual rate of
creatinine requesting
• 446-fold difference in calprotectin
• 4/5-fold difference in average even when
outliers are removed
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Why we need to reduce variation in
test requests?
Appleby J, Raleigh V (2011) Variations in Health Care – the Good, the Bad & the Inexplicable.
The King’s Fund. http://www.kingsfund.org.uk/audio-video/john-appleby-variations-health-care
“…the existence of persistent
unwarranted variations in health care
directly impacts on equity of access to
services, the health outcomes of
populations and efficient use of
resources.”
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Reorders within 24 h took place for only 20-30% of tests
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Types of interventions to improve
appropriateness and standardize test request
Developing and disseminating practice care maps
(agreed in partnership with clinicians), using HTA
approach when guidelines are lacking
Deleting obsolete tests from laboratory order
forms
Avoiding pathophysiologic duplications
Gating policies - Traffic Light Systems (particularly
for complex and costly tests)
Restricting retesting (minimum retesting intervals)
Ferraro S & Panteghini M. Clinical Biochemistry 50 (2017) 555–561
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Markers still used for the diagnosis of AMI in
addition to cardiac troponin
0
10
20
30
40
50
60
70
80
90
100
2006 2010 2013
CK
CK-MB act
CK-MB mass
LD/HBD
Myo
AST
The Cardiac Marker Guideline Uptake in
Europe (CARMAGUE) Study of the EFLM WG Cardiac Markers
Collinson P et al.,
Clinical Chemistry
62:9 1264–1271 (2016)
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Ferraro S & Panteghini M. Clinical Biochemistry 50 (2017) 555–561
Avoid pathophysiologic duplications
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Limiting the testing of AST
Panteghini M, Bais R. Serum enzymes.
In: “Tietz Textbook of Clinical Chemistry and Molecular Diagnostics”. 6th ed. Elsevier Saunders: St. Louis, 2018
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6.7% 5.6% 5.3%
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Adapted from Morgen EK et al. Am J Clin Pathol 2015;144:704.
Annual savings achievable
eliminating the inappropriate
testing in the study institution.
Corresponds to a national
annual cost of 160 million $ CAD
(∼110 million €)
Specialists were more likely than primary care physicians to order repeat tests too soon.
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Prevention is better than cure:
stopping inappropriate requests before they
reach the laboratoryFryer AA & Smellie WSA. J Clin Pathol 2013;66:62.
Ferraro S & Panteghini M. Clin Biochem 2017;50:555.
Institutions should fully
exploit the potential of
electronic requesting acting as
“enabling factor” for
reinforcing educational
messages and sustaining their
effects over time.
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Am J Clin Pathol March 2018;149:197
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The way forward: CPOE standardization
• For any institution trying to achieve optimum
patient care (and control costs), the
appropriate design of information systems for
CPOE is critical.
• Consequently, laboratory professionals must
insist that information system vendors
provide effective systems to assist in the
insitutions’ endeavors to ensure appropriate
test requests.
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Clinicians’ satisfaction with laboratory services:
CPOE performance as a new challenge
McCall SJ et al. Arch Pathol Lab Med. 2016;140:1098
Mean Satisfaction Score
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Zhi M et al. PLoS ONE 2013;8:e78962.
Underutilization in laboratory testing:
an underappreciated problem
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Underutilization of albuminuria results
in morbidity due to delayed diagnoses
and missed early interventions
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Practices for identifying and rejecting
hemolyzed specimens are highly
variable in clinical laboratories.
Hemolysis is still identified using a visual scale by >20% of clinical laboratories in the UK and 48% in the USA.
HEMOLYSIS
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S1 S2 S3 S4 S5
O5 ccTnTTnT
O4 AST, LDH AST, LDH BilirubinBilirubin KK
O3
O2 ALTALT Ca, ClCa, ClCRP, Na, CRP, Na,
CreatCreat
O1 ALP, GGTALP, GGT P, Mg, PROTP, Mg, PROTLaLacct, LIP, t, LIP,
ALB, CKALB, CKGlucoseGlucose
Visual handling of hemolyzed samples increases the risk of reporting inaccurate results for cTnT, K and bilirubin, possibly affecting the clinical decision and patient outcome.
ISO14971:2012 Medical devices: application of risk management to medical devices.
Occure
nce p
robabilit
y
Severity of harm
LifeLife--threateningthreatening
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Giuseppe Lippi & Mario Plebani Giuseppe Lippi & Mario Plebani Journal of Laboratory Automation 2012;18:184Journal of Laboratory Automation 2012;18:184--188188
Copyright © by Society for Laboratory Automation and Screening
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The availability of interference results reported as
continuous values in the LIS is strongly recommended
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Harmonize management of unsuitable
samples: the most challenging issue?
Do not process
specimen and contact
the ward
27%
Perform analysis and
associate comment
54%
Provide comment
and no result
16%
Adjust sample result
using algorithms
3%
Lippi G et al. Clin Chem Lab Med 2006;44:1491
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Challenges reported by US primary care physicians
when using lab test results
Hickner J et al, J Am Board Fam Med 2014;27:268.
% of respondents reporting factor is very
or extremely problematic
Potentially affecting
13 million pts/yr, raising
significant concerns about
the safety and efficient use
of lab tests
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Terminology in Laboratory Medicine:
IFCC Survey 2015
Which nationally agreed system of laboratory
terminology is in use in your country?
LOINCLOINC
NPUNPU
Others (e.g. national system)Others (e.g. national system)
Not specifiedNot specified
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Declared % of SI adoption:
Current use of SI units in EuropeCurrent use of SI units in Europe
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J Clin Pathol 2014;67:179–181
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Barth JH, Panteghini M, Bunk DM et al.
Avoiding the unnecessary use of decimals is matter of patient
safety… Units for cTn should be harmonized regardless of the
analytical sensitivity of the assay used.
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Cardiac troponin Units
The Cardiac Marker Guideline Uptake in
Europe (CARMAGUE) Study of the EFLM WG Cardiac Markers
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Variations in reference intervals:
a risk for lab result interpretation
– The used R.I. are often significantly different
among laboratories
– The origin of these R.I. may be quite different
(manufacturers, literature, internal studies,
other laboratories, undefined)
– In the majority of cases, differences among
laboratories have no justification
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ALT reference limits (adult male) for same method
group: a 2014 national survey
For some analytes, variation in reference intervals
is greater than the analytical inaccuracy in their
measurement
Cattozzo G. biochimica clinica, 2015, vol. 39, 575.
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The comparator is as important as the result
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Infusino I, Schumann G, Ceriotti F, Panteghini M. CCLM 2010;48:301
Ferraro S, Braga F, Panteghini M. CCLM 2016;54:523
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Premise
To be used together with commercial assays that provide traceable results
to established IFCC reference measurement systems
Common reference intervals for enzymes in adults
Infusino I et al. Clin Chem Lab Med 2017; 55:334-40.
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ALP pediatric reference intervals: A chaos
Higgins V et al. 69th AACC Annual Scientific Meeting Abstract A-259
Canadian Reference Intervals Survey
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Ceriotti F, Panteghini M, Guerra E et al. Biochimica clinica, 2017, vol. 41, 166
Traceable reference intervals for alkaline phosphatase in serum of pediatrics
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The result standardization issue:
an absolute priority for public health
→ Our customers (i.e.,
doctors and patients)
expect laboratory
results to be
equivalent for being
interpreted in a
consistent manner
Good results are our contribution to healthcare
Panteghini M. Clin Chem Lab Med 2012;50:1237
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The lack of standardization may
become an ethical issue
“Standardization of laboratory tests has an
ethical dimension as it aims to affect the
way diagnostic tests are used in order to
guarantee optimal care for patients in a
global world.”Bossuyt X et al., Ann Rheum Dis 2008;67:1061
Biased results → Patient harm: • Wrong diagnosis
• Wrong management
• Incorrect monitoring
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→ To become equivalent for being interpreted in a
consistent manner, results must be traceable to higher order references.
EU 98/79/EC-IVD Directive
REGULATION (EU) 2017/746REGULATION (EU) 2017/746 OF THE EUROPEAN OF THE EUROPEAN
PARLIAMENT AND OF THE COUNCIL of 5 April 2017 on PARLIAMENT AND OF THE COUNCIL of 5 April 2017 on
In Vitro In Vitro Diagnostic Medical Devices and Diagnostic Medical Devices and repealing repealing
Directive 98/79/ECDirective 98/79/EC
Both require IVD manufacturers to ensure
traceability of their measuring systems to
recognized higher order references
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IVD manufacturers should define a
calibration hierarchy to assign traceable
values to their system calibrators and to
fulfil during this process uncertainty
limits, which represent a proportion of
the uncertainty budget allowed for
clinical laboratory results.
Role of IVD manufacturers
[Braga F & Panteghini M, Clin Chim Acta 2014;432:55]
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Braga F & Panteghini M. Clin Chim Acta 2014;432:55-61
IVD manufacturers may spend different
amounts of the total uncertainty budget in
implementing traceability of their
measuring systems
TRACEABILITY CHAINS AVAILABLE FOR IVD MANUFACTURERS FOR PLASMA
GLUCOSE
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Braga F, Panteghini M. Clin Chim Acta 2014;432:55-61
Chain A = 0.73% vs. Chain C = 1.63%Chain A = 0.73% vs. Chain C = 1.63%uurefref
(u(u22refref ++ uu22
calcal))½½
((uu22ref ref + + uu22
calcal + + uu22randomrandom))½½
System imprecision
System calibration
uncertainty
Individual lab
performance
Measurement Measurement
uncertaintyuncertainty
budgetbudget
Uncertainty of
references
Measurand definition
Patient result
4.05%4.05% minimumminimum
2.70%2.70% desirabledesirable
1.35%1.35% optimumoptimum
The quality of glucose measurement may be dependent on the type
of traceability chain selected for trueness transferring, sometimes making
difficult (e.g., chain C) to achieve the suitable limits for measurement uncertainty
on clinical samples
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The Essential Question…
“What amount of
medical harm due to
analytical error is it ok
to let go undetected?”
Fit for
purpose?
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Braga F & Panteghini M, Braga F & Panteghini M,
Clin Chim Acta 2014;432:55Clin Chim Acta 2014;432:55
CLASSICAL KEY ELEMENTSCLASSICAL KEY ELEMENTSCLASSICAL KEY ELEMENTS
4th pillar
TRACEABLE REFERENCE
INTERVALS AND DECISION LIMITS
44thth pillarpillar
TRACEABLE REFERENCE TRACEABLE REFERENCE
INTERVALS AND DECISION LIMITS INTERVALS AND DECISION LIMITS
5th pillar
ANALYTICAL (INTERNAL AND
EXTERNAL) QUALITY CONTROL
THAT MEETS METROLOGICAL
CRITERIA
55thth pillarpillar
ANALYTICAL (INTERNAL AND ANALYTICAL (INTERNAL AND
EXTERNAL) QUALITY CONTROL EXTERNAL) QUALITY CONTROL
THAT MEETS METROLOGICAL THAT MEETS METROLOGICAL
CRITERIA CRITERIA
6th pillar
TARGETS FOR
UNCERTAINTY AND
MEASUREMENT
ERROR THAT FIT
FOR PURPOSE
66thth pillarpillar
TARGETS FOR TARGETS FOR
UNCERTAINTY AND UNCERTAINTY AND
MEASUREMENT MEASUREMENT
ERROR THAT FIT ERROR THAT FIT
FOR PURPOSEFOR PURPOSE
THE TEMPLE OF
LABORATORY STANDARDIZATION
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Marjan Van Blerk et al. There are as many limits as there
are EQA providers
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Basic elements that need to be considered:
a)nature of the EQA material, including commutability, which may affect the result interpretation;
b)procedure used to assign the target value;
c)data set to which APS are applied;
d)analytical property being assessed (i.e., TE, bias, imprecision);
e)rationale for the selection of the APS;
f)type(s) of model used to set APS
We need these to:
1.compare APS from EQAs
2.inform users about the APS they use
3.plan standardization (common EQA APS would support uniform analytical performance and true quality improvement)
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Analytical performance specification (APS) derivation should be added to the Miller’s EQAS categorization
Category 1/2A → Milan model 1 or 2 as basis for APSCategory 1/2B → Other models
[Miller WG et al. Clin Chem 2011;57:1670]
Infusino I et al. Clin Chem Lab Med 2017;55:334
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Bargnoux AS et al. Clin Chem 2017;63:833
Evaluation of Standardization of Cystatin C Measurement
From MILAN MODEL 2From MILAN MODEL 2
Validated commutability
EQA
Category 1A
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Results Standardization in Place
Higher Order
References
Laboratories
Patients
Clinicians
IVD Manufacturers EQA Organizers
Reference Materials
Kit Calib
rators
Value Assingment
Performance Specs
Uniform
Clinical Guidelines
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Key Messages
• As leaders in our profession we have a key role to play in
facilitating better patient’s outcome
• One barrier to improved outcome is excessive variability
• Only a relatively small percentage of procedures within the
total examination process (TEP) have been standardized or
harmonized
• Where TEP procedures have been standardized evidence of
improved clinical outcome is emerging
• As a profession we should:• Facilitate the standardization of many procedures as possible
• Work with clinical colleagues to demonstrate improved outcomes
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Thus, we should pursue
standardization as
Shakespeare urged for
truth:
“…till truth makes all
things plain.”[A Midsummer Night’s Dream, Act V, sc. 1]