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CLSI C28-A3: Defining, Establishing, and Verifying Reference Intervals in the Clinical Get your Kindle here, or download a FREE Kindle Reading App. The C28-A3 guideline published by the Clinical and Laboratory Standards Institute (CLSI) and IFCC is still the most widely-used source of. discusses the necessary and recommended data for selecting appropriate breakpoints and quality control ranges for antimicrobial agents. Download M23.
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Tions13,14 and the publication of common IFCC and.
Establishing, and Verifying Reference Intervals in the Clinical. Topics in Pediatrics - American Association for Clinical… pdfwww. Show more from the sitedeline Second ed. Clsi Document C28 A3 - youqian. Written informed consent from participants is needed from each reference individual who agrees to participate in the study.
The consent form should state clearly that laboratory personnel are allowed to obtain specimens, and to use the associated laboratory values and questionnaire information for the determination of RIs 13.
In the a priori sampling approach, exclusion criteria are applied before sampling collection and it is the more appropriate approach when the biology of an analyte is known. In a posteriori sampling, the exclusion criteria are applied after the sampling. Both of these methods are known as direct sampling, which is the primary recommendation of the IFCC. Ideally, RIs are determined on the basis of a healthy population using direct methods 4. However, indirect methods, which are also known as data mining, based on previous laboratory data can also be useful 23.
Various methods may be used for the selection of a group of healthy individuals from a general hospital population and reference values are calculated from hospital data using statistical methods, such as Bhattacharya analysis 24 and some modifications of the method 25 , 26. There is opposition to this approach from some, as there is insufficient knowledge of the subjects and reliance on statistical methods to exclude the unhealthy subjects as explained in C28-A3.
It has also been emphasised that as there is little control of the pre-analytical and analytical conditions, the indirect approach could be used for local situations or difficult groups of subjects such as neonates, children or the elderly, or as a means to confirm the goodness of the selected RI 27. Other researchers favour the indirect method as the results are clinically relevant and much simpler for an individual laboratory to implement than the time-consuming direct a priori method, which requires considerable data and professional input 28 , 29.
Pre-analytical and analytical aspects must be taken into consideration in the implementation of a RI study. Generally, the pre-analytical considerations involve biological i. For reproducibility and standardization, it is essential that the pre-analytical aspects are accurately defined and described as the preanalytical phase is known to have the highest errors in the total test process 30.
Because of the importance of harmonizing pre-analytical phase of the total testing process, an effort has been made by the European Federation for Clinical Chemistry and Laboratory Medicine EFLM Working Group for Preanalytical Phase WG-PRE to support the worldwide harmonization of color coding for blood collection tube closures 31 , 32. Different commercial methods may be used in a trueness-based approach to the reference measurement system providing results traceable to the system and thus, comparable results can be produced in clinical laboratories.
When performing a RI study, the reference measurement systems and standard reference materials are of great importance to ensure traceability of the test results in comparisons 33. Calculation of RIs includes parametric and nonparametric calculation methods, detection of outliers, partitioning, and confidence intervals. The lower reference limits are estimated as the 2.
The reference values of many analytes do not display Gaussian distribution, so the parametric method can be applied after data transformation. The most suitable transformation method must be selected e.
The nonparametric method of estimation does not assume the probability distribution of the observed reference values 7. Although the C28-A3 recommends the nonparametric calculation method, the RIs calculated by the parametric and nonparametric methods were compared in the recent IFCC, C-RIDL study which concluded that the results of the two methods are very close and parametric methods can also be used as a first choice 13.
Whichever method is used in the calculation of the RIs, detection and exclusion of the outliers are very important to obtain reliable RIs.
A simple but effective method for the detection of outliers is visual inspection of the data. However, this method is not very sensitive when there is more than one outlier. The Horn using Tukey method is a more sophisticated method, which includes Box-Cox transformation of the data to obtain Gaussian distribution followed by identification of the outliers in interquartile ranges IQR: Q3-Q1; Q1: lower quartile, Q3: upper quartile.
This method is an iterative approach for the derivation of multiple reference RIs simultaneously, when no exclusion of values has been made in the initial computation of the RIs. Several statistical methodologies have been proposed to be able to make the extremely important decision of whether or not to separate different groups.
The most widely-used partitioning method is that of Harris and Boyd, in which the means and standard deviations of the subgroups are considered as a separate different standard deviation that may produce different limits 38.
However, this method is only appropriate for analytes with a Gaussian distribution with subclasses, where the values are of similar size and standard deviation.
A similar method was proposed by Lahti et al. More recently, Ichihara and Boyd recommended a partioning method on the basis of the magnitude of the standard deviations of test results named standard deviation ratio SDR 37. An SDR greater than 0.