PCN/M13/HOS/6

LABORATORY INVESTIGATIONS

Learning Objectives

i. Describe the scope of laboratory investigations

ii. Understand the importance of laboratory investigations

iii. Provide an overview of practice approaches that ensures an effective patient monitoring

iv. Interpret laboratory results

Course Outline

• Terminologies and definition

• Routinely Requested tests

• Interpretation of results

• Factors that influence Lab results

Introduction
Laboratory tests are essential for the diagnosis and management of many conditions. However,

laboratory tests do not provide clinical value in all scenarios, and in some cases, may even cause

harm through misleading therapies. Before a laboratory test is requested, clinicians should

consider the aim of the test and have a clear understanding of how the result will be interpreted

and how the patient’s management will be affected by the result. Laboratory tests provide

diagnostic test data to aid the detection of disease, diagnose, guide treatment, monitor treatment

and monitor disease progression. These data are used by physicians, nurses, pharmacists and other

health care professionals.

In some cases, patients with underlying emotional distress or psychological illness present with a

complex pattern of medically unexplained symptoms, leading to a degree of diagnostic

uncertainty. An increasing level of uncertainty about the patient’s presenting symptoms and signs,

leads to an increasing number of laboratory tests requested. Rather than clarifying the situation,

sometimes this can lead to “digging an even deeper hole”, and emphasizes the importance of

thoughtful test requesting and interpretation

Terminologies and Definitions

1. Laboratory investigation is a procedure, usually conducted in a laboratory, that is intended to

detect, identify, or quantify one or more significant substances, evaluate organ functions, or

establish the nature of a condition or disease. Laboratory tests range from quite simple to

extremely sophisticated procedures. In modern medical practice they are commonly used to help

establish or confirm a diagnosis and often aid in the management of diseases.

2. Accuracy is defined as the extent to which the mean measurement is close to the true value
3. Reference range: A reference range is a set of values that includes upper and lower limits of a

lab test based on a group of otherwise healthy people. The values in between those limits may

depend on such factors as age, sex, and specimen type (blood, urine, spinal fluid, etc.) and can

also be influenced by circumstantial situations such as fasting and exercise. These intervals are

thought of as "normal ranges or limits." Is a statistically derived numerical range obtained by

testing a sample of individuals assumed to be healthy?

4. Pre-test probability is defined as the probability that the condition being tested for is the cause

of the symptoms, before a diagnostic test result is known.

5. The sensitivity of a test is defined as the proportion of people with the disease who have

“positive” result (above or below the diagnostic threshold used), i.e. the ability of the test to

correctly identify patients with the condition.

6. The specificity of a test is defined as the proportion of people without the disease who have

“negative” result, i.e. the ability of the test to correctly identify patients without the condition

7. Positive predictive value is defined as the probability that a patient with a positive test result

really does have the condition for which the test was requested. Unlike sensitivity and specificity

which are independent of the population being tested, the positive predictive value of a test

changes depending on the prevalence of the disease in the population being tested.

8. The negative predictive value is defined as the probability that a patient with a negative test

result really is free of the condition for which the test was conducted.

9. Decision limits are values that represent either the upper or lower quantity of an analyte that are

consistent with a disease state or indicate a need for treatment.

Reasons for Laboratory tests in primary care:
1. Diagnosis: to either include or exclude a disease, e.g. thyroid stimulating hormone (TSH)

levels in a patient with suspected thyroid dysfunction

2. Establishing a baseline prior to treatment initiation: e.g. liver function test (LFT) before

commencing methotrexate

3. Monitoring:

a. To ensure a medicine is within a therapeutic range, e.g. patients taking lithium where the

serum lithium concentration relates to clinical effect

b. To detect early signs of an adverse effect to treatment, e.g. full blood counts in patients

taking clozapine.

c. To monitor or predict the response to treatment, e.g. International Normalized Ratio (INR)

assessment in patients taking warfarin, serum urate monitoring in patients taking allopurinol,

or antimicrobial.

d. To monitor long-term conditions for disease control and associated complications, e.g. the

monitoring of HbA1c and albumin creatinine ratio (ACR) in people with diabetes.

Targeted testing e.g. antenatal screening for rubella status requires lipid levels as part of a

cardiovascular assessment.

Routinely requested tests

The responsibilities of a clinical laboratory include (See organizational chart below):

• Correct identification, collection and processing of patient specimen

• Accurate performance of testing

 • Timely reporting of results

• Communication with physicians and other health care professionals

Clinical laboratory organizational chart

Clinical laboratory

Anatomical Clinical

Cytology Hematology

Histology Coagulation

Chemistry
Cytogenetic
Blood bank

Serology
(immunology)

Urinalysis

Microbiology

Phlebotomy

Some examples of routinely requested laboratory investigations

 • Salivary chemistry

• Urine analysis

• Biochemistry –Renal function tests, Liver function tests, Lipid profile, Thyroid function,
Estimation of electrolyte, metabolic bone disease tests

• Serology and Immunohistochemistry

• Histopathology, cytology and immunofluorescent studies

• Radiological

Considerations before testing

It is estimated that over half of all errors that occur in the process of laboratory investigation, take

place during the test selection process. To reduce the likelihood of errors clinicians should be

careful not to request tests that are likely to cause confusion or false reassurance. For example, a

faecal occult blood test (FOBT) is inappropriate in an older patient with anaemia, where there is a

high suspicion of bowel cancer, as a negative result is not sufficiently reassuring to avoid

definitive investigation and a positive result could be due to other causes.

Before requesting a laboratory test it may be helpful for clinicians to consider their answers to the

following questions:

o What is my reason for requesting this test?

o Will the test improve patient (or in some cases, family or partner) care?

o Is this the right test or combination of tests for the clinical situation?

o How will the test result be interpreted?

o How will the test result influence patient management?

o Are there potential harms of doing this test?

Laboratory investigations must be thorough, timely, unbiased, scientifically sound and well

documented.

Interpretation of Results
There are two main misconceptions about test results and reference ranges:

Myth: "An abnormal test result is a sign of a real problem."

Truth: A test result outside the reference range may or may not indicate a problem, but it signals

your healthcare provider to further investigate your condition. You can have a value outside the

range and have nothing wrong—but your provider should try to determine the cause.

According to ISO 15189 norms, all pathological results must be verified by a competent

professional. In some countries staffs like clinical scientists do the majority of this work inside the

laboratory with abnormal results referred to the relevant pathologist. In others, only medical staff

(pathologist or clinical biologist) is concerned by this phase. It can be assisted by some software

in order to validate normal or non modified results. Medical staffs are sometimes also required in

order to explain pathology results to physicians. For a simple result given by phone or for a

technical problem it's a medical technologist or medical lab scientist explaining it to a registered

nurse.

Departments in some countries are exclusively directed by a specialized pathologist, in others a

consultant, medical or non-medical, may be the Head of Department. Clinical scientists have the

right to interpret and discuss pathology results in their discipline in many countries, in Europe

they are qualified to at least Masters level, may have a PhD and can have an exit qualification

equivalent to medical staff (e.g., FRCPath in the UK). In France, only medical staff (Pharm.D and

M.D specialized in anatomical pathology or clinical biology) can discuss pathological results,
To determine ranges, labs may conduct their own studies for the tests they perform, they may

adopt reference ranges from test manufacturers or other labs, or they may derive reference ranges

from existing patient data.

• The most important step in determining a reference range for any test is to define the

reference population – the group of people who will be represented in the reference range.

Depending on the test and factors that may influence its results, reference populations may

be chosen based on age, sex, race, general health, and/or medical history.

• Next, a large number (minimum of 120) of people who fit the profile of the reference

population are tested under nearly identical conditions, and the results are analyzed.

• For many tests, reference ranges include the values that are statistically analyzed and

reported for the middle 95% of the reference population.

Reasons for more than one reference range for a test

For some tests, there is no single reference range that applies to everyone. By far, the most

common factors that cause variations in reference values are age and/or sex.

For example, the range used to evaluate a creatinine test result depends on a person's age and sex

as shown in the table below.

Age Sex Creatinine Reference Range

18-20 years Male 0.9-1.3 mg/dL

Female 0.6-1.1 mg/dL

60-90 years Male 0.8-1.3 mg/dL

Female 0.6-1.2 mg/dL

Three important things to know about reference ranges:

1. A normal result in one lab may be abnormal in another: You must use the range supplied by the

laboratory that performed your test to evaluate whether your results are "within normal limits."

While accuracy of laboratory testing has significantly evolved over the past few decades, some

lab-to-lab variability can occur due to differences in testing equipment, chemical reagents used,

and analysis techniques. Consequently, for most lab tests, there is no universally applicable

reference value.

2. A normal result does not promise health: While having all test results within normal limits is

certainly a good sign, it's not a guarantee. For many tests, there is a lot of overlap among results

from healthy people and those with diseases, so there is still a chance that there could be an

undetected problem. Lab test results in some people with disease fall within the reference range,

especially in the early stages of a disease.

3. An abnormal result does not mean you are sick: A test result outside the reference range may or

may not indicate a problem. Since many reference values are based on statistical ranges in healthy

people, you may be one of the healthy people outside the statistical range, especially if your value

is close to the expected reference range. However, the abnormal value does alert your healthcare

provider to a possible problem, especially if your test result is far outside the expected values.

For a small number of tests, long-term studies of certain disease processes have led to the

establishment of decision limits that are more useful than reference ranges in determining clinical

outcomes and guiding treatment decisions. Blood glucose is an example of an analyte for which

decision limits have been established and are widely used by healthcare providers. For adults in a
routine setting in which fasting blood glucose testing is done to detect type 2 diabetes, a fasting

glucose level of 126 mg/dL (7.0 mmol/L) or above, obtained on more than one testing occasion,

indicates diabetes. Treatment is required to reduce the risk for cardiovascular disease, kidney

disease, and other long-term complications of diabetes.

Factor affecting laboratory test results

There are few reasons why a test result could fall outside of the established reference range

despite the fact that you are in good health. Generally, these factors only come into play when the

test value is slightly higher or lower than the reference range.

• Statistical variability: It is common practice for reference ranges to cover 95% of results

for a healthy population. Statistically speaking, that means 5% of people in that same

population will have results that fall outside the limits.

• Biological variability: If your provider runs the same test on you on several different

occasions, there's a good chance that at least one of those times the result will fall outside

the reference range even though you are in good health. Your body is always changing.

Your age, diet, hormonal cycles, physical activity level, alcohol intake, even a change of

season can cause alterations in your body chemistry that will show up on a test result.

• Individual variability: References ranges are usually established by collecting results from

a large population and determining from the data an expected average (mean) result and

expected differences from that average (standard deviation). There are individuals who are

healthy but whose tests results, which are typical for them, do not always fall within the

expected range of the overall population.

If you know of any special circumstances that could affect a test, mention them to your healthcare

provider; don't assume your provider has thought of every possible circumstance.

The differences between reference ranges from different labs typically are generally not

significant, but it is possible that one lab will report a result as being within range while another

could report that same result as being out of range. It should be noted that all clinical laboratories

are periodically inspected as directed by federal guidelines (Clinical Laboratory Improvement Act

of 1988, or CLIA '88) and are subjected to extensive review of quality control procedures. If you

have a health condition that is being monitored with lab tests, it may be recommended to have the

same lab perform the tests for consistency. This is something to keep in mind in the following

circumstances:

• You change healthcare providers and the new practitioner uses a different lab than the one

your previous practitioner used.

• Your provider starts having tests performed by a new lab.

• You have tests performed by a hospital laboratory (if it is different from the lab that

usually performs your tests).

It is your provider's job to not only consider that an out-of-range result could be due to the lab

change but also to consider how great a change is reflected in the new result and the whether it

might actually represent a significant change in your health.

Sources of Errors in laboratory investigations

• Analyst error: Inadequate training of analyst

• Equipment related: Poorly maintained or improperly calibrated equipment

• Procedural: Analyst not following the procedure or procedures technically not appropriate
 • Validated procedures

• Reagents

• Consumables

• Cleanliness of glassware

Conclusion

Some laboratory tests are precise, reliable indicators of specific health problems, while others

provide more general information that gives clinicians clues to your possible health problems.

Information obtained from laboratory tests may help clinicians decide whether other tests or

procedures are needed to make a diagnosis or to develop or revise a previous treatment plan.
Key learning points

• Laboratory investigation is a procedure, usually conducted in a laboratory, that is intended

to detect, identify, or quantify one or more significant substances, evaluate organ
functions, or establish the nature of a condition or disease.

• Laboratory tests are essential for the diagnosis and management of many disease
conditions by health care provider

• Reasons for Laboratory tests in primary care include diagnosis, establishment of a baseline
prior to treatment initiation and monitoring to ensure a medicine is within a therapeutic
range

• Three important things to know about reference ranges: A normal result in one laboratory
may be abnormal in another and does not promise health. An abnormal result does not
mean you are sick.

• Factor affecting laboratory test results include statistical, biological and individual
variability

• Sources of Errors in laboratory investigations could be due to analyst error, inadequate

training of analyst, equipment related, inappropriate procedures, validated procedures,
reagents, consumables and cleanliness of glassware
References

American Association for Clinical Chemistry. Reference Ranges and What They Mean 2015.
Available online at https://labtestsonline.org/understanding/features/ref-ranges/. Accessed July,
2016

Boyd JC. Defining Laboratory Reference Values and Decision Limits: Populations, Intervals, and
Interpretations. Asian Journal of Andrology. 2010;12: 83–90
Ceriotti F, Henny J. Are my laboratory results normal? Considerations to be Made Concerning
Reference Intervals and Decision Limits. Pediatric Reference Intervals. 2008;19:1-9.
Clinical Diagnosis and Management by Laboratory Methods. 20th ed. Henry JB, ed. New York:
Saunders: 2001
Determining Laboratory Reference Intervals: CLSI Guideline Makes the Task Manageable 2009.
Available online at http://labmed.ascpjournals.org/content/40/2/75.full#content-block. Accessed
June 2016.
Graham Jones, Antony Barker. Reference Intervals. Clin Biochem Rev. 2008 Aug; 29(Suppl 1):
S93–S97. Available online at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2556592/. Accessed
July 2016.
Hickner J, Graham DG, Elder NC, et al. Testing process errors and their harms and consequences
reported from family medicine practices: a study of the American Academy of Family Physicians
National Research Network. Qual Saf Health Care 2008;17(3):194–200.
Howanitz JH and Howanitz PJ,. Laboratory Medicine: Test Selection and Interpretation. eds.
New York: Churchill Livingstone; 1991:6-8.
Phillips P. Pitfalls In Interpreting Laboratory Results. Australian Prescriber. 2009;32:43-46.
Walker P, Crook M. Tumour marker requesting in primary care and the role of the laboratory. J
Clin Pathol 2011;64(5):443–6.