DrOghenev

wogagaEDENYA
REFERENCEI
NTERVAL
Interpretati
onofclinicall
aborator
ydatai sacompar ativedeci sionmaki nginwhichal abor atory
testr esultforanindi vi
dualiscompar edwi thar eferencei nter v
al.Thesear evaluest owhi ch
phy sici
anscompar et heirpati
entstestr esulttof acil
itateint er
pretati
ons.Therefor
e,r eliable
referencev al
uesar erequiredforalltestsint hecl i
nicallabor ator
yandmustbepr ov idedby
cli
nicall aborat
ori
esanddi agnosi
skitmanuf acturers.Ref erencei nterv
alisdefi
nedasapai rof
medi caldeci si
onpoi ntst hatspanthel i
mi t
sofr esultsexpect edf oragi v
encondi ti
on.I tis
commonl yusedtodescr ibehealt
hyindivi
duals,thereforetestr esult
sout si
deoftheser eference
i
nter valsmaybeobser vedi ni
ndivi
dual
swi thdiseaseori nst atesofl essthangoodheal th.

I
MPORTANTCONCEPTS
1.Nor
mal
Val
ues

Thesearerefer
encesv al
uesthathavebeenobser vedinnor malorheal
thypersons.Therei
s
oft
enanov erl
apofnor malandabnormalv aluesbecausechangesinanaly
teconcentrat
ioni
n
di
seasestatesoccurinacont inuousfashion.Consequentl
y,“
normal”val
uesdonotal way
s
i
ndicat
ealackofdiseasenordoesav al
ueexceedingadef i
nedli
mital
waysindi
cateadisease.

2.Cl
i
nical
Deci
sionLi
mit
s

Thesear ediff
erentf rom ref
erencei
nter
valsbecausetheyarespeci
fi
cf oragivenmedical
conditi
on,descri
bingaboundar yofanalyt
econcentr
ationsthatr
equi
reimmediatemedical
i
nterventi
onorchangei nmanagement.Theymaybecr i
ti
calval
uesort
herapeut
icwindowl
i
mi t
forpharmaceuti
cal agents

APPLI
CATI
ONOFREFERENCEI
NTERVAL

 Scr
eeni
ngf
oradi
sease

 Di
agnosi
sforadi
sease

 Moni
tor
ingt
her
apy

 Moni
tor
ingdr
ugt
oxi
cit
y

 Reassur
anceofpat
ient

ESTABLI
SHI
NGAREFERENCEI
NTERVAL
Anewr ef
erenceinter
valisestabli
shedwhent hereisnoexi st
inganal yt
eormet hodologyinthe
cl
inicall
aboratory
.Thisisacostlyandlabourintensiv
est udyt
hatr equir
esami nimum of120t o
asmanyas700st udyindivi
duals(ref
erenceindivi
duals)sel
ectedf r
om ar efer
encepopulati
on.
Existi
ngreferenceint
ervalcanhowev erber evi
ewedbyt hecli
nicallaborat
oryont hefol
lowing
grounds;
 1.I
ntr
oduct
ionofanewanal
ytet
othet
estr
eper
toi
re

2.Changei
nanal
ytemet
hodol
ogy

3.Changei
npat
ientpopul
ati
on

STEPSTOESTABLI
SHAREFERENCEI
NTERVAL
1.Def
ine an appr
opr
iat
eli
stofbi
ologi
calv
ari
ati
ons and anal
yti
cint
erf
erences f
rom
medicall
i
ter
atur
e.

2.Choosesel
ect
ionandpar
ti
ti
on(
e.g.age&sex)cr
it
eri
a.

3.Compl
eteawr
it
tenconsentf
orm andquest
ionnai
ret
ocapt
uresel
ect
ioncr
it
eri
a.

4.Cat
egor
izet
hepot
ent
ial
ref
erencei
ndi
vi
dual
sbasedont
hequest
ionnai
ref
indi
ngs.

5.Excl
udei
ndi
vi
dual
sfr
om t
her
efer
encesampl
egr
oupbasedonexcl
usi
oncr
it
eri
a.

6.Defi
nethenumberofrefer
encei
ndi
vi
dual
sinconsi
der
ati
onofdesi
redr
efer
encel
i
mit
s
andstat
ist
ical
accur
acy
.

7.St
andardi
zecoll
ect
ionandanaly
sisofref
erencespeci
mensfort
hemeasur
ementofa
gi
venanal
yteconsi
stentwi
tht
herout
inepr
acticef
orpati
ent
s.

8.I
nspectt
her
efer
encev
aluedat
aandpr
epar
eahi
stogr
am t
oev
aluat
ethedi
str
ibut
ionof
dat
a.

9.I
dent
if
ypossi
bledat
aer
ror
sand/
orout
li
ersandt
henanal
yzet
her
efer
encev
alues.

SELECTI
ONOFREFERENCEI
NDI
VIDUALS
A setofselect
ioncri
teri
adeter
mineswhichindi
vi
dual
sshoul
dbei
ncl
udedi
nthegr
oupof
r
eferencei
ndivi
dual
s.Suchsel
ect
ioncr
it
eri
aincl
ude:

1.St
atementdescr
ibi
ngt
hesour
cepopul
ati
on(
ref
erencepopul
ati
on)
.

2.Speci
fi
cat
ionofcr
it
eri
aforheal
th.

3.Thedi
seaseofi
nter
estwher
eappl
i
cabl
e.

Aft
erdet er
miningtheselect
ioncri
teria,excl
usi
oncrit
er i
aandpartit
ioningi
salsoestabli
shed.A
questi
onnairemayt henbeusedt oev aluat
ethesecri
teri
ainpotenti
alrefer
enceindi
vidual
s.Iti
s
i
mpor tanttodisti
ngui
shbetweensel ectionandpart
it
ioningcri
ter
ia.Select
ioncr
iter
iaisappli
ed
toobtainagr oupofref
erenceindi
viduals.Ther
eaft
er,thi
sgroupisdi v
idedint
osubgroupsusing
part
it
ioningcrit
eri
a.

EXAMPLESOFPOSSI
BLEPARTI
TIONI
NGFACTORS
 1.Age

2.Sex

3.Di
et

4.St
ageofmenst
rual
cycl
e

5.St
ageofpr
egnancy

6.Ci
rcadi
anv
ari
ati
on

7.Race

8.Post
uredur
ingsampl
ecol
l
ect
ion

EXAMPLESOFPOSSI
BLEEXCLUSI
ONCRI
TERI
A

1.Al
cohol
consumpt
ion

2.Recenti
l
lness

3.Obesi
ty

4.Abnor
mal
bloodpr
essur
e

5.Dr
ugabuse

6.Genet
icf
act
or

7.Recentbl
oodt
ransf
usi
on

8.Cur
rent
/recenthospi
tal
i
zat
ion

9.Fast
ingornon-
fast
ing

10.Pr
escr
ipt
iondr
ugs

Thet er
msapr ior
iandposteri
oriareusedto descr
ibet
wo gener
almet
hodsofsel
ect
ing
ref
erencei
ndi
vi
dualsf
rom t
heref
erencepopul
ati
on.

Apr iorisampli
ngisamet hodthatisusedf orestabli
shedlabor
atoryprocedures.Awel l
-defi
ned
exclusioncrit
eriaandpar ti
ti
oni
ngcr i
teri
aar eest abl
ishedbeforeselecti
onoft heref er
ence
i
ndi vi
duals.Thoroughsearchoflit
eratur
et oidentif
yknownsour cesofbiologi
calvari
at i
onsis
under t
akenwi t
hdev el
opmentofappr opri
atequest i
onnairetofacil
it
ateproperselect
ionoft he
referenceindi
vidual
sandpar ti
ti
oni
ngi nt
osubcl asseswher enecessary.Theseprocessest ake
placebef or
ebloodsamplesar ecol
lect
ed.

Theapost eriorimethodi sappropri

atef
ornew orpoor lyst udi
edl aboratoryproceduresf or
whichtheli
teratur
econtainsli
ttl
einf
ormat
ion.I
napost er
iorisampl i
ng,theprocessofexcl usi
on
and part
it
ioning takes place af
tersampli
ng and anal
y t
et est
ing rathert han befor
e.The
questi
onnair
ef orthi
stypeofsampl i
ngmethodshoul
dbemor edetail
edt hantheonef orapr i
ori
,
becauset
hefactor
sdet
ermi
ningsubcl
assi
fi
cat
ionisnotknown.Alargernumberofsubj
ect
s
andsubst
ant
ial
computi
ngpoweri
srequi
redtoi
mplementaposter
ior
imethodeff
ect
ivel
y.

PREANALYTI
CALANDANALYTI
CALVARI
ABLES
Analyt
icalresult
sf r
om r ef
er ence populat
ion st
udies ar
ei nf
luenced by preanal y
ticaland
analyt
icalv
ar i
abl
es.Thesev ariabl
esmustbei denti
fi
edandcont r
oll
edtoensurer el
iabil
i
tyof
deri
ved ref
erence i
nterv
als.Pr eanalyt
icalvari
abl
es arefactor
st hatal
terthe r esults ofa
l
aboratorytestandthatoccurbef oretheprocessofperfor
mingt hetest
.Thesef actorscanbe
groupedint
ot hefol
l
owingcat egories:

1.Subj
ectpr
epar
ati
on

a.Di
et

b.Abst
inencef
rom phar
maceut
ical
agent
s

c. Phy
sical
act
ivi
ty

d.St
ress

e. Rel
ati
ont
obi
ologi
cal
rhy
thms

f
. Restper
iodbef
oresampl
ecol
l
ect
ion

2.Speci
mencol
l
ect
ion

a.Ti
meofday

a.Bodypost
ure

b.Speci
ment
ype

c. Techni
que

3.Speci
menhandl
i
ng

a.Tr
anspor
t

b.Cl
ott
ing

c. Separ
ati
onofser
um/
plasma

d.St
orage

Anal
yti
cal
procedur
eforspeci
menpr
ocessi
ngmustbecl
ear
lyst
atedandshoul
dincl
ude:

a.Accur
acy

b.Pr
eci
sion
 c. Mi
nimum det
ect
ionl
i
mit
s

d.Li
near
it
y

e. Recov
ery

f
.Int
erf
erencechar
act
eri
sti
cs

Otherfact
orsthataff
ectanaly
ticalper
for
mance( requi
ri
ngpropercontr
ol)includeequipment
,
r
eagents(thi
sincl
udeswater)
,calibr
ati
onstandar
ds.Reagentlot
-t
o-l
otvari
ation,inst
rument
-t
o-
i
nstrumentvar
iabi
li
tyaswell
ast echnol
ogi
stvari
abi
lit
ymustalsobedetermined.

ANALYSI
SOFREFERENCEVALUES
Toestabli
shar eferenceinter
val,i
tisrecommendedt hatthestudyincludesami nimum of120
ref
erencei ndi
vi
dual s.Thismakest hepr ocessar duousandcost l
y ,butnecessaryf orsome
esoter
ictests.Afterobtai
ningtherawdat afrom theanalysisofref
erencesampl es,generat
ion
ofthereferenceintervali
sthenextstep.Ther eferenceinter
vali
scal cul
atedstat
isti
call
yusing
methodst hatdependont hedist
ri
buti
onoft hedat a.Datamaybebasi cal
lydescri
bedasbei ng
normall
ydi st
ri
buted( Gaussi
an)orskewed( non-Gaussian).

Thenormaldistr
ibut
ionisadi
str
ibut
ionthathasmostofthedat
ainthecenterwithdecreasing
amountsevenlydist
ribut
edt
otheleftandtotheri
ght
.Theskeweddistr
ibuti
onisadistri
bution
withdat
aclumpedupononesi deortheotherwit
hdecreasi
ngamountstrai
l
ingofftotheleftor
theri
ght
.

NORMALDI
STRI
BUTI
ONDATA

I
fther
eferencedataarenor
mall
ydistr
ibut
ed,t
heref
erenceinterv
alcanbedeter
minedusinga
par
ametr
icmet hod.Apar
ametr
icmethoddefi
nest
hereferenceinter
valbyt
hemean±1.962SDS
bycent
eri
ngont
hemean,
thi
sencompassest
hecent
ral
25%ofv
alues.

SKEWEWDDI
STRI
BUTI
ONDATA

Mostanal y
tesdonothowev erfoll
ow anormaldi str
ibution( Gaussi an)andmustbeanal y
zed
usi
ngnonpar ametricanal y
sis.Nonpar ametr
icdet erminationofr eferenceinterv
alisdoneusing
percent
il
es.Theref erenceintervali
sdeterminedusi ngt hecent ral95%ofv al
ues.Therefer
ence
i
ntervali
stheref
oredef inedbyt he2.5tht
othe97. 5thpercent il
es.Tocal cul
atetheint
erval
,val
ues
t
h th
arerankedfrom lowestt ohi ghestandt he2.5 and97. 5 per centi
lesar ethenchosenast he
l
owerandupperl imits.Mostr eferenceint
erval
sar edet ermi nedusi ngnonpar ametri
canalysi
s
becausemostanal ytesdonotf oll
owanor mal(Gaussi an)di stri
but i
on.

TRANSFERENCE
Duet ot hecostofdet erminat ionofar eliablereferencei nterval
,clinicall aborator iesr elyon
assaymanuf acturersoronpubl i
shedpr i
mar yli
teratureasasour ceofr eferencei nter vals.To
transferr eferencev aluespr oper ly
,acer taincondi ti
onmustbef ulfi
l
led;t heor i
ginalr eference
studymustmeett he mi nimum r equir
ementofa v ali
d st udyas out li
ned byt he Cl i
nical
Labor atory St andardI nsti
tut e.The pr eanal yt
ical,analyticalpr ocedur aldet ail
s,anal yti
cal
per f
ormance,t hecompl etesetofr eferencev al
uesandt hemet hodofest imat ingt her eference
i
nt ervalmustbecl earl
yst at ed.A mi nimum of20subj ecti susedi nv alidati
nganexi sti
ng
referencei ntervalasst i
pulatedbyt heCLSI .Methodv er
ifi
cat i
oncanbeusedi fthet estmet hod
andst udysubj ectsar esi milart ot hev endor ’
sreferencedat aandpackagei nserti nf ormat ion.
The mai n assumpt ion in usi ng t ransfer ence studies ist hatpopul ations ar e si mi lar.The
manuf acturer’
sr eported95%r eferencelimi t
smaybeconsi deredv al
idi fnomor et han10%of
thet estedsubj ectsfalloutsidet heor i
ginal reportedlimits.