dec 9 2015 gent kenneth goossens (ugent)stt-consulting.com/doc/1449757541.pdf · 2 overview 1....
TRANSCRIPT
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The Percentiler - The Flagger:Mid- to long-term quality monitoring
Dec 9th 2015 GentKenneth Goossens (Ugent)
Thienpont & Stöckl
Wissenschaftliches Consulting GbR
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2
Overview
1. Theoretical background
2. The Percentiler
3. The Flagger
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Theoretical Background
“Surrogate” medical decision hyponatremia• Triplication “low versus high” period ( ±2 mmol/L )!• Benchmark stability: 8 years ±1 mmol/L
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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So
diu
m (
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ol/L
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Date (day/month/year)
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Concept
Patient is not measured• By a laboratory
Patient is measured• On rotor 1 of instrument x in laboratory y with the
assay of manufacturer z.
Only The Percentiler and The Flagger deliver thatdepth of information! (by plotting the movingmedians; grouped per 5, 8 or 16 days)• The Percentiler : monitoring of patient medians• The Flagger: monitoring of hypo- and hyper-
flagging rate
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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The Percentiler
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Limits
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
Bias Bias Bias Bias
Biology Empower Biology Empower Median
(%) (%) (unit) (unit) Unit "SI"
ALB 1.3 2.3 0.56 1 g/L 43.0
ALKFOS 6.4 7.0 4.6 5 U/L 71.9
ALT 11.4 11.0 2.1 2 U/L 18.1
AST 5.4 4.9 1.1 1 U/L 20.4
BILTOT 11.4 12.2 0.94 1 µmol/L 8.21
CA 0.8 2.1 0.019 0.05 mmol/L 2.38
CHOL 4 4.1 0.20 0.2 mmol/L 4.91
CL 0.5 1.0 0.51 1 mmol/L 102.0
CRP 21.8 11.0 0.40 0.2 mg/L 1.82
GGT 10.8 9.4 2.3 2 U/L 21.2
GLUC 2.2 3.8 0.12 0.2 mmol/L 5.24
K 1.8 2.3 0.08 0.1 mmol/L 4.44
CREAT 4 4.1 2.9 3 µmol/L 73.0
LDH 4.3 5.4 7.9 10 U/L 183.6
MG 1.8 3.5 0.015 0.03 mmol/L 0.85
NA 0.3 0.7 0.42 1 mmol/L 140.6
P 3.2 3.6 0.036 0.04 mmol/L 1.11
PROT 1.2 1.4 0.83 1 g/L 69.5
UREA 5.5 5.5 0.30 0.3 mmol/L 5.45
URIC ACID 4.9 4.7 15.5 15 µmol/L 317
FT4 3.3 3.4 0.5 0.5 pmol/L 14.9
TSH 7.8 7.3 0.13 0.12 mU/L 1.65
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Percentiler Limits
PotassiumLimits lowered: 0.15 to 0.1 mmol/L(0.08 mmol/L ~ biological variation)
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (lab-specific)
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (lab-specific)
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (lab-specific)
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)
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Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Albumin – Manufacturer A
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Albumin – Manufacturer A
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Albumin – Manufacturer B
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Albumin – Manufacturer B
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Albumin – Manufacturer B
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Albumin – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Albumin – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Albumin – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Albumin – Manufacturer D
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Albumin – Manufacturer E
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Albumin – Manufacturer F
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Albumin – Manufacturer G
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Albumin – Manufacturer G
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Chloride – Manufacturer B
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Chloride – Manufacturer B
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Chloride – Manufacturer B
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Chloride – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Chloride – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Chloride – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Chloride – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)ALT – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)ALT – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)ALT – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)ALT – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)ALT – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)ALT – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Calcium – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Calcium – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Calcium – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Calcium – Manufacturer G
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Calcium – Manufacturer G
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Total-Bilirubin – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Total-Bilirubin – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Total-Bilirubin – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Total-Bilirubin – Manufacturer D
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Total-Bilirubin – Manufacturer D
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Creatinine – Manufacturer B
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler Applications
Identifying problem analytes (peer-specific)Creatinine – Manufacturer B
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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50
Percentiler Applications
Identifying problem analytes (peer-specific)Creatinine – Manufacturer B
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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51
Percentiler Applications
Identifying problem analytes (peer-specific)Creatinine – Manufacturer B
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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52
Percentiler Applications
Identifying problem analytes (peer-specific)Creatinine – Manufacturer F
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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53
Percentiler Applications
Identifying problem analytes (peer-specific)AST – Manufacturer B
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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54
Percentiler Applications
Identifying problem analytes (peer-specific)AST – Manufacturer B
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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55
Percentiler Applications
Identifying problem analytes (peer-specific)Sodium – Manufacturer A
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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56
Percentiler Applications
Identifying problem analytes (peer-specific)Sodium – Manufacturer A
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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57
Percentiler Applications
Identifying problem analytes (peer-specific)Sodium – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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58
Percentiler Applications
Identifying problem analytes (peer-specific)Sodium – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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59
Percentiler Applications
Identifying problem analytes (peer-specific)Sodium – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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60
Percentiler Applications
Identifying problem analytes (peer-specific)Sodium – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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61
Percentiler Applications
Identifying problem analytes (peer-specific)Sodium – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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62
Percentiler Applications
Identifying problem analytes (peer-specific)Sodium – Manufacturer F (several labs, upwards trend)
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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63
Percentiler Applications
Identifying problem analytes (peer-specific)Total-protein – Manufacturer B
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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64
Percentiler Applications
Identifying problem analytes (peer-specific)Total-protein – Manufacturer B
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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65
Percentiler Applications
Identifying problem analytes (peer-specific)Total-protein – Manufacturer B
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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66
Percentiler Applications
Identifying problem analytes (peer-specific)Total-protein – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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67
Percentiler Applications
Identifying problem analytes (peer-specific)Total-protein – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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68
Percentiler Applications
Identifying problem analytes (peer-specific)Total-protein – Manufacturer C
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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69
Percentiler Applications
Identifying problem analytes (peer-specific)Total-protein – Manufacturer F
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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70
Percentiler Applications
Identifying problem analytes (peer-specific)Total-protein – Manufacturer G
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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71
Percentiler Applications
Peer group overviewsPeer Group report #1 ( March 2014 )Peer group report #2 ( July 2015 )
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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72
Percentiler Applications
Bias assessment versus peer
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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73
Potential Issues
Patient population effects & stratification problems
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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74
Potential Issues
Holiday periods
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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75
Potential Issues
Cobas peer influenced by lab chain
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Low population variation
Observation of small (insignificant) effects on a short(er) time-scale
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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77
Low population variation
Observation of small (insignificant) effects on a short(er) time-scale
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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High population variation
Counteract by using high “ n”Example: n = 16
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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High population variation
Cave when using high “ n”Verify at n = 5! (or n = 8)
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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High population variation
Still possible to observe effects on a mid- to long-term scale
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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High population variation
Still possible to observe effects on a mid- to long-term scale
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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The Flagger
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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The Flagger – Application Concept
TheoryEffect of assay instability on surrogate medical decisions
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
A fresh look at analytical performance specifications from biological variation.Stepman HC, Stöckl D, Twomey PJ, Thienpont LM. Clin Chim Acta 2013;421:191-2.
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The Flagger – Application Concept
Example: hypercalcemia surrogate medical decision Triplication of flagging rate in period with high vslow median values
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
Goossens K et al. On-line flagging monitoring – A new quality management tool for the analytical phase. Clin Chem Lab Med 2015; doi: 10.1515/cclm-2015-0066.
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Flagger Limits
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
Original IdeaViolation Flagger limits ~ Violation Percentiler limits
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Flagger Limits
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
Original IdeaViolation Flagger limits ~ Violation Percentiler limitsWould require the use of lab-specific limitsBecause:• Different laboratories apply different reference
intervals→ The long-term flagging rates lie at grossly
different levels• Assays are calibrated differently at different
concentration ranges
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Flagger Limits
Current Limits = Analyte-specific limitsCalculated relatively to the long-term flagging rate
For example:AST limit = relative 30% (absolute minimum = 1%)
Long term flagging rate = 10%Limit = ± 3% (30% of 10%)
Long term flagging rate = 2.5%Limit = ± 1% (NOT 0.75%)
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Flagger Limits
Current Limits = Analyte-specific limitsViolation Flagger limits ≠ Violation Percentiler limits
Treat these limits differently:They give different and additional information aboutyour long-term performance• Percentiler limits ~ Biological variation/State-of-
the-art performance at median concentration• Flagger limits ~ State-of-the-art performance at
low/high concentration
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Flagger Limits
Current Limits = Analyte-specific limitsViolation Flagger limits ≠ Violation Percentiler limits
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Bias Bias Minimum
Biology Empower Limit Limit
(%) (%) (Relative %) (Absolute %)
ALB 1.3 2.3 30 1
ALKFOS 6.4 7.0 40 1
ALT 11.4 11.0 30 1
AST 5.4 4.9 30 1
BILTOT 11.4 12.2 40 1
CA 0.8 2.1 70 1
CHOL 4 4.1 30 1
CL 0.5 1.0 50 1
CRP 21.8 11.0 30 1
GGT 10.8 9.4 50 1
GLUC 2.2 3.8 30 1
K 1.8 2.3 50 1
CREAT 4 4.1 40 1
LDH 4.3 5.4 50 1
MG 1.8 3.5 80 1
NA 0.3 0.7 100 1
P 3.2 3.6 70 1
PROT 1.2 1.4 60 1
UREA 5.5 5.5 30 1
URIC ACID 4.9 4.7 60 2
FT4 3.3 3.4 30 1
TSH 7.8 7.3 30 1
Percentiler Flagger
Flagger Limits
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Flagger Limits
Preliminary!Right now , the limits are biased towards Cobasperformance
We need more instruments from other peer groupsto set state-of-the-art related limits
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Flagger – Peer Group Comparison
Similar as for the Percentiler:All or peer group median = black dotted line
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Flagger – Peer Group Comparison
Is peer group comparison useful?There is limited consensus on the applied referencelimits in the lab!
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Flagger – Peer Group Comparison
Is peer group comparison useful?There is limited consensus on the applied flagginglimits in the lab!
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler - Flagger Link
PrincipleWhen values for patient medians ↑:
• %-hypo ↓• %-hyper ↑
When values for patient medians ↓ :• %-hypo ↑• %-hyper ↓
It allows to translate analytical changes into theireffect on the flagging rate
But exceptions exist!
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler - Flagger Link
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler - Flagger Link
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler - Flagger Link
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler - Flagger Link
Hypo’s comparable despite patient median bias
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler - Flagger Link
Instrument change
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler - Flagger Link
Instrument change
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler - Flagger Link
The effect of analytical changes on the flagging rate
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Percentiler - Flagger Link
The effect of analytical changes on the flagging rate
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Flagger accounts
www.theflagger.be
Percentiler login = Flagger login
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Benefits
Patient percentile (flagging) monitoring
• Gives evidence about stability of performance & the reasons for assay variation (manufacturer, lot-to-l ot, calibration, instrument)
• Enables monitoring the effect of instability on “surrogate” medical decisions (“flagging” frequency )
• Strengthens the laboratory/manufacturer dialogue
• Strengthens the physician/laboratory interface by m ore transparent communication on performance
• Helps with establishment of realistic quality goals
• Provides basis for comparison across manufacturers
Empower Gent Dec 9 2015 – The Percentiler – The Flagger
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Thank you
• The Percentiler/Flagger Laboratories
• Belgian representatives (& headquarters) of Abbott, Beckman/Analis, Ortho, Roche, Siemens
• LIS companies
• Belgian Society for Clinical Chemistry
• Filip Migom (MIPS) & Tom Fiers (Gent University Hospital) & Gudrun Verween
• Bruno Neckebroek (IT)
• Sten Westgard, Hassan Bayat…
Empower Gent Dec 9 2015 – The Percentiler – The Flagger