TRENDS IN TIME. EXTERNAL EVALUATION PROGRAM FOR Immmunoassays - Chemistry

Transcription

1 Commissie voor Klinische Biologie Commission de Biologie Clinique EXTERNAL EVALUATION PROGRAM FOR Immmunoassays - Chemistry TRENDS IN TIME CM Van Campenhout N Hamers JC Libeer WIV/ISP/IPH Clinical Biology Brussels - BELGIUM

2 EQA PROGRAMS - STATISTICAL EVALUATION GENERAL CHANGES EVOLUTIONS IN IMMUNOASSAYS EVOLUTIONS IN CHEMISTRY EQA PROGRAMS THE PLAYERS CONCLUSION

3 EQA PROGRAMS CLINICAL CHEMISTRY - ELECTROPHORESIS IMMUNOASSAYS HEMATOLOGY COAGULATION IMMUNOHEMATOLOGY FLOW CYTOMETRY NON INFECTIOUS SEROLOGY PCR / ONCO-HEMATO / MICROBIOLOGY HEAVY METALS ALLERGY SPERM HbA1c ALCOHOL POCT GLUCOSE MICROBIOLOGY PARASITOLOGY INFECTIOUS SEROLOGY THERAPEUTIC MONITORING

4 TYPES OF CONTROL MATERIAL COMMERCIAL LYOPHYLIZED (human) COMMERCIAL LIQUID (human) PATIENT SAMPLES - pools - single donation MICRO-ORGANISMS

5 STATISTICAL non parametric ANALYSIS OF QUANTITATIVE RESULTS RELATIVE IMPRECISION (own peer group) CRITERIA M - R Z-SCORE = SD limit = 3Z (3SD) SD = P75 P25 / 1,349 RELATIVE ACCURACY (own peer group) M - R U-SCORE = x 100 limit = d (%) M Based on biological variability

6 LABORATORY EVALUATION FOR QUANTITATIVE RESULTS - ANNUAL REPORT- NUMBER OF RESULTS EXCEEDING THE LIMITS FOR IMPRECISION AND ACCURACY ARE ADDED IMPRECISION (relative) Z > 3SD (own peer group) method dependent ACCURACY (relative) U > d (fixed limit) non method dependent NZ Nu Percentages of Nz (=Pz) and Nu (Pu) for each laboratory are calculated

7 LABORATORY EVALUATION FOR QUANTITATIVE RESULTS - ANNUAL REPORT- PRECISION (relative) ACCURACY (relative) P N N Z Z = 100 (%) P N N U U = 100 (%) 90 th percentile (P 90 ) of the distribution of all Pz and all Pu values of all laboratories is calculated criterion for performance evaluation. Pz > P (90) z Poor performance for PRECISION Pu > P (90) u Poor performance for ACCURACY

8 Cumulative Pz- en Pu-distribution for all laboratories - EQA CHEMISTRY (N=213) Cumulative freq distrib.o Pz Pu Percentage z-scores and u-scores "out of limit values"

9 EQA PROGRAMS - STATISTICAL EVALUATION GENERAL CHANGES EVOLUTIONS IN IMMUNOASSAYS EVOLUTIONS IN CHEMISTRY EQA PROGRAMS THE PLAYERS CONCLUSION

10 CHANGES OVER TIME - GENERAL CHANGES IN NUMBER OF PARTICIPATING LABORATORIES CHANGES IN REQUESTED ANALYTES MAJOR CHANGES IN METHODOLOGIES MAJOR CHANGES IN REPORTING EQA RESULTS

11 EVOLUTION OF PARTICIPATING LABORATORIES BIOCHEMISTRY IMMUNOASSAY

12 EVOLUTION IN EQA IMMUNOASSAYS INCREASE IN REQUESTED ANALYTES CHANGES IN METHODOLOGY

13 REQUESTED ANALYTES EQA IMMUNASSAYS 1995 AFP CA 125 CA 15.3 CA 19.9 CEA Cortisol c-peptide DHEA-S Ferritine Folate FSH FT3 FT4 hcg hgh IgE Insulin LH NSE Oestradiol Parathormone Progesterone Prolactine PSA Testosteron Thyroglobulin TSH Vitamin B12 Anti TG/TPO Salicylate Amikacin Carbamazepin Digoxin Gentamicin Lithium Paracetamol Phenobarbital Phenytoin Theophylline Valproic acid Vancomycin

14 REQUESTED ANALYTES EQA IMMUNASSAYS AFP CA 125 CA 15.3 CA 19.9 CEA Cortisol c-peptide DHEA-S Ferritine Folate FSH FT3 FT4 hcg hgh IgE Insulin LH NSE Oestradiol Parathormone Progesterone Prolactine PSA Testosteron Thyroglobulin TSH Vitamin B12 Anti TG/TPO Salicylate Amikacin Carbamazepin Digoxin Gentamicin Lithium Paracetamol Phenobarbital Phenytoin Theophylline Valproic acid Vancomycin

15 CHANGES IN METHODOLOGY from RIA to non RIA METHODS %RIA % non RIA EXAMPLE FOR PROGESTERON

16 CV(%) CV(%) IN FUNCTION OF TIME RIA and non RIA METHODS RIA non RIA EXAMPLE FOR PROGESTERON % 20%

17 CV(%) IN FUNCTION OF METHODS Analytical systems CV (%) DHEA-S Patient 1.68 µmol/l Biorad 1.69 µmol/l Patient 1.69 µmol/l Biorad µmol/l Randox µmol/l Immunotech Siemens (4) Coat-a-count (coat-acount) (n=9) (n=4) (9) Access (6) (n=6) Liaison (6) (n=6) Elecsys Cobas e (n=29) (29) Immulite (38) (n=38) Global (102) (n=102)

18 EVOLUTION OF FIXED LIMITS d IN TIME d (%)1993/2004* Vit B12 TSH Testosteron* PSA Prolactine* Progesteron LH IgE hcg FT4* FT3* FSH Ferritine Cortisol CEA* AFP* d (%) 2008 TE-WESTGARD

19 Vancomycine* Valproïnezuur* Theophylline Digoxine Amikacine* EVOLUTION OF FIXED LIMITS d IN TIME d (%)1993/2004* d (%) 2005 d (%) 2008

20 18 16 P(90)U P(90) U EVOLUTION OF PU and Pz IN TIME CYCLE P(90)Z INTRODUCTION OF NEW PARAMETERS CHANGES IN CONCENTRATIONS (e.g. low values) P(90) Z CYCLE

21 EVOLUTION IN EQA CHEMISTRY INCREASE IN REQUESTED ANALYTES CHANGES IN METHODOLOGY

22 REQUESTED ANALYTES EQA CHEMISTRY 1995 ALBUMIN* ALT AMYALSE AST* BILIRUBINE DIRECTE* BILIRUBINE TOTAL* CALCIUM CHLORIDES CHOLESTEROL HDL* CHOLESTEROL TOTAL CREATININE γ GT egfr* GLUCOSE IgA IgG IRON LDH MAGNESIUM PHOSPHORUS* POTASSIUM SODIUM TOTAL PROTEIN TRIGLYCERIDES URIC ACID UREA

23 REQUESTED ANALYTES EQA CHEMISTRY ALBUMIN* ALT AMYLASE AST* BILIRUBIN DIRECT* BILIRUBIN TOTAL* CALCIUM CHLORIDES CHOLESTEROL HDL* CHOLESTEROL TOTAL CREATININE γ GT egfr* GLUCOSE IgA IgG IRON LDH MAGNESIUM PHOSPHORUS* POTASSIUM SODIUM TOTAL PROTEIN TRIGLYCERIDES URIC ACID UREA

24 CHANGES IN METHODOLOGIES UNIFORMIZATION OF TEMPERATURE FOR ENZYMES ELECTROLYTES: Flame photometry POTENTIOMETRY STANDARIZATION OF SERUM PROTEINS (CRM 470) STANDARDIZATION OF CREATININE (IDMS)

25 ELECTROLYTES SODIUM POTASSIUM CHLORIDES CALCIUM

26 POTASSIUM (mmol/l) N CV(%) MEDIAN SURVEY / / / /01 N CV(%) MEDIAN SURVEY / / / /01

27 CHLORIDES (mmol/l) N CV(%) MEDIAN SURVEY / / / /03 N CV(%) MEDIAN SURVEY / / / /01

28 SODIUM (mmol/l) N CV(%) MEDIAN SURVEY / / / /01 N CV(%) MEDIAN SURVEY / / / /01

29 CALCIUM (mmol/l) N CV(%) MEDIAN SURVEY /04 (Serum) / / /01 N CV(%) MEDIAN SURVEY / / / /01

30 ,00 5,00 4,00 3,00 2,00 1,00 0,00 EVOLUTION OF CV(%) for CALCIUM OVER TIME Arsenazo O-Cresol Indirect Pot.

31 CHANGES IN METHODOLOGIES UNIFORMIZATION OF TEMPERATURE FOR ENZYMES ELECTOLYTES: Flame photometry POTENTIOMETRY STANDARIZATION OF SERUM PROTEINS (CRM 470) STANDARDIZATION OF CREATININE (IDMS)

32 IgG (g/l) N CV(%) MEDIAN SURVEY / / / /01 N CV(%) MEDIAN SURVEY / / / /01 BEFORE BEFORE CRM 470 AFTER AFTER CRM 470

33 IgA (g/l) N CV(%) MEDIAN SURVEY / / / / /01 N CV(%) MEDIAN SURVEY / / /03 BEFORE BEFORE CRM 470 AFTER AFTER CRM 470

34 ,00 25,00 20,00 15,00 10,00 5,00 0,00 IgA CRM 470 EVOLUTION of CV(%) over time Introduction of CRM ,00 20,00 15,00 10,00 5,00 0,00 IgG CRM

35 CREATININE(µmol/L) N CV(%) MEDIAN SURVEY / / / /01 N CV(%) MEDIAN SURVEY / / / /01

36 d (%) 1993/2004* d (%) 2008 Uric Acid Urea Triglycerides Protein total EVOLUTION OF FIXED LIMITS d IN TIME Magnesium LDH Potassium Iron IgG IgA HDL-Cholesterol * Glucose g GGT Phosphorus* Creatinine Chloride Cholesterol Calcium Bilirubin total* Bilirubin direct* ASAT* Amylase ALAT Albumin* Sodium 0 TE - WESTGARD

37 35 30 P(90)U P(90) U EVOLUTION OF PU and Pz IN TIME P(90)Z Changes in fixed limit d Amylase K Mg Cholesterol tot/hdl Glucose LDH Uric acid Iron Urea P(90) Z

38 FIXED LIMITS (d) - TEa - U > d (%) - Z > 3 (%) ANALYTE d(%) * d (%) 2008 TE - WESTGARD U > d % Z > 3 % ANALYTE d(%) * d (%) 2008 TE - WESTGARD U > d % Z >3 % Albumin* 6,2 6,2 3,9 15,7 4,2 Glucose 14 6,9 6,9 1,5 1,9 ALT ,1 12,6 2,8 HDL-Chol.* 15 13,4 11,1 4,4 3,0 Amylase ,6 1,6 2,5 IgA ,5 1,0 4,2 AST* 15,2 15,2 15,2 4,5 2,6 IgG 11,5 11,5 8 4,0 2,9 Bilirubin dir.* 24,1 24,1 44,5 9,6 8,3 Ijzer 20 9,5 30,7 2,2 2,3 Bilirubin tot.* 16,2 16,2 31,1 10,9 3,4 K 8 5,8 5,8 1,4 6,9 Ca Cholesterol tot.. Chlorides Creatinine 4,5 10,5 3 8,3 4, ,3 2,4 8,5 1,5 8,2 8,9 1,6 17,4 9,3 1,5 2,4 2,6 2,9 LDH Mg Na Proteins tot. Triglyc. 14 9,5 2 5, ,4 8,8 2 5, ,4 4,8 0,9 3,4 27,9 1,0 2,5 14,2 4,8 0,2 3,7 3,1 2,4 2,1 5,8 Phosporus* 10,2 10,2 10,2 1,2 1,5 Ureum 21 15,7 15,7 0,6 1,5 ggt ,2 3,9 5,4 Uric acid 15 11,9 12,4 1,5 4,2 FIXED LIMITS ARE BASED ON Westgard TEa or on the 90th percentile of intra-laboratory CV s (multiplied by 3) of about 10 laboratories using different techniques

39 CHANGES OVER TIME - GENERAL DECREASE IN NUMBER OF PARTICIPATING LABORATORIES INCREASE IN REQUESTED ANALYTES MAJOR CHANGES IN METHODOLOGIES MAJOR CHANGES IN REPORTING EQA RESULTS

40 CHANGES OVER TIME - GENERAL AMELIORATION OF RELATIVE ACCURACY AMELIORATION OF RELATIVE PRECISION MAJOR CHANGES IN METHODOLOGIES dedicated systems generally lesser method principles (ex enzymes, electrolytes, ) MAJOR CHANGES IN REPORTING EQA RESULTS more documented reports educative messages graphs -.

41 EQA PROGRAMS - THE PLAYERS PARTICIPANTS = LABORATORIES ORGANIZERS = WIV/ISP EQUIPEMENT/REAGENTS = MANUFACTURERS ALL PLAYERS AFFECT THE RESULTS OF EQA SURVEYS

42 EQA ORGANIZERS WIV/ISP LABORATORIES MANUFACTURERS

43 PARTICIPANTS - LABORATORIES INCORRECT choice of units (e.g. mg/dl mmol/l) INCORRECT choice of method INCORRECT interpretation of limit of detection and limit of quantification (LOQ LOD) INCORRECT SAMPLE IDENTIFICATION

44 ORGANIZERS = WIV/ISP CHOICE OF CONTROL MATERIAL CONCENTRATION RANGES FIXATION OF LIMIT d PARTITION OF METHODS AND METHOD GROUPS MEASURING PRINCIPLE MANUFACTURER

45 PHOSPHORUS - d (%) : 10.2 C/8181 (2008/01) METHOD Median Mmol/L SD CV % Median mg/dl No.labs 001 Unreduced phosphomolybdate complex / UV % Reduced phosphomolybdate complex / VIS **** **** Reflectometry - OCD % Global results (all methods and all measuring systems) % PHOSPHORUS - d (%) : 10.2 C/8202 (2009/01) METHOD Median mmol/l SD mmol/l CV % Median mg/dl N labs 301 Unreduced phosphomolyb./ UV-Other **** **** Reflectometry - OCD Unreduced phosphomolyb./ UV-Abbott Unreduced phosphomolyb./ UV-Coulter (Beckman) Unreduced phosphomolyb./ UV-Siemens (Dade) Unreduced phosphomolyb./ UV-Olympus Unreduced phosphomolyb./ UV-Roche (Cobas/Integra) Unreduced phosphomolyb./ UV-Roche (Hit/Modular) Unreduced phosphomolyb./ UV-Siemens (Bayer) Global results (all methods and all measuring systems) %

46 PHOSPHORUS 2008/01 C/8181 8/19 labs U > d (=10,5%) 12/19 labs R > 3Z 1,65 C/8181 METHOD 1 PHOSPHORUS (mmol/l) 1,55 1,45 1,35 1, MANUFACTURER 001 Unreduced phosphomolybdate complex / UV

47 301 Unreduced phosphomolyb./ UV-Other 303 Reflectometry - OCD 2008/ / Unreduced phosphomolyb./ UV-Abbott 305 Unreduced phosphomolyb./ UV-Coulter (Beckman) 306 Unreduced phosphomolyb./ UV-Siemens (Dade) 307 Unreduced phosphomolyb./ UV-Olympus P U (%) P Z (%) N 6,40 4, ,45 2, Unreduced phosphomolyb./ UV-Roche (Cobas/Integra) 309 Unreduced phosphomolyb./ UV-Roche (Hit/Modular) 310 Unreduced phosphomolyb./ UV-Siemens (Bayer)

48 TRIGLYCERIDES URATE UREA 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% INFLUENCE OF PEER GROUPING ON p U(%) % citations for U > d; relative accuracy p U% 2008/1 p U% 2009/1 AST BILIRUBIN TOTAL CALCIUM CHLORIDE CHOLESTEROL-HDL CHOLESTEROL-Total CREATININE GGT GLUCOSE IGA IGG IRON LDH MAGNESIUM PHOSPHORUS POTASSIUM SODIUM TOTAL PROTEIN ALT AMYLASE ALBUMIN

49 TRIGLYCERIDES URATE UREA 8% 7% 6% 5% 4% 3% 2% 1% 0% INFLUENCE OF PEER GROUPING ON p Z(%) % citations for Z > 3; relative imprecision p Z% 2008/1 p Z% 2009/1 ALT AMYLASE AST BILIRUBIN TOTAL CALCIUM CHLORIDE CHOLESTEROL-HDL CHOLESTEROL-Total CREATININE GGT GLUCOSE IGA IGG IRON LDH MAGNESIUM PHOSPHORUS POTASSIUM SODIUM TOTAL PROTEIN ALBUMIN

50 EQUIPEMENT/REAGENTS = MANUFACTURERS INFORMATION ON NEW or CHANGED REAGENT / EQUIPEMENT MEASURING PRINCIPLE CALIBRATION INFORMATION ON CALIBRATION / LINEARITY CORRECT AND FULLY DOCUMENTED INSERTS COMMUNICATION WITH WIV/ISP ON EPXIRED REAGENTS/EQUIPEMENT

51 BILIRUBIN TOTAL (21670) µmol/l C/7521 METHOD Median SD CV No.labs 1 Diazo sulfanilic acid % 97 2 Diazo sulfanilic acid (blue color) % 19 4 Dichloraniline % 6 5 Diphenyldiazonium (DPD) % 42 6 Reflectometry % 35 7 Reduction (biliverdin) % 9 obal results (all methods and all measuring systems) % 208 BILIRUBIN TOTAL - d (%) : 16.2 Conversion factor : µmol/l / 17.1 = mg/dl METHOD Median µmol/l SD µmol/l C/7522 CV % Median mg/dl 301 Diazo sulfanilic acid-siemens (Dade) Diazo sulfanilic acid (blue color)-coulter Diazo sulfanilic acid-other Dichloraniline- Abbott Diphenyldiazonium (DPD)-Olympus Reflectometry-OCD Reduction (biliverdin)-siemens (Bayer) Reduction (biliverdin)-abbott Diazo sulfanilic acid-roche (Cobas/Integra) Diazo sulfanilic acid-roche (Hit/Modular) Diphenyldiazonium (DPD)-Roche (Cobas) N labs Global results (all methods and all measuring systems) ?

52 EQA is not just statistics! EQA ORGANIZERS WIV/ISP LABORATORIES MANUFACTURERS evaluation - amelioration - education communication Having confidence is good, to check your confidence is better

53 Coming up soon 2009 / 2010 DOA urine Cardiac markers Specific proteins CRP With sincere thanks to all laboratories for their willing collaboration N Hamers Y Lenga C Van Campenhout P Van de Walle