Primary Care Pathology
Monday 27 January 2020
Tuesday 26 November 2019
On the impact of seasonal variation in potassium results in primary care
Although we
do not know the reason for the difference between potassium result
distributions in ED and primary care, we do know that there are seasonal
differences in primary care results that can be removed by specimen stabilisation.
We can see the impact of this by looking at the predicted number of patients in
primary care who would be placed in different categories if all practices
performed at the level of Black Torrington and Lynton (Table 8)
|
Black Torrington / Lynton
|
All GP
|
Low
|
0.015
|
0.013
|
Normal
|
0.98
|
0.96
|
Low High
|
0.0058
|
0.022
|
Moderate
high
|
0.00075
|
0.0017
|
High high
|
0.000068
|
0.00027
|
Table 8 Actual proportion of potassium tests in
different result categories comparing the two practices that stabilise all
specimens by centrifugation, and all other practices
From this
analysis, we can work out the number of patients in primary care who would be
placed in different categories if all practices stabilised specimens (Table
9).
Predicted number of additional
patients in primary care who would have a low potassium if specimens
stabilised
Low
168
|
Predicted number of additional
patients per year in primary care who have a high potassium due to seasonal
variation
|
Low high
|
1953
|
Mod high
|
116
|
High high
|
25
|
Table 9 Predicted annual number of patients who fall
into different result categories in primary care due to seasonal variation compared
with practices that stabilise all specimens (based on 124,000 tests per year in
primary care).
Conclusions
From the data
in this blog we can estimate that about 2% of primary care potassium results
across the year are mis-categorised as a result of specimen stability issues.
If we combine this effect with the systematic shift in results described in the
previous blog, we can estimate that around 1 in 10 potassium results from
primary care would be significantly different if taken in the emergency
department.
The current
focus of laboratory accreditation has done little or nothing to address the
issues that lead to this, and as a result patients and clinicians are being
falsely reassured about the accuracy and validity of results. We can say with
confidence that the current standard of practice is leading to patient harm on
a large scale. This should be an issue of national importance.
On the systematic difference between ED and GP potassium results
Primary care
potassium results show large seasonal variation due to problems with specimen
stabilisation. This may mask other underlying reasons for variation. If we plot
the distribution of potassium results from ED and primary care side by side we
can see what appears to be a systematic difference between the two populations
(Figure 6)
In North
Devon, two practices (Black Torrington and Lynton) have centrifuged all
specimens on site since 2014. This has resulted in much more stable potassium
results. We can see the same shift in mean potassium result in these practices
that occurred when the analyser was changed in 2018. However, we also see a
large systematic shift in the result between the primary care and ED
populations (Figure
7).
Figure 7 Mean
monthly potassium in ED compared with 2 practices that stabilise all specimens
at point of care by centrifugation. Note that in this analysis we only looked
at “first time tests” by removing any test that was repeated on a specific
patient within 3 months
Impact of demographic differences on potassium
result
One
explanation for this result is that the people tested in ED are very different
to those tested in primary care. The following population pyramid shows the
differences in the demographic groups that are tested in ED compared with Lynton
and Black Torrington (Figure 8).
Figure 8 Population
pyramids showing demographic differences in people having a potassium test in
the ED compared with Black Torrington / Lynton GP practices.
To examine whether
these demographic differences could account for the systematic difference in
potassium results, we looked at the results of first time testing (i.e.
ignoring repeats within 3 months) in specific demographic groups. For
simplicity, we looked at just the potassium results before the analyser change,
as this gave us the largest dataset. We can see that the difference in mean
potassium exists across all demographic groups (Table 4).
Impact of disease severity on
potassium result
Patients in
the ED who have a test are more likely to be acutely unwell than patients in
general practice. In an attempt to determine whether the difference in
potassium might be accounted for by differences in clinical reason for the
test, we repeated our analysis looking at different groups that we could
identify either through the clinical details on the request form, or from their
testing history. The comparator group might be expected to contain patients who
were more likely to be acutely unwell (Table 5). We can see no significant difference between the
patient groups and their comparators, and conclude that disease severity is
unlikely to be a reason for the systematic difference in potassium between the
ED and primary care.
Table 5 Difference in mean potassium between
patients in different clinical groups, as identified from clinical details on
request form.
Location of patient group
|
Patient group
|
Comparator
|
No of patients in group
|
Number of patients in comparator
|
Mean
K in group
|
Mean
K in comparator
|
Difference
|
GP
|
Blood
requested for chronic disease monitoring (asterisk in clinical details)
|
Not
requested for chronic disease monitoring
|
667
|
3978
|
4.68
|
4.59
|
-0.09
|
GP
|
Patient
has no repeat test within next week
|
Patient
has repeat test in hospital within next week
|
162161
|
1381
|
4.46
|
4.51
|
0.05
|
ED
|
Patient
has no repeat test within next week
|
Patient
has repeat test within hospital within the next week
|
13996
|
1017
|
4.21
|
4.24
|
0.03
|
ED
|
Patient
has no repeat test within next week
|
Patient
has repeat test on ICU within the next week
|
13996
|
241
|
4.21
|
4.22
|
0.01
|
What does this mean for patients?
We cannot
account for this systematic difference in potassium results between the ED and
primary care. It does not appear to be due to demographic or disease
differences. It would seem to be unlikely to be due to specimen stability as we
see the effect in locations where specimens are stabilised at the point of draw
and where results appear stable across the year. Both ED and primary care use
the same equipment manufacturers and specimens are run on the same analysers.
Nonetheless,
we can estimate the impact of this difference on the rate of abnormal results. The
following table shows the proportions of patients who fall into different
potassium result groups (Table 6).
Table 6 Proportion of potassium tests in different
result categories comparing ED and the two practices that stabilise all
specimens by centrifugation
From this
analysis, we can work out the number of patients in primary care who would be
placed in different categories if all practices stabilised specimens and if
analyser performance was the same as that seen for ED specimens (Table 7).
Table 7 Predicted annual number of patients who fall
into different result categories using actual primary care mean compared with theoretical
mean derived from ED results (based on 124,000 tests per year in primary care).
Conclusions
We will talk
in a subsequent blog about the impact of specimen stability on potassium
results. This blog looks only at the clinical impact of a systematic shift in
result depending on the location of where the blood has been taken.. We can
estimate that about 1 in 12 potassium results taken in primary care would be in
a different result category if the test was done in a different location. We do
not understand the reasons for this but clearly it is important to study this
further, and to understand whether this is a phenomenon seen in other regions.
Bias in laboratory results – how we can see this in real patient data and the correlation with External Quality Assurance
In this blog
we will consider just the mean potassium result for samples taken in the ED,
plotted here in a statistical process chart (Figure
3).
Figure
3 Statistical process chart for mean monthly
potassium taken in the ED. Mean results pre and post analyser change are shown
(dotted lines). Results within 2 standard deviations of the mean prior to the
analyser shift (solid line) are shown in the shaded area
We can see a
shift in the ED mean potassium in March 2018. In the language of the SPC, the
system went “out of control.” This correlates with the laboratory switching its
analyser provider.
Correlation with EQA performance
We can look
at the performance of the laboratory in the external quality assurance scheme
over these periods. The following plot (Figure
4) shows the bias of different
analysers in this scheme. This laboratory moved from the 13OL, which has a
strong negative bias, to the 13BO analyser, which has a positive bias. It is
not therefore surprising that we saw the shift in laboratory mean when the analysers
were changed.
The impact of the shift in laboratory
performance on patients
Although
potassium results essentially form a continuous distribution, clinicians tend
to view these as categorical results (see blog 2 Table
1). This means that it is not that meaningful to look at
distribution parameters if we are to understand the clinical impact of changes.
Instead, we need to look at how this impacts on the proportion of results that
fall into different result categories
Using theoretical “normal” populations
to model the analyser effect
To analyse
this, we applied a theoretical distribution to our data (using a technique
called Kernel Density Estimation; Figure
5). We then calculated the impact of the shift in the
potassium mean (due to the analyser change) on the expected numbers of patients
who would fall into each category.
Figure 5
Histograms of potassium results from the ED before and after analyser change,
with theoretical distributions as determined by KDE analysis.
We can use
these distributions to calculate the proportion of results falling into
different result categories before and after the analyser switch (Table 2).
Table 2 Proportion of ED potassium results falling
into different result categories before and after analyser change in 2018.
(Note the normal range is from 3.5 to 5.3 inclusive)
We can then
apply these proportions to the number of patients that are tested in our ED
each year (approximately 27000 tests;Table 3). In our small ED, 2 patients a day would have been
diagnosed with hypokalaemia on the old analyser, but would be normal with the
current analyser. 3 patients a week are diagnosed with a significantly higher
potassium since the switch to the new analyser.
Table 3 Predicted change in annual number of
patients in different result categories before and after analyser change.
Conclusions
We are making
no value judgement about which analyser is correct. This blog merely notes the
effect that laboratory performance has on patient outcome – 3% of ED potassium
results are significantly altered (i.e. change category) merely by changing the
analyser.
Setting aside
wider considerations of normality and uncertainty, there are mechanisms to
remove these biases in laboratory performance. For instance, real time inter-laboratory
comparison of performance with continual adjusting of parameters can ensure
that result distributions remain constant.
For the
non-biochemist, it is hard to understand how different analysers can produce
different results when, according to the ISO15189 standard to which they all
comply, all measurands must be traceable back to an international standard.
These are clinically important uncertainties that are perhaps under-recognised.
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