Accred Qual Assur (2002) 7:488–493

DOI 10.1007/s00769-002-0523-6 PRACTITIONER’S REPORT

© Springer-Verlag 2002

Per Hyltoft Petersen Importance of the choice of assumptions

and models in the estimation of analytical
quality specifications

Received: 1 June, 2002
Accepted: 17 July 2002
Presented at the European Conference on
Quality in the Spotlight in Medical Labora-
tories, 7–9 October 2001, Antwerp,
Belgium
P.H. Petersen
Department of Clinical Biochemistry,
Odense University Hospital,
5000 Odense-C, Denmark
e-mail:
per.hyltoft.Petersen@ouh.fyns-amt.dk
NOKLUS
Norwegian centre for external quality
assurance of primary care laboratories,
Division of General Practice,
University of Bergen, Norway
Abstract The validity of any model
depends on its ability to imagine the
situation or problem to which it is
applied. Further, the assumptions
made in relation to the model are de-
termining for the actual outcome.
Within the field of clinical biochem-
istry a lot of models for analytical
quality specifications, based on a va-
riety of concepts and ‘clinical set-
tings’, have been proposed. A hierar-
chical structure for application of
these approaches and models has
been agreed on at several occasions
in 1999. In this hierarchy, the highest
rank is given to evaluation of analyt-
ical quality specifications based on
‘clinical settings’/’clinical outcome’
models, followed by specifications
based on biological variation and on
‘clinicians opinions’. This contribu-
tion, deals with the problems of
combining random and systematic
errors and the implications of appli-
cation of different models to a vari-
ety of clinical settings.
Keywords Analytical bias ·
Bi-modal distributions · Ordinal
scale · Point-of-care-testing (POCT) ·
Random error · Ratio scale ·
Systematic errors · Uni-modal
distributions

Introduction fications. The basic idea was presented in an editorial in

Since Tonks presented his analytical quality specifica-
tions in 1963 [1] a great number of proposals for such
goals has been presented. The principles and applications
of all these suggestions were mainly linked to certain
purposes relevant for the proposer’s position, e.g. statis-
ticians and some clinical biochemists produced analyti-
cal quality specifications based on biology, other clinical
biochemists closer related to the use of data based their
specifications on clinical strategies/clinical settings/clini-
cal outcome, whereas external quality assessment orga-
nizers based their specifications on “the state of the art”
(which in this context means something like the current
quality as estimated from surveys).
There was no real co-ordination of all these approach-
es and proposals for analytical quality specifications un-
til 1999, where four different events resulted in an agree-
ment between scientists within this area on a hierarchy
of models and approaches to set analytical quality speci-
Clinical Chemistry [2] and accepted by ISO (ISO/TC
212 WG 3: 15196) and again at a conference in Stock-
holm (Strategies to Set Global Analytical Quality Speci-
fications in Laboratory Medicine) from which the pro-
ceedings were published in Scand J Clin Lab Invest [3]
the same year.
The consensus document from the Stockholm confer-
ence [4] is close to the proposal from the editorial in Clin
Chem [2], so the approaches and models for clinical use
of biochemical and haematological data were placed on
the top of the hierarchy. The next level was “evaluation
of the effect of analytical performance on clinical deci-
sions in general: data based on components of biological
variations and data based on analysis of clinicians opin-
ion”, followed by other approaches. In this paper I will
only look at the models related to the clinical settings
and start with a more general discussion of the models
for combining random and systematic errors in relation
to biochemical measurements.

Models for combining random and systematic
errors
A fundamental problem in the estimation of analytical
quality specifications is the combination of random and
systematic errors.
The nature of random errors is different from system-
atic errors and they are described by standard deviations
(or coefficients of variation) and differences (from de-
fined target values), respectively. It would be logical to
keep these two incommensurable concepts separated, but
there is a considerable desire and pressure for creation of
such models. Some of these models have been compared
in a recent publication [5], where three main concepts
were linear models, squared models and combinations of
the two.
1. The linear model has the form ‘total error’ TE=“bi-
as”+z×s, where bias is the systematic error defined as
a constant deviation from a target value (the truth), z
is the standard deviate for a certain probability and s
is the random error component, expressed as a stan-
dard deviation. The equation describes a straight line
in a TE-s plot with intercept=“bias” and slope=z. The
line will vary with “bias” and chosen z-value. This
model is mostly used in relation to internal control.
2. There are two main models for combination of ran-
dom and systematic error based on variances:
a) The classical variance model sqrt(s2+bias2), which
turns out to be a circle in a simple plot. This model
has mainly been used in relation to description of
within- and between-variation, whether for biological
or analytical variation.
b) The GUM-model (Guide to expression of Uncer-
tainty in Measurement) which transforms all linear
deviations into variances, as for example a rectangu-
lar distribution with the length 2×a which is trans-
formed into a standard deviation of a/31/2. This model
is used in accreditation.
3. These combined models are created in relation to the
estimation of analytical quality specifications and usual-
ly include biological variation. One of the simplest
models based on the strategy of establishing common
reference intervals is 1.96×(sBiological2+sAnalytical2)1/2+
“bias”, where sBiological and sAnalytical are biological and
analytical standard deviations, respectively. More mod-
els will be described in the following.
These examples demonstrate that random and systematic
errors can be combined according to different models,
and that the result will be different, not only according to
the model but also according to the assumptions applied,
e.g. dependent on the probability chosen. Consequently,
the models should only be used for the purpose to which
they have been invented, and when models are used they
should be validated for the purpose. In this context it
489
should be remembered what Box and Luceño write [6]:
“All models are wrong – but some models are useful”. In
the following, models for estimation of analytical quality
specifications for the highest level in the hierarchy, ‘clin-
ical strategies’/’clinical settings’/’clinical outcome’ will
be discussed.
The scale of measurement
Most measurements in clinical biochemistry are per-
formed on a ratio scale, where proportions are constant
and there is a true zero point. Using this scale, calcula-
tions of means, standard deviations and coefficients of
variation are allowed. The difference scale is much like
the ratio scale, but it has no true zero (as the temperature
measured in degrees C). Means and standard deviations
can be calculated, but not coefficients of variation. The
ordinal scale has ranks, but there is no guarantee of any
constancy of the steps. An example is joy, which is diffi-
cult to quantify but obviously has several ranks. In clini-
cal biochemistry the ordinal scale is mostly used as a
substitute for a ratio scale, where an exact number is not
important, or where speed or costs make a simple solu-
tion acceptable (i.e. there is an underlying ratio scale).
The nominal scale is independent of magnitude and re-
fers to clear qualities without rank as for example col-
ours (red and green) or classification of cells, where it is
possible to count the numbers of the different groups.
Most analytical quality specifications are derived for the
ratio scale, but examples from the ordinal scale will be
discussed.
Analytical quality specifications
The creation of analytical quality specifications in rela-
tion to clinical settings has been concentrated on two
clinical decision situations: classification and monitoring
of patients.
Classification
Classification is usually based on measurements of the
concentration of a component in a single sample from
the patient, but the interpretation of the result may be
performed according to a uni-modal or a bi-modal model
as illustrated in Fig. 1.
Uni-modal distributions
The uni-modal distribution presents the classification ac-
cording to risk as discussed by Klee et al. for plasma-
cholesterol [7]. The decision limit is set according to
490
Fig. 1 Principle models in classification. Upper: uni-modal distri-
bution. An increasing risk according to measured concentration is
assumed and the chosen decision limit separates the otherwise ho-
mogeneous distribution into two groups with high and low risk,
respectively. There is no underlying dichotomy, so the apparent
prevalence is not real, but determined by the decision point. Low-
er: bi-modal distribution with a well defined (but often unknown)
prevalence for the disease under consideration. Characteristic esti-
mates are fractions of true positives, TP, true negatives, TN, false
positives, FP, and false negatives, FN
some clinical decision (often a recommendation) which
divide the population into people at risk (high risk) or
not (low risk). It is important to realize that the decision
limit determines the prevalence as clearly demonstrated
for plasma-glucose, where the new ADA- and WHO-cri-
teria increase the number (and fraction) of diabetics by
changing the decision point [8]. The implications of ana-
lytical bias (systematic error) on the classification of in-
dividuals from the population according to plasma-cho-
lesterol and combinations of random error and bias for
plasma-glucose result in considerable misclassifications
of individuals for relatively small errors. The analytical
quality specifications are defined for the combination of
random and systematic error, for which, the outcome is
still acceptable according to the fraction of misclassifica-
tions. In general the analytical quality specifications de-
rived from uni-modal distributions are demanding.
Bi-modal distributions
The bi-modal concept (Fig. 1) is based on the assump-
tion of a prevalence which is independent of the mea-
surement. The test is performed with the purpose of clas-
sifying the patient correctly in the diseased or non-dis-
eased group. A change of cutoff point will not result in
another prevalence, but in a change in fractions of true
positive, TP, true negative, TN, false positive, FP, and
false negative, FN, and thus on the outcome of the result.
Fig. 2 Combined FP and FN from a bi-modal distribution. The
‘outcome’ as function of analytical bias is calculated for two pre-
valences and two sets of weighting factors and for three different
assumed values of analytical imprecision. Upper: prevalence=0.2,
weight of FP=3 and FN=1. Lower: prevalence=0.8, weight of
FP=1 and FN=3
As for the uni-modal distributions, the evaluation of
analytical quality specifications are performed by simu-
lation of combinations of increasing random and system-
atic errors and calculation of the fractions FP and FN,
until a level where these values are not longer accept-
able. When the fractions of acceptable FP and FN are de-
cided from a clinical point of view, then the analytical
quality specifications can be read off from curves where
the simulated errors equal these acceptable values.
It is also possible to combine FP and FN (and even
also with TP and TN) resulting in a sum of misclassifica-
tions [9] as shown in Fig. 2. Here are two examples illus-
trating the effect of prevalence as well as the influence of
weighting factors for FP and FN on an outcome (in arbi-
trary units) as function of analytical bias for three differ-
ent values of imprecision. In the case of a prevalence of
0.2 and weights of FP=3 and FN=1, the effect of nega-
tive bias is small and the influence of imprecision negli-
gible, whereas positive bias increases the complex sum
of misclassifications considerably. Here the outcome is
also heavily dependent on the imprecision. This is in
contrast to a prevalence of 0.8 and weights of FP=1 and
FN=3, where a negative bias has considerable effect on
the outcome, but not a positive bias, and further, the in-
fluence of imprecision is nearly constant and of less im-
portance.

Ordinal scale
A special form of classification is related to the ordinal
scale where there is an underlying ratio scale for bi-mod-
al distributions. This is mostly for urine analyses, preg-
nancy-tests, where the simple dichotomy classifies the
patients according to a single measurement with the pos-
sible results 0 and 1 (minus and plus). The reason for
choosing the ordinal scale measurement is often econo-
my or the need of a quick result, by use a dip-stick or
simple device to be used by non-professional persons.
The main problem with this type of measurement is
that within a wide concentration range, the outcome ‘0’
or ‘1’ is a statistical event, i.e. there is a certain probabil-
ity (for example 10%) for getting the result ‘1’. Conse-
quently, it is not wrong to get the result ‘0’, neither to get
the result ‘1’. In order to estimate such percentages a
great number of independent measurements is needed,
which can only be obtained under certain conditions as,
for example, external surveys where the same control
samples of concentrations within this range are sent to a
great number of laboratories. The combined results will
then disclose increasing percentages of ‘1’ for increasing
concentrations which, when plotted on a probit scale
with logarithmic abscissa, will fit to a straight line as
shown for some components in urine and for samples of
streptococcus [10]. Consequently, control samples with
concentrations within this interval cannot be used to val-
idate the single laboratory, but to characterise and vali-
date the different kits/methods when split into peer-
groups. To control the single laboratories, control sam-
ples with concentrations just outside the interval (100%
‘0’ and 100% ‘1’) should be applied.
The analytical quality specifications for measure-
ments on an ordinal scale has only been set arbitrarily
until now [10], but in the following, a new approach to
this is proposed based on biology.
Analytical quality specifications for measurements on
ordinal scale based on biology
Assuming a log-Gaussian distribution of reference val-
ues for a component, which could have been measured
on the ratio scale, e.g. urine-Bilirubin or urine glucose,
and a dip-stick which give the result ‘0’ or ‘1’, character-
ized by the percentages of measured ‘1’ for known con-
centrations which fits to a straight line in a probit plot
with logarithmic abscissa. A principle example is shown
in Fig. 3, where the distribution of healthy individuals is
shown as Gaussian according to the logarithmic abscissa
and the probability of measuring ‘1’ is illustrated by the
straight line in the probit plot. For each small concentra-
tion interval the frequency distribution of reference val-
ues from the healthy population denotes a certain frac-
tion of the total population. For this interval there is a
491
Fig. 3 Estimation of analytical quality specifications for ordinal
scale based on biological principles. The frequency distribution of
a log-Gaussian distribution of reference values from a healthy
population is illustrated on a log-scale abscissa (Doh). Further, the
line of probability of obtaining the result ‘1’ by measurement is
shown on a probit scale with the same abscissa (Po1). For each
small interval the fraction of individuals is multiplied with the
probability of getting the result ‘1’, and the distribution of mea-
sured ‘1’ is drawn (Doh×Po1=Dom1)
certain probability of measuring ‘1’, so by multiplying
these two values the fraction of healthy individuals to get
the result ‘1’ is calculated. When this process is per-
formed for all concentration intervals a curve describing
the distribution of measured ‘1’ is formed. By integrat-
ing this distribution, the fraction of healthy reference in-
dividuals to be measured as ‘1’ (tested positive) is deter-
mined. The desired percentage may be 2.5%, as for tradi-
tional estimation of reference intervals. Thus the analyti-
cal quality specifications for the tests are to obtain an an-
alytical quality, which will result in 2.5% of the healthy
population to be measured as ‘1’. This may be obtainable
for different methods with varying position and slope of
the probability line.
Monitoring
In monitoring of patients using measurements of a single
component, only a few attempts have been made to de-
rive analytical quality specifications for the monitoring
against a defined concentration, e.g. [11], whereas the
monitoring using just the change in concentration be-
tween two samplings has been investigated intensely,
e.g. [12], using the formula
CD = z × 21/2 × (CV2W-S + CVA2 )1/2+∆ in analytical bias
where CD is the critical difference, z is the standard devi-
ate for a defined probability, e.g. z=1.65 for a one-tail
probability of 95%, 21/2 is a factor due to the two measure-
ments, CVW-S is the biological within-subject variation,
CVA is the analytical imprecision and ∆ in analytical bias
denotes the possible change in bias between the two mea-
surements. Assuming z=1.96 (two tailed probability of
492
Fig. 4 Comparison of measurements performed in laboratory and
POCT. Upper: the simple model for a linear increase in the me-
asurand at time 2 h. Lower: there are three steps: A) measure-
ments in laboratory of samplings at time 2 and 3 h plus 1 h turn-
around time gives the result at 4 h; B) POCT measurement under
same conditions as A), but without turnaround time – result at 3 h
– same analytical quality specifications as A); C) POCT measure-
ments at 2 and 4 h – result at 4 h (as in A)), but wider analytical
quality specifications
95%), ∆ in analytical bias=0 and CVA=0.5×CVW-S, CD
becomes equal to 3.1×CVW-S. This is often called the ref-
erence change, RC, and used as the basis for interpretation
of differences and based on this RC can be used for the
calculation of analytical quality specifications.
POCT
For Point-Of-Care-Testing, POCT, measurements are
performed ‘on location’, saving the time usually spent
with transport to the central laboratory and time for the
analytical procedure, turnaround time. This aspect is evi-
dent, but it has been difficult to combine this time-saving
with the analytical quality specifications, as these speci-
fications should be the same as the general for laborato-
ries in order to get the same data – but at an earlier time.
A direct relationship between time and analytical
quality specifications can, however, be established by
changing the sampling interval. In Fig. 4 is shown the
concentration of a component as function of time. At a
certain time (here 2 h), a change in the patient initiates
an increase in the component. In order to make it simple
we assume that the increase is linear for the period of
time under consideration and that the turnaround time is
1 h. Further, we assume that the sample interval is 1 h
and that the change during this hour is equivalent to the
reference change, RC, discussed above, i.e. CVA=
0.5×CVW-S, but here CVW-S describes the short-term
within-subject variation under the specific conditions
(and not the long-term biological variation tabled in
many articles). Three simplified situations are illustrated
in the lower part of Fig. 4:
1. Measurement in laboratory: samples are drawn at
2 and 3 h and the samples are analysed in the labora-
tory, which makes the result available at the time 4 h.
2. POCT measurements at location: samples are drawn
at 2 and 3 h and analysed at location, which makes
the result available at the time 3 h.
3. POCT measurements at location: samples are drawn
at 2 and 4 hours and analysed at location, which
makes the result available at the time 4 h.
Examples 1 and 2 illustrate the usual comparison be-
tween POCT and laboratory. The benefit is the early re-
sult, but the analytical quality specifications are the same
for POCT and laboratory. In example 3, however, the re-
sult from POCT is not earlier than from the laboratory,
but as the change is larger, the analytical quality specifi-
cations must be wider as well. Using any sampling inter-
val between 1 and 2 h for POCT will allow both for an
earlier result and for wider analytical quality specifica-
tions. Thus, it may be possible to find a relationship be-
tween analytical quality specifications for POCT, sam-
pling interval, and turnaround time, when CVW-S and
slope of expected increase are known.
Discussion
In the process of establishing analytical quality specifi-
cations, a variety of different models and assumptions
must be used and applied. As demonstrated for the rela-
tive simple combinations of random and systematic er-
rors, [8] how difficult it is and how different the outcome
may be, it is necessary to be cautious when it comes to
estimation of analytical quality specifications according
to different clinical settings. We can say with Box and
Luceño’s words [6] that any model applied is wrong, so
the task is to make probable that the model is useful for
the purpose.
One of the first considerations may be to define cor-
rectly the scale of measurements, and next to describe
the clinical setting, whether classification or monitoring
– or any other. For classification, whether it is a uni- or
bi-modal situation (Fig. 1). In the case of uni-modal dis-
tributions – usually risk as for cholesterol [7], but also
diagnostic in diabetes [8] – the prevalence is determined
by the decision limit (and the population sample). In the
 493

uni-modal concept the analytical quality specifications
will mostly be very demanding. If a uni-modal concept is
treated as bimodal with FP and FN results, absurd con-
clusions may be drawn.
For bi-modal distributions the primary outcome is a
combination of FP, FN, TP and TN, which can be treated
in many ways, as known for calculations of sensitivity
and specificity. Most important for the interpretations,
and for further calculations, is the prevalence [9]. A vari-
ety of possibilities are, however, open for further calcu-
lations in estimation of analytical quality specifications,
e.g. predictive values and costs, and it is also possible to
vary weighting factors for the FP and FN groups togeth-
er with investigation of the influence of prevalence on
the outcome (Fig. 2 and [9]).
A special type of measurement, which needs a totally
different interpretation, is measurements on the ordinal
scale, where the analytical quality specifications must be
defined via probabilities for getting the result ‘0’ or ‘1’
[10]. Here there are still lots of unanswered questions,
and it will probably take some time to create the needed
relevant models and to understand the complex nature of
this type of result. Measurements on the ordinal scale are
interesting from a theoretical point of view, but measure-
ments on the ratio scale should be preferred whenever
possible, as the quality – and thereby the information
value – of ordinal measurements is considerable lower.
In this paper an attempt to create analytical quality
specifications for measurements on the ordinal scale, has
been proposed (Fig. 3), parallel to the biological approach
(for sharing common reference intervals) based on a well
known model [8]. This model can only give an interval for
the analytical quality to be obtained in order to produce a
certain percentage of values from a healthy distribution.
In monitoring, a distinction between monitoring against
a certain concentration value and estimation of the differ-
ence between two measurements must be performed. In
this contribution only the difference between two measure-
ments is dealt with. Here the well known formulas can be
applied without any problems [12], but in order to investi-
gate specific analytical quality specifications for POCT the
time must be involved in the assumptions and calculations.
Further, a change in sampling strategy with prolonged
sampling intervals must be introduced in order to obtain
analytical quality specifications which are different from
the traditional for analytical work. In the example (Fig. 4),
simple assumptions are made, such as linear increase of the
measurand and round hours of sampling intervals and turn-
around time. These assumptions and the applied model are
much too simple to draw definite conclusions.
Conclusion
The choice of model and the assumptions applied are
crucial for the reliability of analytical quality specifica-
tions, so these presumptions must be validated painstak-
ingly in each specific clinical setting.

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