REFERENCE INTERVALS, FACTORS AFFECTING

THEM AND RESULT VARIABILITY

• Reference Interval is defined as the interval
between and including two reference limits
• It is designed as the central interval of values
bounded by the lower reference limit and the
upper reference limit at designated percentiles i.e.
• For fasting glucose the central 95th percentile
reference interval is 3.1-6.1 mmol/L
• 95 % of apparently health population will have a
fasting glucose value between 3.1-6.1 mmol/L
• They are also known as reference ranges or
expected values
• Reference Interval usually refer to population –
based reference values obtained from a well-
defined group of reference individuals
• This value (RI) is computed by means of either a
parametric or non parametric approach
• The parametric approach is based on the
assumption that values from healthy subjects
follow a Gaussian distribution
• Then the X ± 2SD would encompass ̴ 95 % of
values of a given population
• The non-parametric approach makes no
assumption pertaining to the distribution of
values
• In this approach, one obtains a series o results
in a population of healthy subjects
• Results are then listed in ↑ or ↓ order and the
2.5 and 97.5 percentile values determined
• This values will contain the middle 95 % interval
• The parametric approach can be applied to ̴ 50
% of laboratory data
• For the remaining 50 % a transformation of the
data is necessary to normalize the distribution
• The Mean and the SD are then calculated and
the reference interval will then be X ± 2SD
• Where transformation is not successful in
normalizing the distribution, non-parametric
approach should be used

FACTORS AFFECTING REFERENCE VALUES

 Instrument analysis (reagents, calibration etc)
 Age
 sex
 Body weight – less important though a +ve correlation
exists for ALP, CK, ALT (males), AST, ᵞGT and urate
 Effects of smoking, blood pressure and social
class have always been considered small
 Between day variation larger than the diurnal
variation but origin uncertain
 May represent dietary, climatic changes or
attributable to biological rhythms of longer
duration
• Sodium, potassium and urate may follow food
consumption
• Calcium, oxalate and phosphate are more
dependent on hours of sunshine
 Genetic Factors - play a role but difficult to
demonstrate
 However, they are important in Bilirubin, glucose, urate and
urea
 RESULT VARIABILITY

• Changes in serial patient results can be due to the

following:
 Patient getting better
 Patient getting worse
 Preanalytical variation
- subject preparation
- fasting vs. non-fasting
- drug regimen
- physical activity
 - stress
- time of sample collection
- stasis
- transport
- clotting
- separation
- storage
- preparation for analysis
 Analytical variation
 This may result in bias and inherent precision
 Biological variation
• One can minimize preanalytical sources of
variation by:
 Good phlebotomy
 Standard sample transport
 Proper handling and storage techniques
• To assess whether a patient has improved or not
• Change in the result must exceed the inherent
variation due to biological and analytical
variation
• The Reference Change Value (RCV) must
exceed
Z [ CVₐ + CV₁ ]⁰̇ ̇⁵
Z = std deviate =1.96