Correction factor to improve agreement between point-of-care and laboratory International Normalized Ratio values

Evaluation of point-of-care International Normalized Ratio in sickle cell disease

Background

Point‐of‐care (POC) International Normalized Ratio (INR) measurement provides efficient monitoring of warfarin therapy; however, its reliability may be affected in patients with anemia, such as those with sickle cell disease (SCD).

Objectives

To evaluate the correlation of POC‐INR to clinical laboratory INR (CL‐INR) in SCD and use of a correction factor.

Patient/Methods

In this retrospective study, the accuracy of POC‐INR compared to CL‐INR was evaluated in a cohort of patients with SCD and in a non‐SCD Black cohort.

Results

Despite the difference in anemia, the SCD cohort showed a similar percentage of in‐range POC‐INR values as observed in the non‐SCD cohort (37% vs 42%). The SCD cohort was randomly divided to form discovery and validation cohorts. In the discovery cohort, 86% of POC‐INRs were in range when the POC‐INRs were ˂4.0, but only 24% were in range if POC‐INRs were ≥4.0. A linear regression of CL‐INR versus POC‐INR for POC‐INR values ≥4.0 yielded a coefficient of 0.72 (95% confidence interval, 0.69‐0.75); Multiplying POC‐INR by this correction factor, rounded to 0.7 for ease of use in clinical practice, improved the proportion of in‐range POC‐INR values ≥4.0 from 24% to 100% in the SCD discovery cohort and from 19% to 95% in the SCD validation cohort. Similar findings applied to analyses of the non‐SCD cohort.

Conclusions

POC‐INR and CL‐INR in patients with SCD are similar when POC‐INR is <4.0, and the accuracy of POC‐INR values ≥4.0 can be improved by applying an institution‐specific correction factor.

Chemical clocks, oscillations, and other temporal effects in analytical chemistry: oddity or viable approach?

Most analytical methods are based on "analogue" inputs from sensors of light, electric potentials, or currents. The signals obtained by such sensors are processed using certain calibration functions to determine concentrations of the target analytes. The signal readouts are normally done after an optimised and fixed time period, during which an assay mixture is incubated. This minireview covers another-and somewhat unusual-analytical strategy, which relies on the measurement of time interval between the occurrences of two distinguishable states in the assay reaction. These states manifest themselves via abrupt changes in the properties of the assay mixture (e.g. change of colour, appearance or disappearance of luminescence, change in pH, variations in optical activity or mechanical properties). In some cases, a correlation between the time of appearance/disappearance of a given property and the analyte concentration can be also observed. An example of an assay based on time measurement is an oscillating reaction, in which the period of oscillations is linked to the concentration of the target analyte. A number of chemo-chronometric assays, relying on the existing (bio)transformations or artificially designed reactions, were disclosed in the past few years. They are very attractive from the fundamental point of view but-so far-only few of them have be validated and used to address real-world problems. Then, can chemo-chronometric assays become a practical tool for chemical analysis? Is there a need for further development of such assays? We are aiming to answer these questions.

Level of agreement between laboratory and point-of-care prothrombin time in patients after stopping or continuation of acenocoumarol anticoagulation: A comparison of diagnostic accuracy

BACKGROUND

Procedures requiring optimisation of the coagulation status of patients using vitamin K antagonists are frequently postponed due to the late availability of laboratory international normalised ratio (INR) test results. A point-of-care (POC) alternative may facilitate early decision-making in peri-operative patients.

OBJECTIVES

To assess the level of agreement between the POC-INR and the laboratory INR in patients who continue or stop vitamin K antagonists to determine whether the POC test may be a good alternative to the laboratory INR.

DESIGN

Study of diagnostic accuracy.

SETTING

Single-centre study at Zaans Medical Centre, The Netherlands.

PATIENTS

Included patients were scheduled for cardioversion (these continued taking vitamin K antagonists), or a surgical procedure (these stopped taking vitamin K antagonists).

MAIN OUTCOME MEASURES

The level of agreement and clinical acceptability of the laboratory and POC-INR results, evaluated by Bland-Altman analysis and error grid analysis.

RESULTS

The surgical and cardioversion groups consisted of 47 and 46 patients, respectively. The bias in the INR in the surgical group was -0.12 ± 0.09 with limits of agreement of -0.29 to 0.05, whereas the cardioversion group showed a bias in the INR of -0.22 ± 0.36 with limits of agreement from -0.93 to 0.48. The percentage errors between methods in the surgical and cardioversion groups were 16 and 21%, respectively. Error grid analysis showed that the diagnostic accuracy of the POC prothrombin time is clinically acceptable as the difference did not lead to a different clinical decision in the surgical group with INR values less than 1.8.

CONCLUSION

The current study shows a good level of agreement and clinical accuracy between the laboratory and POC-INR in patients who stopped anticoagulation intake for surgery. However, in patients who continued their anticoagulation therapy, the agreement between the two methods was less accurate.

Comparison of two point-of-care international normalized ratio devices and laboratory method

: A number of factors contribute to interlaboratory variation of international normalized ratio (INR) results. This variability can lead to differences in clinical decision-making. This prospective cohort study evaluated the accuracy, precision, and clinical decision-making variability of two point-of-care (POC) devices (CoaguChek XS and the Coag-Sense) to a clinical laboratory method of INR measurement as the 'reference' and by using the laboratory's accuracy standard (±25% of the reference INR). Study subjects included adults taking warfarin undergoing a POC INR with each device and a laboratory INR on the same day and evaluated differences in clinical decision-making using a warfarin nomogram. A correction factor was derived for each POC method to estimate the corresponding laboratory INR for POC INRs more than 3.0. A total of 100 patient encounters (76 unique patients) included INR testing by all three methods. Both POC devices demonstrated excellent precision across the entire range (r = 0.98), but poor accuracy relative to the laboratory standard for POC INRs greater than 3.0 (accuracy CoaguChek 19% and Coag-Sense 35%). A correction factor applied to POC INRs greater than 3.0 improved accuracy to 99% for both devices. Applying the correction factor also significantly reduced differences in clinical decision-making (49-28% for CoaguChek and 56-40% for Coag-Sense, P < 0.001). Both POC devices demonstrated poor accuracy for INRs over 3.0. A device-specific, institution-specific correction factor applied to POC INRs greater than 3.0 can provide better accuracy of INR measurement and can significantly reduce variability in warfarin dosing decisions. More study is needed to assess impact on clinical adverse events.