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Genzen JR, Moser KA. The FDA's proposed rule on laboratory-developed tests: what happens next? Lab Med 2024; 55:109-110. [PMID: 38373253 DOI: 10.1093/labmed/lmae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024] Open
Affiliation(s)
- Jonathan R Genzen
- Department of Pathology, University of Utah Health, Salt Lake City, UT, US
- ARUP Laboratories, Salt Lake City, UT, US
| | - Karen A Moser
- Department of Pathology, University of Utah Health, Salt Lake City, UT, US
- ARUP Laboratories, Salt Lake City, UT, US
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Lu J, Butler-Wu SM. Home and Clinical Laboratory Improvement Amendments-Waived Testing for Infectious Diseases-How Do These Fit in the Testing Landscape? Clin Lab Med 2024; 44:13-21. [PMID: 38280794 DOI: 10.1016/j.cll.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Though testing for infectious diseases has long been performed in traditional clincial laboratory settings, more widespread availability of waived testing is expanding accessibility of patients to rapid test results. This is being further expanded to home testing. Nevertheless, with this greater democratization and availability of clinical testing there are important limitations that need to be balanced. In this article, we review the current test landscape for infectious diseases waived testing and opportunities for assuring optimal quality testing.
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Affiliation(s)
- Jacky Lu
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA
| | - Susan M Butler-Wu
- Department of Pathology, Keck School of Medicine of the University of Southern California, HMR 211, 2011 Zonal Avenue, Los Angeles, CA 90033, USA.
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Rychert J, Schmidt RL, Genzen JR. Laboratory-Developed Tests Account for a Small Minority of Tests Ordered in an Academic Hospital System. Am J Clin Pathol 2023; 160:297-302. [PMID: 37265129 DOI: 10.1093/ajcp/aqad051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/13/2023] [Indexed: 06/03/2023] Open
Abstract
OBJECTIVES To determine the frequency of use of laboratory-developed tests (LDTs) in an academic medical center system. METHODS Retrospective analysis of 2021 test order data from an academic medical center (hospital, outpatient clinics, and cancer center) was done. Measures included assay type, assay methodology, regulatory status, test order volume, inpatient vs outpatient setting, and provider medical specialty. RESULTS Of the 3,016,928 tests ordered in 2021, 2,831,489 (93.9%) were tests cleared, approved, and/or authorized by the US Food and Drug Administration (FDA); 116,583 (3.9%) were LDTs; and 68,856 (2.3%) were standard methods. These test orders were performed using a total of 1,954 distinct assays. Of these, 983 (50.3%) were FDA assays, 880 (45.0%) were LDTs, and 91 (4.7%) were standard methods. Laboratory-developed tests were more commonly ordered in the outpatient vs inpatient setting and represented a higher proportion of the test volume at the cancer center compared with the university hospital (5.6% vs 3.6%, respectively). The top 167 LDT assays accounted for 90% of the LDT volume (104,996 orders). Among the 20 most frequently ordered LDTs were mass spectrometry assays and tests used in the care of immunocompromised patients. Internal/family medicine placed the greatest number of orders (1,044,642) and ordered one of the lowest proportions of LDTs (3.2%). CONCLUSIONS Laboratory-developed tests made up a small percentage of the total laboratory tests ordered within the academic health system studied.
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Affiliation(s)
- Jenna Rychert
- Department of Pathology, University of Utah Health, Salt Lake City, UT, USA
- ARUP Laboratories, Salt Lake City, UT, USA
| | - Robert L Schmidt
- Department of Pathology, University of Utah Health, Salt Lake City, UT, USA
- ARUP Laboratories, Salt Lake City, UT, USA
| | - Jonathan R Genzen
- Department of Pathology, University of Utah Health, Salt Lake City, UT, USA
- ARUP Laboratories, Salt Lake City, UT, USA
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Abbasi M, Smith AD, Swaminathan H, Sangngern P, Douglas A, Horsager A, Carrell DT, Uren PJ. Establishing a stable, repeatable platform for measuring changes in sperm DNA methylation. Clin Epigenetics 2018; 10:119. [PMID: 30227883 PMCID: PMC6145208 DOI: 10.1186/s13148-018-0551-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 08/31/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Several independent research groups have shown that alterations in human sperm methylation profiles correlate with decreased fecundity and an increased risk of poor embryo development. Moving these initial findings from the lab into a clinical setting where they can be used to measure male infertility though requires a platform that is stable and robust against batch effects that can occur between sample runs. Operating parameters must be established, performance characteristics determined, and guidelines set to ensure repeatability and accuracy. The standard for technical validation of a lab developed test (LDT) in the USA comes from the Clinical Laboratory Improvement Amendments (CLIA). However, CLIA was introduced in 1988, before the advent of genome-wide profiling and associated computational analysis. This, coupled with its intentionally general nature, makes its interpretation for epigenetic assays non-trivial. RESULTS Here, we present an interpretation of the CLIA technical validation requirements for profiling DNA methylation and calling aberrant methylation using the Illumina Infinium platform (e.g., the 450HM and MethylationEPIC). We describe an experimental design to meet these requirements, the experimental results obtained, and the operating parameters established. CONCLUSIONS The CLIA guidelines, although not intended for high-throughput assays, can be interpreted in a way that is consistent with modern epigenetic assays. Based on such an interoperation, Illumina's Infinium platform is quite amenable to usage in a clinical setting for diagnostic work.
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Affiliation(s)
| | - Andrew D. Smith
- University of Southern California, 1051 Childs Way, Los Angeles, 90089 USA
| | | | - Peer Sangngern
- National Genetics Institute, 2440 S Sepulveda Blvd, Los Angeles, 90064 USA
| | - Amanda Douglas
- National Genetics Institute, 2440 S Sepulveda Blvd, Los Angeles, 90064 USA
| | - Alan Horsager
- Episona, 69 N. Catalina Ave., Pasadena, USA
- University of Southern California, 1051 Childs Way, Los Angeles, 90089 USA
| | - Douglas T. Carrell
- University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, 84132 USA
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Kaul KL, Sabatini LM, Tsongalis GJ, Caliendo AM, Olsen RJ, Ashwood ER, Bale S, Benirschke R, Carlow D, Funke BH, Grody WW, Hayden RT, Hegde M, Lyon E, Murata K, Pessin M, Press RD, Thomson RB. The Case for Laboratory Developed Procedures: Quality and Positive Impact on Patient Care. Acad Pathol 2017; 4:2374289517708309. [PMID: 28815200 PMCID: PMC5528950 DOI: 10.1177/2374289517708309] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 04/06/2017] [Accepted: 04/10/2017] [Indexed: 12/16/2022] Open
Abstract
An explosion of knowledge and technology is revolutionizing medicine and patient care. Novel testing must be brought to the clinic with safety and accuracy, but also in a timely and cost-effective manner, so that patients can benefit and laboratories can offer testing consistent with current guidelines. Under the oversight provided by the Clinical Laboratory Improvement Amendments, laboratories have been able to develop and optimize laboratory procedures for use in-house. Quality improvement programs, interlaboratory comparisons, and the ability of laboratories to adjust assays as needed to improve results, utilize new sample types, or incorporate new mutations, information, or technologies are positive aspects of Clinical Laboratory Improvement Amendments oversight of laboratory-developed procedures. Laboratories have a long history of successful service to patients operating under Clinical Laboratory Improvement Amendments. A series of detailed clinical examples illustrating the quality and positive impact of laboratory-developed procedures on patient care is provided. These examples also demonstrate how Clinical Laboratory Improvement Amendments oversight ensures accurate, reliable, and reproducible testing in clinical laboratories.
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Affiliation(s)
- Karen L Kaul
- Department of Pathology and Laboratory Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Linda M Sabatini
- Department of Pathology and Laboratory Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Gregory J Tsongalis
- Laboratory for Clinical Genomics and Advanced Technology, Department of Pathology, Dartmouth Hitchcock Medical Center and Norris Cotton Cancer Center, Lebanon, NH, USA.,Laboratory Medicine, Dartmouth Hitchcock Medical Center and Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Angela M Caliendo
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Randall J Olsen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | | | - Sherri Bale
- Department of Pathology, University of Colorado, Aurora, CO, USA
| | - Robert Benirschke
- Department of Pathology and Laboratory Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Dean Carlow
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Birgit H Funke
- Laboratory for Molecular Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Wayne W Grody
- Departments of Pathology and Laboratory Medicine, Pediatrics and Human Genetics, UCLA School of Medicine, Los Angeles, CA, USA
| | - Randall T Hayden
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Madhuri Hegde
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, USA
| | - Elaine Lyon
- Pathology Department, University of Utah School of Medicine/ARUP Laboratories, Salt Lake City, UT, USA
| | - Kazunori Murata
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melissa Pessin
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Richard D Press
- Department of Pathology and Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Richard B Thomson
- Department of Pathology and Laboratory Medicine, NorthShore University HealthSystem, Evanston, IL, USA
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Bacci JL, Klepser D, Tilley H, Smith JK, Klepser ME. Community pharmacy-based point-of-care testing: A case study of pharmacist-physician collaborative working relationships. Res Social Adm Pharm 2018; 14:112-5. [PMID: 28082033 DOI: 10.1016/j.sapharm.2016.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 12/02/2016] [Indexed: 11/22/2022]
Abstract
Building collaborative working relationships (CWRs) with physicians or other prescribers is an important step for community pharmacists in establishing a collaborative practice agreement (CPA). This case study describes the individual, context, and exchange factors that drive pharmacist-physician CWR development for community pharmacy-based point-of-care (POC) testing. Two physicians who had entered in a CPA with community pharmacists to provide POC testing were surveyed and interviewed. High scores on the pharmacist-physician collaborative index indicated a high level of collaboration between the physicians and the pharmacist who initiated the relationship. Trust was established through the physicians' personal relationships with the pharmacist or due to the community pharmacy organization's strong reputation. The physicians' individual perceptions of community pharmacy-based POC testing affected their CWRs and willingness to establish a CPA. These findings suggest that exchange characteristics remain significant factors in CWR development. Individual factors may also contribute to physicians' willingness to advance their CWR to include a CPA for POC testing.
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Davey DD, Austin RM, Birdsong G, Zaleski S. The impact of the Clinical Laboratory Improvement Amendments of 1988 on cytopathology practice: a 25th anniversary review. J Am Soc Cytopathol 2014; 3:188-198. [PMID: 31051685 DOI: 10.1016/j.jasc.2014.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 04/15/2014] [Indexed: 11/26/2022]
Abstract
The Clinical Laboratory Improvement Amendments of 1988 were passed into law on October 31, 1988; regulations implementing this law have had a dramatic impact on the practice of cytology as well as the operations of the entire laboratory. Articles in the popular press followed by congressional hearings exposed faulty laboratory practices, with false-negative Pap tests being a major focus. The impact of this law on the cytology profession is reviewed in this paper. We discuss the response by professional organizations and laboratories to proposed regulations, including formation of consortium groups, development of interlaboratory comparison programs, and more stringent laboratory accreditation and inspection procedures. Public perceptions related to false-negative Pap tests and the litigation crisis are reviewed, as well as the development of new technologies that would improve test accuracy. Finally, the role of the Clinical Laboratory Improvement Advisory Committee in advising the government on laboratory regulations and cytology proficiency testing is discussed. Many of the regulations have promoted quality practices and cytology accuracy, but others have proven relatively inflexible and may have blocked innovation.
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Affiliation(s)
- Diane Davis Davey
- Department of Clinical Sciences, University of Central Florida College of Medicine and Orlando VAMC, Orlando, Florida.
| | - R Marshall Austin
- Department of Pathology, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - George Birdsong
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine and Grady Health System, Atlanta, Georgia
| | - Sue Zaleski
- Office of Operations Excellence, University of Iowa Health Care, Iowa City, Iowa
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Bielinski SJ, Olson JE, Pathak J, Weinshilboum RM, Wang L, Lyke KJ, Ryu E, Targonski PV, Van Norstrand MD, Hathcock MA, Takahashi PY, McCormick JB, Johnson KJ, Maschke KJ, Rohrer Vitek CR, Ellingson MS, Wieben ED, Farrugia G, Morrisette JA, Kruckeberg KJ, Bruflat JK, Peterson LM, Blommel JH, Skierka JM, Ferber MJ, Black JL, Baudhuin LM, Klee EW, Ross JL, Veldhuizen TL, Schultz CG, Caraballo PJ, Freimuth RR, Chute CG, Kullo IJ. Preemptive genotyping for personalized medicine: design of the right drug, right dose, right time-using genomic data to individualize treatment protocol. Mayo Clin Proc 2014; 89:25-33. [PMID: 24388019 PMCID: PMC3932754 DOI: 10.1016/j.mayocp.2013.10.021] [Citation(s) in RCA: 222] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 10/16/2013] [Accepted: 10/23/2013] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To report the design and implementation of the Right Drug, Right Dose, Right Time-Using Genomic Data to Individualize Treatment protocol that was developed to test the concept that prescribers can deliver genome-guided therapy at the point of care by using preemptive pharmacogenomics (PGx) data and clinical decision support (CDS) integrated into the electronic medical record (EMR). PATIENTS AND METHODS We used a multivariate prediction model to identify patients with a high risk of initiating statin therapy within 3 years. The model was used to target a study cohort most likely to benefit from preemptive PGx testing among the Mayo Clinic Biobank participants, with a recruitment goal of 1000 patients. We used a Cox proportional hazards model with variables selected through the Lasso shrinkage method. An operational CDS model was adapted to implement PGx rules within the EMR. RESULTS The prediction model included age, sex, race, and 6 chronic diseases categorized by the Clinical Classifications Software for International Classification of Diseases, Ninth Revision codes (dyslipidemia, diabetes, peripheral atherosclerosis, disease of the blood-forming organs, coronary atherosclerosis and other heart diseases, and hypertension). Of the 2000 Biobank participants invited, 1013 (51%) provided blood samples, 256 (13%) declined participation, 555 (28%) did not respond, and 176 (9%) consented but did not provide a blood sample within the recruitment window (October 4, 2012, through March 20, 2013). Preemptive PGx testing included CYP2D6 genotyping and targeted sequencing of 84 PGx genes. Synchronous real-time CDS was integrated into the EMR and flagged potential patient-specific drug-gene interactions and provided therapeutic guidance. CONCLUSION This translational project provides an opportunity to begin to evaluate the impact of preemptive sequencing and EMR-driven genome-guided therapy. These interventions will improve understanding and implementation of genomic data in clinical practice.
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Affiliation(s)
| | - Janet E Olson
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | - Richard M Weinshilboum
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN; Center for Individualized Medicine, Mayo Clinic, Rochester, MN
| | - Liewei Wang
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN
| | - Kelly J Lyke
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Euijung Ryu
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Paul V Targonski
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN
| | | | | | - Paul Y Takahashi
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN
| | - Jennifer B McCormick
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Center for Individualized Medicine, Mayo Clinic, Rochester, MN; Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Kiley J Johnson
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN
| | | | | | | | - Eric D Wieben
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN
| | - Gianrico Farrugia
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN; Division of Gastroenterology, Mayo Clinic, Rochester, MN
| | | | - Keri J Kruckeberg
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Jamie K Bruflat
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Lisa M Peterson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Joseph H Blommel
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Jennifer M Skierka
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Matthew J Ferber
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - John L Black
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Linnea M Baudhuin
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Eric W Klee
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Jason L Ross
- Department of Information Technology, Mayo Clinic, Rochester, MN
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Abstract
Recent upward trends in the prevalence of abuse of prescription drugs and illicit substances have resulted in increased demands for toxicology testing to support the emergency department and drug treatment in pain management programs. This review will discuss the challenges faced by clinical laboratories to manage the utilization of toxicology tests, particularly those ordered in managing poisoned patients in the emergency department and chronic pain patients on opioid therapy. Optimal utilization of toxicology tests to support the emergency department relies on selecting the appropriate tests for the patient, and the availability of the results in a timely fashion. Two tiers of toxicology testing systems with different requirements for turnaround time will be discussed. In patients with chronic pain urine drug testing, including screening and confirmation testing are used extensively in pain management to monitor patient compliance. A thorough understanding of the performance characteristics of the test methodologies and drug metabolism is a key to making a proper analytical and clinical interpretation of the test results and will contribute to effective utilization of these tests. In addition, the reimbursement system is an important factor in the decision making process for test selection utilization as significant costs can be incurred by both payers and patients. Collaboration, trust, and effective communication among clinicians, patients, and clinical laboratory professionals are essential for effective utilization of toxicology testing.
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Affiliation(s)
- Yan Zhang
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, United States.
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