Reporting lab test results as meaningful grades as well as measurement values

General
1

Topic: Converting lab test results from measurement values to meaningful grades

Problem: When patients get results from their bloodwork or other lab test, they do not get a clear idea of the actionable meaning of each test result. Each test result is shown as a value, with its dimensional units, and often, an indication of how that value compares with the “normal” range. The patient does not get any idea of the measurement’s import or what the clinician will suggest to do about that result.

Suggested Solution: Do the same for lab test results across all lab tests as we do for cancer. Oncology uses a standard “stages” (I, II, III, IV) grade scale for cancer, used by physicians and patients across all cancers, throughout the health care world. Create a grade scale for lab test results.

Proposal: Seven-level set of grades for lab test results with consistent meanings and implications:

  1. Severely below normal: Must treat urgently

  2. Below normal: Treat

  3. Low normal: OK. Monitor more often

  4. Normal: Be happy. Test periodically

  5. High normal: OK. Monitor more often

  6. Above normal: Treat

  7. Severely above normal: Must treat urgently

On the lab test results report, the grade for each test result could be printed on the same line as the measurement value and the same-line range chart.

Value of this grade scale: Patients and clinicians have a concept of the grades and the actionable implications. A finer scale, such as one with 10 steps, does not explain the semantic difference between, say, 6 and 7. A coarser scale does not include a different grade for each action.

Problem: Different clinicians may map measurements to these grades using different breakpoints.
However, this is only a problem where the clinicians have the independence to decide their own breakpoints. In many health systems, they do not.

Problem: Comorbidities and other individual differences change the grade appropriate to the measurement.

Solution: The clinician tells the patient his own professional assessment of the grade for the individual patient. The patient would still understand the meaning of the grade within the range of grades.

Questions:

  1. Is this reasonable?
  2. Does it need improvement?
  3. Is LOINC the channel to advocate for it?
  4. Where else?
2

Hello,

Welcome to the LOINC Forum.

Your proposal would not be a LOINC issue, but rather a change in clinical and/or laboratory protocols that are typically determined by clinical/professional bodies.

I appreciate making laboratory results more usable for patients.
However, there are so many permutations (combinatorial explosion) of the impact/meaning of individual lab results for a variety of diseases and conditions. I highly doubt clinicians will want to “grade” each combination as it adds to their clinical burden and would quite a bit of time out of their patient visit or pajama time.

Cancer TNM staging is done by a pathologist, while much of the routine high volume clinical lab results reporting is automated without human intervention, such an assessment would require human intervention, including staffing and costs associated with the shortage of laboratory professionals. It would delay lab reporting especially for critical/stat tests such as those in OR, ED, code patients, etc. where the patient may not even be conscious. (Although they may review their results in their patient portal at a later time.)

In order to provide actionable meaning, whomever is reviewing the result values, need to have current and accurate patient information about the patient, disease or medication effects, etc. Many laboratories currently don’t have access to all this information (laboratory interoperability challenges).

Also all lab results that are above or below normal are not necessarily treated. For example, a White Blood Count may be elevated due to white coat hypertension. This goes away on its own after the clinical visit. “Treating” may cause harm to the patient, whether financial, or due to treatment side effects, etc. and is not standard clinical practice and considered malpractice.

Other labs depend on the patient age, sex or other factors. A severely above normal cholesterol may not treated urgently like a Potassium. There is no critical cholesterol value. Grading it as such may cause undue patient anxiety and harm.

Assessment of lab results is by the ordering provider as they know the complete context of why they ordered the test and what is occurring in the patient.

There may be value in taking a lab value, and the reference range and laboratory high or low flags to propose a problem on the patient problem list for a provider to confirm or not. A high triglycerides may warrant a problem of “hypertriglyceridemia” for example. Again this is beyond the scope of LOINC.

Hopefully, the info above shows it may not be reasonable and LOINC is not where it should be advocated as it’s not a LOINC issue, but clinical practice/implementation issue.

I should ask where/which country(ies) is this proposed? Different countries have different medical organizations, societies, regulations too.

Best,

3

Thank you for your thorough and clear reply.

re: “I should ask where/which country(ies) is this proposed?”
“Proposed” is a stronger word than is appropriate yet. I have been living in Israel for 10 years, where there are four health plans, each analogous to a Kaiser Permanente. Each has its own labs. They and the Ministry of Health set standards, treatment protocols and guidelines for their physicians.

A physician with whom I discussed the idea also made similar points to yours, as did some lay people. I accept the validity of the assessments and the consensus.
I do not expect to pursue this further.
Thank you,
David A. Kra