Interpretative commenting

Last update: March 21, 2019.

What is Interpretative commenting?

 
 
Interpretative commenting acts in the post-analytical phase when the analytical results (or data) is assessed against other available laboratory and clinical data.

The interpretative comment is formulated as guidance that should maximize beneficial impact on patient management. This transition from analytical data to clinical wisdom is achieved through the intermediate steps of assembling all the information and applying medical knowledge.

Known as the “knowledge pyramid”, the hierarchical transition data – information – knowledge – wisdom (DIKW), is a well-established model of information hierarchy:
 
 


 

Highlighting analytical data


 

Information on patterns


 

Applying medical knowledge


 

Clinical wisdom and actions

 
 
Interpretative commenting is becoming more valued every day ―as well as demanded―, by healthcare workers due to its potential to prevent or reduce errors and improve patient outcomes.
 
 

Wording

 
 
Like verbal communication, words used in comments can be confusing; therefore, some rigor is required to make comments clear. For example, the pattern of laboratory data supporting a particular diagnosis can be described as being “suggestive of”, “consistent with”, “indicative of”, or “diagnostic for”, and these terms often represent ambiguous levels of interpretative confidence.

Similarly, terms such as “possibly”, “probably”, and “definitely” need to be used with care.

Some of these terms, e.g. “diagnostic” or “definite”, may convey a greater confidence than intended and should be avoided, or only be used with great caution.

Medical science has some common norms regarding confidence, including statistical 95% confidence and likelihood ratios (i.e. >50:50 chance), which should be considered as a basis for terminology.
 
 

Interpretative commenting basis

 
 
It is important to ensure that interpretative comments provided are of high quality: Comments should be patient focused and answer the implicit or explicit question raised by the requesting clinician.
 
 

Components of a good comment

 
 


 

The absence or presence of an abnormality and its degree or severity.


 

Possible clinical implications of abnormality and/or a diagnosis.


 

Suggested follow-up including further testing and specialist referral.

 
 

The need for interpretative comments

 
 
The current demand for interpretative comments and its desirability spring from both clinical, technical and financial catalysts.
 
 

Clinical drivers

 
 

Evidence has accumulated to demonstrate the risk of errors due to misinterpretation of diagnostic tests in different clinical settings (e.g. primary care, emergency departments, internal medicine) and their impact on patient safety.

The inclusion of interpretative comments in laboratory reports could decrease error rates, thus improving the quality of laboratory information and patient safety.

There are many instances in which the value of a laboratory result can be considerably enhanced by an accompanying comment.

In laboratory practice, many of the verbal (phoned) requests for interpretations are related to the common and routine tests (such as iron studies, liver function tests and renal profile), in addition to hormone profiles (such as thyroid function tests) and protein electrophoresis.

There is a specific requirement in the International Standard for laboratory accreditation International Standards Organization (ISO 15189: 2012) for Laboratory Directors to provide clinical advice in the interpretation of examination results, including the inclusion of “interpretative comments on results” and “where applicable”.

The addition of interpretative comments has been recommended in several clinical guidelines to improve the utilization of laboratory data.

Monitoring of interpretative comments is now included in the list of consensually accepted quality indicators for the post-analytical phase.

Customer satisfaction of interpretative service is backed by evidence; contributing factors include a significant reduction of errors and improvement of clinical outcomes.

New and complex tests represent a major driver for the inclusion of interpretative comments in the laboratory report. This is particularly true in some diagnostic areas such as coagulation, autoimmunity, allergy testing, and molecular diagnostics that present major challenges due to the need of advanced expertise for the correct interpretation of the laboratory data.

In addition, interpretative comments are increasingly welcomed by the requesting physicians particularly when they provide clinical advice on “what to do next”.

Great variation exists in the ways that medical students learn the principles of laboratory medicine in different countries.

However, current evidence highlights that medical education on laboratory testing is inadequate and that junior doctors do not feel confident in interpreting even common laboratory tests, at least in part because many medical schools have moved toward newer ways of undergraduate teaching which have reduced the time available for teaching the pathology disciplines.

In some surveys, health practitioners have requested the inclusion of interpretative comments in laboratory reports in addition to teaching and education.

Healthcare staff other than doctors are increasingly receiving laboratory reports and might especially benefit from any guidance provided.

The lack of harmonization of the laboratory information, not only in analytical methodology but also in measurement units, reference intervals and decision limits, is a further driver for the inclusion of interpretative comments.

The increase in electronic data communication requires clinicians to cope with huge data traffic, thus increasing the risk of misinterpretation of laboratory results.

This, in turn, increases the desirability of interpretative comments to facilitate the physicians’ decision making.

Increasing competition between clinical laboratories that is predominantly based on costs could be better addressed if other variables that provide evidence of the quality of laboratory services are considered.

The availability of interpretative comments could represent “added value” to requesting physicians and users.

The need to reduce cost of healthcare, specifically, costs related to laboratory testing, should shift the focus from volume reduction to the reduction of inappropriate requests and, even more important, inappropriate utilization of laboratory information.

Current evidence highlights the huge percentage of laboratory results that are poorly acknowledged and misinterpreted, leading to missed or delayed diagnoses and treatments.

Together, these drivers require careful consideration of the need for translating the activity of interpretative commenting from a research area to a well-established routine activity of clinical laboratories.
 
 

Bibliographic references

 

Scientific publications

  1. Bezzegh, A., Takács, I., & Ajzner, É. (2017). Toward harmonization of interpretive commenting of common laboratory tests. Clinical Biochemistry, 50(10-11), 612–616. doi:10.1016/j.clinbiochem.2017.05.012
  2. Challand, G. S., Vasikaran S. D. (2007), The assessment of interpretation in clinical biochemistry: a personal view, Ann Clin Biochem 2007; 44: 101–105
  3. Lim, E. M. (2004). Quality Assessment of Interpretative Commenting in Clinical Chemistry. Clinical Chemistry, 50(3), 632–637. doi:10.1373/clinchem.2003.024877
  4. Plebani, M. (2009). Interpretative commenting: A tool for improving the laboratory–clinical interface. Clinica Chimica Acta, 404(1), 46–51. doi:10.1016/j.cca.2009.03.012
  5. Rowley, J. (2007). The wisdom hierarchy: representations of the DIKW hierarchy. Journal of Information Science, 33(2), 163–180. doi:10.1177/0165551506070706
  6. Vasikaran, S., Penberthy, L., Gill, J., Scott, S., & Sikaris, K. (2002). Review of a pilot quality-assessment program for interpretative comments. Annals of Clinical Biochemistry, 39(3), 250–260. doi:10.1258/0004563021901955
  7. Vasikaran, S., Sikaris, K., Kilpatrick, E., French, J., Badrick, T., Osypiw, J., … on behalf of the IFCC WG Harmonizat. (2016). Assuring the quality of interpretative comments in clinical chemistry. Clinical Chemistry and Laboratory Medicine (CCLM), 54(12). doi:10.1515/cclm-2016-0709

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