In 2019, the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for Preanalytical Phase (WG-PRE) developed a specific checklist – called PREDICT – for preventing preanalytical diagnostic errors in clinical trials. This checklist is focused particularly on covering the most important pre-analytical aspects of blood sample management in clinical studies:
- Test selection.
- Patient preparation.
- Sample collection.
- Management and storage.
- Sample transportation.
- Specimen retrieval before testing.
Errors happen, also in laboratory diagnostics. Although many efforts have been made for improving standardization and harmonization across various activities of the total testing process have made in vitro diagnostic testing a relative safe environment compared to other diagnostic disciplines, some error opportunities persist, most of which originate from extra-analytical activities.
Most of these errors (approximately 60–70%) are the result of manually intensive activities at the preanalytical phase, followed by post-analytical errors (approximately 20–30%) and analytical mistakes. The various consequences of these potential errors include increased patient risk and waste of economic resources, as well as organisational issues within and outside the laboratory.
Pre-analytical quality is an essential requirement of clinical trials, in that there is a tangible risk that some clinical studies may fail to generate their true outcomes because of a variety of laboratory errors, including those arising from the pre-analytical phase.
Laboratory testing in clinical trials
Laboratory diagnostics play an essential role in clinical trials, since many diagnostic tests are used for defining whether or not a study participant will fulfil eligibility criteria; they are also used for assessing the baseline values of many parameters that can then be modified by the clinical intervention, as well as for demonstrating the efficacy of investigational product(s) and for monitoring the safety of study participants throughout the clinical trial.
The adoption of strict pre-analytical requirements is equally mandatory for clinical diagnostic testing as it is for clinical trials, as the risk of errors in the latter scenario may generate several unfavourable consequences (eg, rejecting samples due to lack of conformity at pre-analytical stage could subsequently result in exclusion of not only the specific samples, but also the entire data of the individual involved).
Failures of clinical trials
There is consolidated evidence that the risk of obtaining a misleading outcome for a clinical trial (ie, either positive or negative) is particularly high – ie, an event included in the conventional concept of ‘lost in translation from the bench to the bedside’, encompassing the lack of translation of basic research findings into effective clinical interventions.
There are many factors leading to the failure of a clinical trial (beyond lack of efficacy or safety concerns with the intervention), including:
- A different human response to interventions compared with that observed in preclinical models.
- Lack of human and/or economic resources.
- Poor study design.
- Inaccurate site selection.
- Poor recruitment figures or large numbers of dropouts.
- Patient safety issues.
- Poor execution of the study or inappropriate (statistical) analysis of the data.
Among these various factors, diagnostic errors (thus including pre-analytical mistakes) are usually overlooked as a possible cause of clinical trial failure, despite emerging evidence which seems to point to the contrary.
In a recent report published by Schultze and Irizarry, the major sources of uncertainty in laboratory data generated within safety assessment studies were:
- The ignorance of standard operating procedures (SOPs).
- Sample misidentification.
- Equipment malfunctioning.
- Quality control failures.
- Test interference.
It is worth noting that the risk of clinical trial failure for delayed processing of blood specimens for glucose testing has also been highlighted. In fact, blood tubes, which cannot be centrifuged for up to 24 hours after phlebotomy, will experience a gradual (spurious) decline of glucose concentration, which may finally impair data interpretation for assessing the health status of potential study participants. In multi-centre trials, the use of different types of blood collection tubes or additives may be a source of diverging results, heavily impacting the statistical evaluation.
In addition, evidence has been provided to demonstrate that using inadequate pre-analytical procedures or overlooking SOPs for collection, processing and storage of biospecimens, may generate a negative bias in experimental outcomes and could also impair the reproducibility of the scientific data.
It is crucial to have a standardised collection and documentation system for all pre-analytical conditions during the process of patient preparation, collection and storage of biospecimens – in order to be able to exclude any pre-analytical bias in results in future studies. In particular, the cumulative risk of pre-analytical bias gradually increases in parallel with the complexity of the study, being lower in single-centre studies, intermediate in multicentre studies characterised by multiple peripheral collection sites and local testing, and predictably highest in multi-centre studies, where there are many peripheral collection sites and a single reference laboratory (ie, centralised testing). In this last case, not only do local procedures for blood sample collection and handling need to be standardised, but strict harmonisation is also required in local management and specimen transportation to the reference laboratories.
Managing pre-analytical variability in clinical trials
There are no guidelines available on how to manage pre-analytical variability in clinical studies and there are no specific indications for standardising or harmonising the different pre-analytical steps within a clinical trial, either single or multicentre. For all these reasons, the PREDICT checklist has been developed.
The most appropriate selection of laboratory tests is as critical in routine clinical practice as in clinical trials. In the case of the latter, it is quite common to review study protocols, including obsolete, redundant and even useless tests, due to the persistence of old habits – along with inadequate or insufficiently updated knowledge on test significance – while drafting protocols. The use of the most appropriate and updated laboratory investigations in clinical trials – due to their potential use for establishing participant eligibility, for identifying side-effects and for defining clinical outcomes – is to be considered as mandatory here as it is in routine clinical practice.
Analytical methodology should also be selected according to the test’s aim, thus identifying in advance whether it is to be used for screening, diagnosis, prognostication, therapeutic monitoring or follow-up. In this way, the analysis, the analytical technique and the test concentration cut-offs can be selected according to diagnostic performance and customised for the study protocol’s intended use.
It is essential that the process of patient preparation for sample collection is standardised. This will involve the accurate standardisation of blood collection from one patient to another when samples are drawn in a single centre, but also when blood is collected from different centres, a standardised process is essential. This will require the accurate collection of clinical information, followed by strict standardisation of fasting time, collection time, abstaining from cigarette smoking and drinking coffee, and a period of rest before drawing blood; the patient also needs to be in a standardized position during sampling.
Blood sample collection and handling
The study protocol will contain clear indications on sample type and volume, sample matrix, blood collection device and blood collection tubes/additives, as well as time of tourniquet application, preferred venipuncture site, order of draw and sample mixing. The use of identical automatic tube labeling devices is a reasonable option for improving standardisation.
Blood sample preparation, transportation and/or storage
The risk of analytical bias is lower with centralised testing, but local analysis would limit the risk of pre-analytical bias arising from sample transportation. Both solutions are suitable, provided that a detailed protocol, containing accurately standardised analytical or preanalytical procedures, is made available. For those clinical trials involving sample shipment from remote collection centres to the reference laboratory, it is essential to locally centrifuge the specimens when there is a tangible risk that the stability of analytes in serum or plasma may be jeopardised during transportation. Whether centrifugation is performed locally or in the reference laboratory, centrifuge conditions must be standardised, with serum or plasma separated as soon as possible after centrifugation.
The condition of sample transportation (ie, time and temperature) must be accurately standardised, recorded and monitored. In the case of samples where analysis cannot immediately be done, they need to be stored according to the evidence available, in terms of analyte stability at different temperatures and lengths of storage. Repeated freezing and thawing cycles should normally be avoided, preferably by aliquoting samples into volumes fitting the analytic need prior to storage, according to the study protocol.
Tools such as the platform developed by Groenlandia Tech guarantee traceability in logistics processes of this type. The platform also has the Nuuk cooler as a key element: it’s a device that incorporates a real-time control system that optimizes the logistics process, improves content safety, and reduces laboratory costs.
Nuuk guarantees various aspects, such as real-time control of the interior temperature, it has an alert system incorporated -informs about possible impacts or damages in the transport process-, it offers total access control where only the initial user and the recipient end can access the content inside and has a cooling technology adaptable to different temperature ranges.
Specimen retrieval before testing
Finally, in those clinical trials entailing the use of biobanks for long-term storage of biological material, sample retrieval before testing may be an additional critical issue. It is recommended that SOPs be made available to all the participating laboratories, with the aim of standardising the procedures used for preparing samples for testing; they should also cover procedures for the thawing and mixing of specimens, as well as clear indications that unsuitable samples should not be analysed. This is particularly important for haemolysed samples, which are the first cause of test suppression in clinical laboratories.
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