Effect of Outliers and Nonhealthy Individuals on Reference Interval Estimation

Abstract Background: Improvement in reference interval estimation using a new outlier detection technique, even with a physician-determined healthy sample, is examined. The effect of including physician-determined nonhealthy individuals in the sample is evaluated. Methods: Traditional data transformation coupled with robust and exploratory outlier detection methodology were used in conjunction with various reference interval determination techniques. A simulation study was used to examine the effects of outliers on known reference intervals. Physician-defined healthy groups with and without nonhealthy individuals were compared on real data. Results: With 5% outliers in simulated samples, the described outlier detection techniques had narrower reference intervals. Application of the technique to real data provided reference intervals that were, on average, 10% narrower than those obtained when outlier detection was not used. Only 1.6% of the samples were identified as outliers and removed from reference interval determination in both the healthy and combined samples. Conclusions: Even in healthy samples, outliers may exist. Combining traditional and robust statistical techniques provide a good method of identifying outliers in a reference interval setting. Laboratories in general do not have a well-defined healthy group from which to compute reference intervals. The effect of nonhealthy individuals in the computation increases reference interval width by ∼10%. However, there is a large deviation among analytes.