Diagnostic Kits/Glossary

Analyte Specific Reagent (ASR)

Code of Federal Regulations Title 21 (21CFR809.30) states that ASRs may only be sold to: IVD manufacturers, CLIA labs capable of high-complexity testing, and organizations that use the reagents for non-clinical uses.

There are 3 classes of ASRs, I, II, and III. The analytical and performance characteristics of Class I ASRs are not established by the FDA, and for Class II and III ASRs are only established as a component of a cleared test. Because ASRs do not generally require full FDA pre-market review, they can be developed more quickly for less money. But they are not sold as complete diagnostics - instead, CLIA labs purchase ASRs to use in diagnostic tests they develop internally.

"ASRs were initially introduced to improve the availability of immunohistochemical stains for which manufacturers had not sought FDA market clearance because the cost was too high for the revenues that would come from such products. The ASR regulatory path has become the chosen commercialization route for many molecular tests for similar cost-versus-revenue reasons. The minimal regulatory burden involved in releasing tests as ASRs allowed for a lucrative market, even in the earliest stages of this market sector." [3]

Examples of ASRs:

• Microarrays
• Antibodies
• Algorithms for interpreting IVDMIAs?

Can non-CLIA customers purchase ASRs for non-clinical use?

What is the distinction between the three classes of ASRs?

• [1] http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?FR=809.30
• [2] Phillips, K.a., Van Bebber, S. & Issa, A.M., 2006. Diagnostics and biomarker development: priming the pipeline. Nature reviews. Drug discovery, 5(6), 463-9
• [3] Kalorama Information (Rosen). Diagnostic Test Service Commercialization: A Roadmap to Diagnostics in the 21st Century. (2008), pg 10.

Clinical Laboratory Improvement Amendments (CLIA)

Passed by Congress in 1988, CLIA established "quality standards for all laboratory testing to ensure the accuracy, reliability and timeliness of patient test results regardless of where the test was performed. A laboratory is defined as any facility which performs laboratory testing on specimens derived from humans for the purpose of providing information for the diagnosis, prevention, treatment of disease, or impairment of, or assessment of health."[1]

The stringency of CLIA regulations increase with the complexity of the test being performed. Three categories have been established: waived complexity, moderate complexity, and high complexity.

The CMS implements CLIA (and receives certification and inspection fees from labs), the CDC is responsible for CLIA studies, and the FDA is responsible for test categorization.

"To enroll in the CLIA program, laboratories must first register by completing an application, pay fees, be surveyed, if applicable, and become certified."[1]

[1] http://www.cms.hhs.gov/CLIA/07_Program_Descriptions_Projects.asp
[2] http://www.fda.gov/cdrh/CLIA/

In-Vitro Diagnostic (IVD)

There are 5 main categories of IVDs: General (Clinical) chemistry, Immunochemistry, Hematology/Cytology, Microbiology/Infectious Disease, & Molecular, Genomic, Proteomic, & Metabolomic (Omics).

What they are not: Imaging (CAT/MRIs, ultrasounds) or In-Vitro: (assess health status inside of body or measure body functions as they occur, like a heart rate monitor, blood pressure, temperature)

Examples:

• cholesterol test, urinalysis strips (Clinical Chemistry)
• blood count, pap smear (Hematology/Cytology)
• Strep test, SARS blood screening (Microbiology)
• PSA test for prostate cancer, HIV antibody testing (Immunochemistry)
• SARS PCR assay, HIV viral load, CYP450 diagnostics, BRCA cancer screening (Omics)

FDA Definition: "In vitro diagnostic products are those reagents, instruments, and systems intended for use in diagnosis of disease or other conditions, including a determination of the state of health, in order to cure, mitigate, treat, or prevent disease or its sequelae. Such products are intended for use in the collection, preparation, and examination of specimens taken from the human body. [21 CFR 809.3]" [1]

"While this broad definition is sufficient for identifying IVDs for regulatory purposes, the FDA’s definition does not capture the true scope, nature and utility of IVDs. More specifically, IVDs are reagents, instruments and systems for testing specimens taken from the body and intended for use in a broad spectrum of health care applications, including:

• evaluation of an individual’s risk(s) for developing specific diseases or conditions
• early detection of diseases and conditions
• generation of risk-related medical information that informs clinical action (e.g., helping clinicians to rule in/rule out disease)
• diagnosis of diseases and conditions
• identification or quantification of medication or other treatment risks and/or targeted treatment selection
• estimation of patient prognosis (e.g., risk for recurrent stroke, heart attack, or infection)
• monitoring of treatment effectiveness
• informing the development of targeted, patient-specific disease management strategies
• identification of environmental risks to patients’ or the public’s health

from [3]

Regulation

"There are essentially two kinds of tests: those that are manufactured and sold in volume as kits to laboratories and those that are developed within a particular laboratory (called laboratory-developed assays). In each case, their development and entry into the market - that is, their use on patient specimens - is governed by sets of rules that ensure their accuracy and reliability.

The clinical laboratory tests that are performed using commercially manufactured kits and equipment (primarily tests done on body fluid samples like blood and urine) are subject to the regulations imposed by the U.S. Food and Drug Administration (FDA). In addition, other federal and state health agencies ensure that these laboratory tests meet stringent standards both during the manufacturing process and when they are used in the clinical laboratory." [2]

The primary components of the diagnostic process: samples, controls, instruments, and accessories. [3]

• [1] http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/IVDRegulatoryAssistance/ucm123682.htm
• [2] http://www.labtestsonline.org/understanding/features/market.html
• [3] Goodman et al. The Value of Diagnostics: Innovation, Adoption and Diffusion Into Health Care. (2005) pp. 14-15

Direct Access Testing (DAT)

"As with home testing, direct access testing (DAT) has been growing in popularity over the past few years. Currently, 34 states permit consumers to order their own lab tests - without a medical order from their health care provider. Also known as patient authorized testing, DAT is a reflection of Americans' focus on health and preventive medicine, offering the opportunity for patients to take a more active role in their own health care.

In some respects, direct access testing has been around for some time. Over-the-counter home tests are a type of DAT since they do not require a prescription and can be bought and used at the consumer’s discretion. Now, the trend has expanded to include laboratories offering clinical tests at the patient’s request. In retail centers in Colorado, Montana, Missouri, Kansas, and Utah, patients can walk into a lab and request certain tests; wellness centers offer health screens and other lab tests; and free-standing and mobile testing facilities offer screening tests to the public, such as in grocery stores and pharmacies.

Most DAT labs limit the availability of tests to simple, general health tests such as complete blood counts (CBC), cholesterol levels, throat and urine cultures, diabetes screening (blood glucose tests), chemistry panels, PSA for prostate cancer, thyroid tests, HIV antibody tests, blood typing, pregnancy tests, and urine drug screens.

Direct access testing may reduce costs for the patient by eliminating the expense of doctor’s office visits, providing vital information to patients who are concerned with a particular health problem or who may otherwise avoid testing due to inconvenience or concerns over anonymity. However, most insurance companies do not cover tests that are not ordered by a physician; therefore, you should expect to pay out-of-pocket for these services. In addition, labs providing DAT services must provide consumers with reference ranges and some assistance in interpreting the results. However, you are not operating under the guidance of your physician, who may be better able to determine what tests you really need but also what the results of those tests mean in light of your specific clinical signs, symptoms, and medical history." [1]

• [1] http://www.labtestsonline.org/lab/labtypes-6.html

Reference Lab

"Reference labs are usually private, commercial facilities that do high volume routine and specialty testing. Most of the tests performed are referred from physician’s offices, hospitals and other health care facilities (e.g., nursing homes and other facilities). While most hospitals try to do as many tests as possible in-house, reference labs are used for specialized tests that are ordered only occasionally or that require specialized equipment." [1]

Market Share
"The major national reference labs including Quest, LabCorp, Specialty/Ameripath, Mayo and others account for at least 60% of the market for esoteric test services. The remaining 40% is shared by a group of some 3000 small, local market laboratories. The major reference labs have built a comprehensive menu of specialized test services and continue to expand their offerings via collaborations with leading medical research centers. They offer a huge presence in the market and manage distribution networks that touch just about every medical specialty. Thus many CLIA-registered company sponsored test services avail themselves of the marketing resources offered by the national reference labs." [2]

Margins & Growth
The bulk of reference lab test services cover highly commoditized routine tests. Here the margins are low because labs compete for clients based on cost per test. As lab medicine evolved with the development of personalized medicine, the complexity of testing has increase significantly.

New technologies are fueling faster growth in segments such as analysis of biopsy tissue, protein biomarkers and genetic testing. LabCorp and Quest have developed tests in these areas, but most have been developed by smaller reference labs such as Esoterix and US Pathology Labs.

Part of the growth in the new single analyte and multiplexed molecular and protein tests is related to the perception that these tests offer physicians decision making information not available with conventional tests. As such they command premium pricing. Therefore Quest and LabCorp have acquired several of the major esoteric testing companies to enhance their position in this high-growth segment.

These labs and other specialised reference labs have a clear advantage over test services offered by companies in their CLIA-registered labs. They have established distribution networks and immediate access to medical specialists. Thus the esoteric test segment is a clear winner for them. The average cost of a molecular test performed in a reference lab ranges from $10 to $50, reimbursement is usually at least $100 and the labs often charge as much as $500 for these tests.

Promotional and clinical study activities that provide scientific and economic evidence of the value of high-priced esoteric tests do not come cheap. None of the test companies that have launched in-company test services are in the black. Genomic Health’s success has been hard bought. The company has invested in researching a panel of biomarkers that has proved effective and has supported numerous clinical studies. Where Genomic Health and other companies that market test services save is in lab technologist training costs, after sales service and continuing education.

The reagent and instrumentation costs for many multiplexed esoteric and genomic tests are still high and demand is relatively low, most hospital labs would not be able to justify investment in offering these tests. Thus, it may appear that profit consideration is the driving force for test services. In effect, the most obvious route to market for complex and still esoteric tests is via collaboration with a reference lab or a CLIA-registered company lab. In this way the test becomes available to the largest number of physicians and patients. [3]

• [1] http://www.labtestsonline.org/lab/labtypes-3.html
• [2] Rosen. Diagnostic Test Service Commercialization: A Roadmap to Diagnostics in the 21st Century. (2008) pg. 22
• [3] Ibid. pp. 47-48

PreMarket Approval (PMA)

"Premarket approval (PMA) is the FDA process of scientific and regulatory review to evaluate the safety and effectiveness of Class III medical devices. Class III devices are those that support or sustain human life, are of substantial importance in preventing impairment of human health, or which present a potential, unreasonable risk of illness or injury. Due to the level of risk associated with Class III devices, FDA has determined that general and special controls alone are insufficient to assure the safety and effectiveness of class III devices. Therefore, these devices require a premarket approval (PMA) application under section 515 of the FD&C Act in order to obtain marketing clearance. Please note that some Class III preamendment devices may require a Class III 510(k). See "Historical Background" for additional information.

PMA is the most stringent type of device marketing application required by FDA. The applicant must receive FDA approval of its PMA application prior to marketing the device. PMA approval is based on a determination by FDA that the PMA contains sufficient valid scientific evidence to assure that the device is safe and effective for its intended use(s). An approved PMA is, in effect, a private license granting the applicant (or owner) permission to market the device. The PMA owner, however, can authorize use of its data by another." [1]

[1] http://www.fda.gov/medicaldevices/deviceregulationandguidance/howtomarketyourdevice/premarketsubmissions/premarketapprovalpma/default.htm