title: 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 approximately 10%. However, there is a large deviation among analytes.
authors.affiliation: Department of Mathematical Sciences, University of Cincinnati, Cincinnati, OH 45221-0025. Mount Carmel Health System, Columbus, OH 43222, USA. paul.horn@uc.edu
authors.forename: P S
authors.initials: PS
authors.lastname: Horn
authors.forename: L
authors.initials: L
authors.lastname: Feng
authors.forename: Y
authors.initials: Y
authors.lastname: Li
authors.forename: A J
authors.initials: AJ
authors.lastname: Pesce
mesh_terms: D004194:Disease; D006304:Health Status; D006801:Humans; D016011:Normal Distribution; D012016:Reference Values