Clinical Laboratory Improvement Amendments

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The Clinical Laboratory Improvement Amendments (CLIA) of 1988 are United States federal regulatory standards that apply to all clinical laboratory testing performed on humans in the United States, except clinical trials and basic research.[1]

CLIA Program

In accord with the CLIA, the CLIA Program sets standards and issues certificates for clinical laboratory testing.[2] CLIA defines a clinical laboratory as any facility which performs laboratory testing on specimens derived from humans for the purpose of providing information for:[citation needed]

  • prevention
    , or treatment of disease or impairment
  • health assessments

An objective of the CLIA is to ensure the accuracy, reliability and timeliness of test results regardless of where the test was performed. Most

Laboratory Developed Tests have been regulated under this program.[3] In 2014 the FDA started a public discussion about regulating some LDTs.[4]

Test Complexity

A CLIA Certificate of Compliance (CoC).

Per CLIA, each specific laboratory system, assay, examination is graded for level of complexity by assigning scores of 1, 2, or 3 for each of the following seven criteria. A score of 1 is the lowest level of complexity, and a score of 3 indicates the highest level. Score 2 is assigned when the characteristics for a particular test are intermediate between the descriptions listed for scores of 1 and 3.[5]

Criteria for categorization:

  1. Knowledge
  2. Training and experience
  3. Reagents and materials preparation
  4. Characteristics of operational steps
  5. Calibration, quality control, and proficiency testing materials
  6. Test system troubleshooting and equipment maintenance
  7. Interpretation and judgment

Centers for Medicare and Medicaid Services
(CMS) has the primary responsibility for the operation of the CLIA Program. Within CMS, the program is implemented by the Center for Medicaid and State Operations, Survey and Certification Group, and the Division of Laboratory Services.

List of CLIA test complexity categorizations:

  • Waived
  • Moderate
  • Provider-performed Microscopy (PPM)
  • High
    • Laboratory Developed Test (LDT)s

Complementary and Alternative Medicine Laboratories

naturopaths, and nutritionists and accompanied by non-validated clinical interpretations which are used to recommend or justify costly, unnecessary, and potentially damaging treatments.[8][9] A 2001 OIG report found that the majority of laboratories performing CAM tests were not enrolled in CLIA and that CAM laboratory personnel did not meet the high complexity qualifications.[10] For laboratories enrolled in CLIA, they had their certificates revoked or were sent deficiency notices for failing to adhere to CLIA regulations.[10] No CLIA laboratory has been able to validate their LBA CAM tests per standards.[10] CAM tests are not covered by health insurance.[6] The number of CAM laboratories is unknown and the sales of supplemental remedies based on the results of these tests is unknown.[11] Since CLIA does not regulate the clinical validity/usefulness of a test, it is possible for a CLIA laboratory to offer tests that have no clinical utility.[8][12]

Getting laboratories that conduct CAM testing to enroll in CLIA is itself a challenge. Medical laboratories enroll in CLIA to qualify for Medicare/Medicaid reimbursement, nearly all providers bill patients directly for CAM laboratory tests.[10] Additionally, CAM providers are concerned by the closure of other CAM laboratories under CLIA, and have sought to avoid detection.[10] Some CAM providers and laboratory personnel have not had exposure to laboratory curriculum and are unaware of CLIA requirements.[10] CLIA is largely reliant on laboratories to self-identify themselves for enrollment.[10]

Providers of CAM laboratories have opposed oversight by CLIA and have suggested they should regulated by their peers or under a CAM specific division.

pathologists have stated that CAM testing falls within the scope of their medical license and should not be regulated under CLIA.[10]

CLIA provisions are geared towards CLIA certified laboratories, but not for those that have not enrolled. When a CAM laboratory is found to be operating without a CLIA certificate, they are sent a cease and desist letter to stop testing until the laboratory is CLIA certified.[10] There are no administrative remedies available to CMS when a laboratory refuses to enroll in CLIA and refuses to cease testing.[10] CMS cannot impose monetary or other administrative penalties on laboratories that defy the law, but can only refer cases to other Federal or State agencies.[10] CMS plays the primary role in federal oversight of laboratories under CLIA and there are limited regulations at the state level that restrict CAM laboratories.[10]

Andrology and Embryology laboratories and Reproductive Tissue Banks

CLIA applies to

sperm analysis and the postcoital test, but does not apply to andrology nor embryology laboratories, nor testing performed as part of an assisted reproductive technology (ART), nor reproductive tissue banks. There are no federal personnel requirements.[14][15][16][17]

The lack of CLIA applicability has been criticized noting how semen analysis is categorized as a high complexity test whereas the analysis of oocytes and embryos is unregulated, despite similar equipment and techniques in use.[18] There are accreditation programs such the CAP/ASRM Reproductive Laboratory Accreditation Program (RLAP), and TJC and CAP offer specialty accreditations, but these are voluntary in nature.[18][15]

In the summer of 1991, HHS notified the

amicus brief opposing AAB's lawsuit.[14] On March 8, 2000, the lawsuit was dismissed by Thomas F. Hogan due to lack of standing.[14]

In 1994, the

embryologists.[14]

Fees/Funding

The CLIA Program is funded by user fees collected from approximately 200,000 laboratories, most located in the United States.[3]

CLIA-waived tests

Under CLIA, tests and test systems that meet risk, error, and complexity requirements are issued a CLIA certificate of waiver.[20] In November 2007, the CLIA waiver provisions were revised by the United States Congress to make it clear that tests approved by the FDA for home use automatically qualify for CLIA waiver,[21] although many waived tests are not done according to designed protocols – more than 50% of such tests are done incorrectly – and result in medical errors, some with fatal consequences.[22]

Record and specimen retention

CLIA[23] and the College of American Pathologists (CAP)[24] have written policies for the minimum period of that laboratories should keep laboratory records and materials, with some examples as follows:

Microscopy slides Histology and non-forensic autopsy 10 years[23]
Forensic autopsy Indefinitely[23]
Cytology, fine needle aspiration 10 years[24]
Cytology, apart from fine needle aspiration 5 years[23]
Paraffin-embedded blocks Non-forensic 2[23] or 10 years[24]
Forensic Indefinitely[23]
Requisition form and test report Pathology reports 10 years[23]
Other 2 years[23]
Blood bank records Quality control records 5 years[24]
Donor and recipient records 10 years[24]
Records of indefinitely deferred donors Indefinitely[24]
Wet tissues Until report is completed[23] or 2 weeks thereafter[24]
Proficiency testing records and quality management/quality control records 2 years[23]
Discontinued procedures 2 years[23]
Blood smears and other body fluid smears, microbiology slides (including Gram stains) 7 days[24]
Flow cytometry plots 10 years[24]

During the retention period, specimens are considered to be part of the medical record and must be kept under a CLIA accredited laboratory to ensure compliant handling and storage conditions.[25][26] If a specimen is sent-out to a non-CLIA biorepository and recalled, the additional testing would not be in compliance.[25] There is an effort to make more biobanks CLIA equivalent as specimen recalls become more common due to expanded testing.[25]

Specimen ownership and utilization

Main articles: biobank, biorepository, DNA bank, virtual biobank, and tissue bank

Though CLIA does specify minimum retention periods, it does not explicitly specify which entity maintains ownership of the specimen while it is being retained and after the retention period has passed.The US currently does not have well-defined federal regulations regarding the ownership and utilization of physical human tissue specimens, their derivatives, as well as the biological information they contain.[27][28][29][30][31][32] The current standing by bioethicists is that patients who have consented to have their diagnostic specimens collected have also abandoned them, and thus have no ownership rights.[29][33] The Common Rule permits the use of biospecimens that would otherwise be discarded provided that the donor can not be identified, though utilization of the materials for research may require Institutional review board (IRB) approval.[29] The Association of American Medical Colleges (AAMC) has taken the stance that it "unambiguously rejects the concept that individuals retain any property interest in their excised tissues."[34]

Proponents of patient ownership rights advocate that patients must own their samples so that they can make informed decisions about how the tissues will be used, such as in

stem cell research, and for-profit ventures.[31] The 21st Century Cures Act enacted in December 2016 allows researchers to waive the requirement for informed consent
when clinical testing "poses no more than minimal risk" and "includes appropriate safeguards to protect the rights, safety, and welfare of the human subject."

The probability that a patient may sue researchers who utilize tissues that would typically be discarded is low, but as genetics research becomes more prevalent, this likelihood may increase.[29] Ideally, researchers should obtain informed consent from individuals, and aim for transparency in their intended use for the human tissue while protecting the privacy of the donor.[29]

CAP and other laboratory accreditation organizations (AO) have additional requirements and protocols for repurposing biospecimens that would otherwise be discarded.[31]

In July 2011, an

Advance Notice of Proposed Rule Making (ANPRM), entitled "Human Subjects Research Protections: Enhancing Protections for Research Subjects and Reducing Burden, Delay, and Ambiguity for Investigators" was published in the Federal Register.[35]

The rise in direct-to-consumer (DTC) genetic testing has created concerns for secondary use of both patient samples and their data.[36]

Newborn screening card retention & utilization

Main article: Newborn screening

These newborn screening DNA databases make a complete mockery of informed consent. What people also don't know is...it is done by the state department of public health.

Jeremy Gruber, Council for Responsible Genetics[37]

In the US, newborn screening (NBS) is mandated in all states, though parents may decline the screening process based on religious beliefs or philosophical reasons in some states.[37] Few parents opt of the program due to health concerns, and a lack of awareness of the ability to opt-out.[37] After the initial testing is complete, the residual dried blood spots (DBS) on newborn screening cards may be used for secondary purposes including shared with law enforcement and sold for research.[38] The decreasing costs of whole genome sequencing have also raised concerns that blood spots may be sequenced in the future, limiting any de-identificaiton procedures.[39][40][41] While CLIA does specify minimum retention requirements, it does not specify a federal maximum retention period. Retention periods for NBS cards vary by state with several states storing the cards long-term such as New Jersey with 23 years, or Texas which may keep the cards indefinitely.[42][43] The absence of parental awareness and consent for these activities, and a lack of transparency and federal regulations, has led to significant public concern and apprehension. [44][45][46][47]

New Jersey is this blank void where there’s no statute telling the health department that they can keep it, and there’s no oversight or limits on what they can do with it. It’s limited only to the health department’s imagination on how they want to use this blood.

Brian Morris, Institute for Justice(2023)[48]

The CDC

patient population that would otherwise be impossible to get.[46] The American Civil Liberties Union (ACLU), Council for Responsible Genetics(CRG), and the International Association of Privacy Professionals(IAPP) oppose the long term storage of identifiable NBS blood spots.[50]

In 2009, the Texas NBS program had to destroy millions of stored blood spots that were stored for decades without consent.[51] In Michigan, a 2022 lawsuit found that the NBS program long term storage and sales to third-parties was found to violate state statues noting how "post-testing conduct is not necessary to effectuate that interest because 'the health of the child is no longer at stake.'"[52] In New Jersey, the Institute for Justice filed a class-action lawsuit in 2022 under the 4th amendment seeking to limit the retention period of NBS cards after they were found to be used in warrantless law enforcement investigations without consent.[48][53][54]

History

The origins of CLIA can be traced back to the late 1960s, when cytology laboratories faced issues due to overworked personnel and a high incidence of errors in reading PAP smears. In response to these concerns, the Clinical Laboratory Improvement Amendment was introduced in 1967, which laid down the first set of regulations for laboratory standards, focusing mainly on independent and hospital laboratories.[55]

The Clinical Laboratory Improvement Act of 1988 (CLIA 88) was passed in the USA subsequent to the publication of an article in November 1987 in

false negative tests resulted largely from the carelessness of doctors. Subsequent to this, claims involving pap smears showed an alarming growth. The Act aimed at a comprehensive regulation of gynecologic cytology laboratories.[56]

CLIA certificates

Types of CLIA certificates[57]
Acronym Certificate Notes
CoW Certificate of Waiver Issued to a laboratory that performs only waived tests.
PPM Certificate for Provider-performed Microscopy procedures Issued to a laboratory in which a physician, midlevel practitioner or dentist performs specific microscopy procedures during the course of a patient's visit. A limited list of provider-performed microscopy procedures is included under this certificate type, which are categorized as moderate complexity testing.
Certificate of Registration ssued to a laboratory to allow the laboratory to conduct nonwaived (moderate and/or high complexity) testing until the laboratory is surveyed (inspected) to determine its compliance with the CLIA regulations. Only laboratories applying for a certificate of compliance or a certificate of accreditation will receive a certificate of registration.
CoC Certificate of Compliance Issued to a laboratory once the State Agency or CMS surveyors conduct a survey (inspection) and determine that the laboratory is compliant with the applicable CLIA requirements. This type of certificate is issued to a laboratory that performs nonwaived (moderate and/or high complexity) testing.
COA Certificate of Accreditation Issued to a laboratory on the basis of the laboratory's accreditation by an accreditation organization approved by CMS. This type of certificate is issued to a laboratory that performs nonwaived (moderate and/or high complexity) testing.

Accrediting organizations

For CLIA laboratories licensed under a Certificate of Accreditation (CoA), bi-annual inspections are conducted by an third-party accreditation organization (AO) that meets or exceeds the CLIA requirements.

Though Foundation for the Accreditation of Cellular Therapy (FACT) (formerly Foundation for Accreditation of Hematopoietic Cell Transplantation) does not have deeming status under CLIA, most laboratories involved in cell therapies are accredited by FACT.[58]

In Dec 2022, TJC announced they would no longer recognize Commission on Office Laboratory Accreditation (COLA) for lab accreditation at TJC hospitals as of Jan 1, 2023 and facilities would have until Dec 31, 2024 to transition accredidation.[59][60] With the COVID-driven inspection backlog and a lack of inspectors, the move was criticized as being purely a financially driven attempt to capture additional market share.[61][62] No reason for the change was given by CLIA, COLA., or TJC TJC had originally begun recognizing COLA accreditation in 1997.[63][64]

CLIA Accreditation organizations (AO)[65][58]
Acronym Accrediting Organization Deemed Notes
AABB
Association for the Advancement of Blood & Biotherapies
 1995 formerly American Association of Blood Banks
A2LA American Association for Laboratory Accreditation 2014
ACHC Accreditation Commission for Health Care 1995 Formerly (AOA/AAHHS/HFAP)American Osteopathic Association / Accreditation Association for Hospitals and Health Systems/ Healthcare Facilities Accreditation Program
ASHI American Society for Histocompatibility and Immunogenetics 1995
COLA Commission on Office Laboratory Accreditation 1993
CAP College of American Pathologists 1994
TJC
The Joint Commission
 1995 formerly Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Specialty/Subspecialty by CLIA Accreditation Organizations (AO)[66]
Specialty Subspeciality AABB A2LA ACHC ASHI COLA CAP TJC
Histocompatibility X X X X X
Microbiology Bacteriology X X X X X X
Microbiology Mycobacteriology X X X X X
Microbiology Mycology X X X X X
Microbiology Parasitology X X X X X
Microbiology Virology X X X X X X
Diagnostic Immunology Syphilis Serology X X X X X X
Diagnostic Immunology General Immunology X X X X X X X
Chemistry Routine Chemistry X X X X X X
Chemistry Urinalysis X X X X X
Chemistry Endocrinology X X X X X
Chemistry Toxicology X X X X X X
Hematology X X X X X X
Immunohaematology ABO/Rh Group X X X X X X X
Immunohaematology Antibody Transfusion X X X X X X
Immunohaematology Antibody Non-Transfusion X X X X X X
Immunohaematology Antibody Identification X X X X X X
Immunohaematology Compatibility Testing X X X X X X
Pathology Histopathology X X X X X
Pathology Oral Pathology X X X X X
Pathology Cytology X X X X X
Radiobioassay X X X X
Cytogenetics X X X X

Validation Surveys

FY 2020 CLIA Validation Survey Results[67]
AABB A2LA ACHC ASHI CAP COLA TJC
Number of Accredited Labs 186 3 127 111 6339 5965 1927
Validation Surveys 1 1 1 1 38 71 10
Surveys with Condition-Level Deficiencies NA NA NA NA 2 10 4
Surveys with One or More Condition-Level Deficiencies missed by AO NA NA NA NA 1 8 3
Disparity Rate NA NA NA NA 2.6% 11.3% 30.0%
*N/A: When a minimum sample size of five is not achieved for an AO, no data is reported given the lack of statistical significance.[67]

Laboratory directors

Clinical laboratories in the US that perform high complexity testing require a high complexity laboratory director (HCLD) that has earned doctoral degree in a chemical, physical, biological or clinical laboratory science from an accredited institution and be certified and continue to be certified by a board approved by HHS. The current approved boards are the following:

Certifying Boards for a high complexity laboratory director (HCLD)[68]
Acronym Name Notes
ABB
American Board of Bioanalysis
ABCC American Board of Clinical Chemistry
ABFT American Board of Forensic Toxicology (limited to individuals with a doctoral degree with Fellow status)
ABMGG American Board of Medical Genetics and Genomics (formerly known as American Board of Medical Genetics (ABMG))
ABMLI American Board of Medical Laboratory Immunology no longer accepting new exam applicants
ABMM American Board of Medical Microbiology
ACHI American College of Histocompatibility and Immunogenetics (formerly known as American Board of Histocompatibility and Immunogenetics (ABHI))
NRCC National Registry of Certified Chemists
ASCP American Society for Clinical Pathology Diplomate in Medical Laboratory Immunology (DMLI)

See also

References

  1. ^ CLIA related Federal Register and Code of Federal Regulation Announcements, and the FDA's Clinical Laboratory Improvement Amendments (CLIA). Accessed Nov. 14, 2015.
  2. ^ CLIA Program homepage
  3. ^ a b "CLIA Overview". CMS. 11 April 2018.
  4. ^ "Laboratory Developed Tests". FDA. 26 March 2018.
  5. ^ CLIA Categorization Criteria (December 2012)
  6. ^ a b "CLIA: Special Alert Live Blood Cell Analysis (LBA) Under CLIA [Alternative - Non-Traditional Laboratory Testing]" (PDF). Centers for Medicare & Medicaid Services. Mar 17, 2017. Retrieved 27 February 2024.
  7. ^ Stephen Barrett (March 9, 2004). "CLIA Hits Questionable Tests". Quackwatch. Retrieved 27 February 2024.
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  10. ^ a b c d e f g h i j k l m n "CLIA Regulation Of Unestablished Laboratory Tests" (PDF). Office of Inspector General, U.S. Department of Health and Human Services. July 2001. OEI-05-00-00250. Retrieved 27 February 2024.Public Domain This article incorporates text from this source, which is in the public domain.
  11. ^ a b Grob, George F. (Jan 2000). "Medicare Payments for Clinical Laboratory Services Vulnerabilities and Controls - Statement Before the Expert Committee on Medicare Payment Methodology for Clinical Laboratory Services of the Institute of Medicine" (PDF). Office of Inspector General, U.S. Department of Health and Human Services. OEI-05-00-00070. Retrieved 27 February 2024.Public Domain This article incorporates text from this source, which is in the public domain.
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  19. ^ "The Fertility Clinic Success Rate and Certification Act". Assisted Reproductive Technology (ART). CDC. 20 March 2023. Retrieved 16 March 2024.Public Domain This article incorporates text from this source, which is in the public domain.
  20. ^ "CLIA Waived Testing booklet" (PDF). December 2012.
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  22. ^ Gabler, Ellen (2015-10-31). "Hidden Errors – A Watchdog Report – Common medical tests escape scrutiny but often fall short". Milwaukee Journal Sentinel. Retrieved 2017-10-10.
  23. ^ a b c d e f g h i j k "42 CFR § 493.1105 - Standard: Retention requirements". Cornell Law School. [68 FR 3703, Jan. 24, 2003; 68 FR 50723, Aug. 22, 2003]
  24. ^ a b c d e f g h i "CAP Policy Manual - Policy PP. Minimum Period of Retention of Laboratory Records and Materials" (PDF). CAP.org. Adopted August 1995. Revised September 2020
  25. ^ a b c Today, Cap (20 October 2019). "For accredited biobanks, a path to CLIA equivalence - CAP TODAY". CAP Today. Retrieved 9 March 2024.
  26. doi:10.1309/LM3XP8HBKDSGICJH
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  27. ^ Moskaluk, Christopher (2011). "Tissue Tug of War: Issues in tissue procurement for research and banking" (PDF). 2011 ASCP Annual Meeting. ASCP. Retrieved 8 March 2024.
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  37. ^ a b c Scutti, Susan (24 July 2014). "The government owns your DNA. What are they doing with it?". Science. Newsweek. Retrieved 31 March 2024.
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  40. ^ Grant, Crystal (19 April 2023). "Widespread Newborn DNA Sequencing Will Worsen Risks to Genetic Privacy ACLU". American Civil Liberties Union. Retrieved 31 March 2024.
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  42. ^ "New Jersey - Baby's First Test - Newborn Screening". babysfirsttest.
  43. ^ "Newborn Screening - Use and Storage of Dried Blood Spots after NBS". Texas Department of State Health Services. Specimen Collection Date May 27, 2009, through May 31, 2012 - All blood spots are stored indefinitely, unless DSHS receives a Directive to Destroy Newborn Screening Blood Spot Card Following Testing form.
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  50. ^ Grant, Crystal (26 July 2022). "Police Are Using Newborn Genetic Screening to Search for Suspects, Threatening Privacy and Public Health ACLU". American Civil Liberties Union.
  51. ^ "Parents win key ruling in Michigan newborn blood dispute". TheDailyPress. Sep 17, 2022. Retrieved 31 March 2024.
  52. New Jersey Monitor
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  53. ^ DiFilippo, Dana (28 September 2022). "New bill would limit police use of DNA collected from newborn blood screening • New Jersey Monitor". New Jersey Monitor. Retrieved 31 March 2024.
  54. ^ Trager, Lauren (19 May 2023). "News 4 Investigates: Why the state may keep your baby's blood". First Alert 4. Retrieved 31 March 2024.
  55. ^ "Clinical Laboratory Improvement Act (CLIA)". New Mexico Department of Health. Retrieved 2023-04-18.
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  57. ^ "Clinical Laboratory Improvement Amendments (CLIA): How to obtain a CLIA Certificate" (PDF). CMS. Retrieved 27 January 2024.Public Domain This article incorporates text from this source, which is in the public domain.
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  59. ^ "COLA Cooperative Agreement Transition" (Dec 9, 2022). Missouri Hospital Association.
  60. ^ "Change in Joint Commission Laboratory Cooperative Agreement". www.jointcommission.org. The Joint Commission.
  61. ^ Wall, Scott (23 January 2023). "What's Behind Joint Commission Move to Not Accept COLA Labs?". The Dark Report.
  62. ^ Wallask, Scott (13 February 2023). "CAP, Joint Commission Under Pressure to Add More Inspectors". The Dark Report.
  63. ^ "Misinformation about Accrediting Bodies". COLA. 19 July 2023.
  64. ^ "JCAHO recognizes COLA accreditation. - Free Online Library".
  65. ^ "List Of Approved Accreditation Organizations Under The Clinical Laboratory Improvement Amendments (CLIA)" (PDF). CMS. May 30, 2022. OMB control number 0938-0686. Retrieved 3 March 2024.
  66. ^ "March 7, 2022 Specialty/Subspecialty Information For Approved Accreditation Organizations Under CLIA" (PDF). CMS. March 7, 2022. Retrieved 27 February 2024.Public Domain This article incorporates text from this source, which is in the public domain.
  67. ^ a b "FY 2021 Report to Congress (RTC): Review of Medicare's Program Oversight of Accrediting Organizations (AOs) and the Clinical Laboratory Improvement Amendments of 1988 (CLIA) Validation Program" (PDF). Center for Clinical Standards and Quality/Quality, Safety & Oversight Group. SECTION 7: Clinical Laboratory Improvement Amendments Validation Program: CMS. May 10, 2023. pp. 92–97. QSO-23-14-AO/CLIA. Retrieved 28 February 2024.{{cite web}}: CS1 maint: location (link)Public Domain This article incorporates text from this source, which is in the public domain.
  68. ^ "Certification Boards for Laboratory Directors of High Complexity Testing | Guidance Portal". www.hhs.gov. Retrieved 28 January 2024.Public Domain This article incorporates text from this source, which is in the public domain.

External links

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