The Quo-Test Alc System is intended for the in vitro quantitative determination of glycated hemoglobin (%HbA1c) levels in venous whole blood samples (using K2EDTA and lithium heparin anticoagulants). Measurement of percent glycated hemoglobin (%HbA1c) is effective for monitoring long-term glycemic control in individuals previously diagnosed with diabetes mellitus.

The Quo-Test A1c System is not intended for screening or diagnosis of diabetes or neonatal use. The device is intended for professional use in a clinical laboratory setting.

Device Description

The Quo-Test Analyzer and A1c Test Kit (Quo-Test A1c System) are intended for the in-vitro quantitative determination of glycated hemoglobin in whole blood samples obtained from venous samples. The system contains a fluorimeter and two photometers to enable both fluorescent and photometric measurements to be made. The Quo-Test A1C Assay is calibrated by the manufacturer using European Reference Laboratory (ERL) calibrators. There are no user-serviceable parts in the analyzer. It has ports to support a printer and barcode scanner plus a USB port. It is powered by an AC/DC adapter plugged into a 100-240V AC outlet. The Quo-Test A1c Test Cartridge contains all the reagents, in a plastic cuvette, required to perform an HbA1c test on the Quo-Test Analyzer. The reagents consist of a lysing agent, buffer and a boronate fluorophore conjugate. A low level of sodium azide preservative is used to enhance the shelf life of the test cartridge. Each test cartridge is for single-use. The test cartridges are supplied in individual foil pouches and should be stored at 2 - 8°C.

AI/ML Overview

This document describes the premarket notification (510(k)) for the Quo-Test A1c System, a device intended for the in vitro quantitative determination of glycated hemoglobin (%HbA1c) levels in venous whole blood samples for monitoring long-term glycemic control in individuals previously diagnosed with diabetes mellitus.

Here's an analysis of the acceptance criteria and the study proving the device meets them:

1. A Table of Acceptance Criteria and the Reported Device Performance

The acceptance criteria are generally implied by the performance characteristics demonstrated to be comparable (substantially equivalent) to the predicate device and compliant with relevant CLSI guidelines. While explicit "acceptance criteria" are not presented in a single table with pass/fail marks, the results provided in the analytical performance sections serve as the evidence that the criteria were met.

Here's a table summarizing the implicit acceptance criteria (based on common industry standards and the predicate device's performance, and supported by the study methodologies) and the reported performance:

Performance Characteristic	Implicit Acceptance Criteria / Guideline	Reported Device Performance (Quo-Test A1c System)
Precision/Reproducibility	Imprecision ≤3 % CV (industry standard/predicate's expected performance); Evaluated per CLSI EP05-A3	Whole blood samples: Total Precision CV % ranged from 1.00% to 1.79%. Controls: Total Precision CV % ranged from 1.00% to 1.11%. Conclusion: Supports claim of ≤3 % CV.
Linearity	$r^2 \geq 0.99$; Slope in the range 0.98 - 1.02; Intercept $\leq \pm 0.4 %A1c$; Evaluated per CLSI EP6-A	Achieved for all three cartridge lots: $r^2$ 0.999-1.000; Slope 0.9872-1.001; Intercept 0.05292-0.1983. Conclusion: Supports linear range of 4-15%A1c.
Traceability	Traceable to international standards (NGSP, IFCC)	Certified by NGSP and IFCC; Calibrated using ERL samples via NGSP network, traceable to IFCC reference method.
Stability (Reconstituted Controls)	Control results within allowable deviation to target value; CVs within acceptable limits.	Stable for 16 days when stored at 2-8°C; Single CVs ranged from 0.50% - 3.37%.
Stability (Cartridges - Shelf Life)	Performance maintained over claimed shelf life (25 months desired, 12 months minimum implied from predicate/typical IVD).	Confirmed shelf life of 12 months at 2-8°C; "still operational for at least three months after the expiry date."
Analytical Specificity (Interference)	No significant interference observed from common endogenous and exogenous substances at specified concentrations.	No interference observed at tested concentrations for Bilirubin, Creatinine, Triglycerides, Uric Acid, Ascorbic Acid, Glucose, Cholesterol, RF IgA/IgG/IgM, Acetaminophen, Caffeine, Dopamine, Glybenclamide, Hydroxyzine dihydrochloride, Ibuprofen, Metformin, Acetylsalicylic Acid, Salicylic Acid, Tetracycline, Tolazamide, Tolbutamide.
Analytical Specificity (Hemoglobin Variants)	No interference from specified common hemoglobin variants.	Unaffected by HbAS, HbAC, HbAD, HbAJ, HbDD, β-thalassemia, elevated fetal hemoglobin, labile glycated hemoglobin, and carbamylated hemoglobin.
Method Comparison (Correlation with Reference)	Strong correlation (e.g., high R^2$, slope near 1, intercept near 0) with NGSP-certified reference laboratory results.	For all subjects (n=423, K2EDTA): Slope 0.964, Intercept 0.084, R^2 0.993. For diabetes subjects (n=308, K2EDTA): Slope 0.959, Intercept 0.130, R^2 0.991.
Matrix Equivalence	K2EDTA and Heparin venous blood samples should be interchangeable.	Strong agreement (y = 0.9960x + 0.0408, R^2 = 0.9937, n=149); Conclusion: Interchangeable.

2. Sample Size Used for the Test Set and the Data Provenance

Precision Study (20-day precision):
- Sample Size: Three venous blood samples (High, Medium, Low A1C) and two control solutions. Each was tested in duplicate at two separate occasions per day over twenty days.
- Data Provenance: Internal evaluation by the manufacturer. Not specified if retrospective or prospective, but the design suggests a prospective, controlled laboratory study. Country of origin not explicitly stated for samples but manufacturer is Germany.
Linearity Study:
- Sample Size: 11 patient samples (mixed in incremental amounts to generate a series of 11 samples over a broad HbA1c concentration range). All samples were analyzed fivefold.
- Data Provenance: Study carried out by Isala Ziekenhuis, Department of Clinical Chemistry, Zwolle, The Netherlands in August 2018. This was a prospective study using patient samples.
Stability Study (Reconstituted Controls):
- Sample Size: Three EKF A1c Control Kits, each with a Normal Control. 4 bottles of each level (Normal/Abnormal) from each lot were pooled after reconstitution.
- Data Provenance: Internal testing (manufacturer or OEM). Prospective.
Stability Study (Cartridges - Shelf Life):
- Sample Size: Three blood samples (covering the relevant clinical range 5-11% A1C) and the normal and abnormal kit controls. Each of five samples measured n=3 times on each of three Quo-Test analysers at five interval time points over a 15-month period.
- Data Provenance: Internal testing (manufacturer). Prospective, real-time study.
Analytical Specificity (Interference):
- Sample Size: Not explicitly stated for the number of blood samples or replicates, but the study design evaluated the effects of various interfering substances.
- Data Provenance: Not specified, but likely internal laboratory testing.
Analytical Specificity (Hemoglobin Variants):
- Sample Size: Venous whole blood samples collected in K2 EDTA tubes spread across the analytical measurement range (4.6-11.6 % HbA1c) for each variant.
- Data Provenance: Not specified, but likely internal laboratory testing.
Method Comparison Studies:
- Sample Size: Total of 424 subjects across three clinical sites. 423 K2EDTA venous samples and 149 heparin venous samples. 115 normal subjects (27.1%) and 308 diabetes subjects. 209 male and 215 female subjects, ranging from 21 to 89 years of age.
- Data Provenance: Prospective study conducted at three clinical sites. IRB approval was obtained. Samples were sent to an NGSP-certified reference laboratory (Diabetes Diagnostic Laboratory, Columbia. MO). Country of origin for clinical sites/subjects is not specified, but the reference lab is in the US (Missouri).

3. Number of Experts Used to Establish the Ground Truth for the Test Set and the Qualifications of Those Experts

The concept of "experts" as human readers/interpreters establishing ground truth, as typically seen in AI/imaging studies, does not directly apply here. This is an in vitro diagnostic (IVD) device measuring a biochemical analyte.

Ground Truth for Analytical Performance: Established by quantitative laboratory methods and reference standards.
- Precision/Linearity/Stability/Analytical Specificity: Ground truth is the quantitative value determined by the instrument/method under evaluation, compared against expected ranges or reference methods / defined mixtures. No human "experts" are adjudicating individual results in the sense of image interpretation.
- Traceability: The ground truth for calibration and methods is tied to IFCC reference methods and NGSP certification, which involve a network of reference laboratories and expert committees, not individual human readers.
Ground Truth for Method Comparison: Established by a NGSP-certified reference laboratory using the Tosoh 8 analyzer. The NGSP certification process ensures that laboratories meet stringent criteria for accuracy and precision in HbA1c measurement. This is the gold standard for HbA1c testing.

4. Adjudication Method for the Test Set

Not applicable in the conventional sense of image interpretation or clinical diagnosis by multiple readers. The "ground truth" for the quantitative HbA1c measurements (analyte levels) is established by the NGSP-certified reference method, which is a highly standardized and validated laboratory process, not a subjective human interpretation requiring adjudication.

5. If a Multi-Reader Multi-Case (MRMC) Comparative Effectiveness Study Was Done, and What Was the Effect Size of How Much Human Readers Improve with AI vs. Without AI Assistance

Not applicable. This is an in vitro diagnostic (IVD) device designed for direct quantitative measurement of HbA1c in blood, not an AI system assisting human readers in interpreting complex medical images or data. There are no "human readers" involved in interpreting the results of the Quo-Test A1c System in a manner that would necessitate an MRMC study.

6. If a Standalone (i.e., Algorithm Only Without Human-in-the-Loop Performance) Was Done

Yes, the studies presented are standalone performance evaluations of the Quo-Test A1c System itself. The device is designed to provide a quantitative HbA1c result directly from a blood sample. Its output is a numerical value (%HbA1c), which is then used by laboratory professionals or clinicians for patient management. There is no "human-in-the-loop" interaction for interpreting the device's output in the way an AI imaging algorithm might require a radiologist's review. The device performs its measurement and calculation independently.

7. The Type of Ground Truth Used

Analytical Performance (Precision, Linearity, Stability, Analytical Specificity): The ground truth is effectively the expected value or the reference method/instrument's value for the specific analyte concentration in control materials, spiked samples, or serially diluted/mixed patient samples. For traceabilty, the ground truth is established by the IFCC reference method and NGSP-certified standards.
Method Comparison: The ground truth for patient samples was established by an NGSP-certified reference laboratory using the Tosoh 8 analyzer, which serves as the gold standard/reference method for HbA1c measurement.

8. The Sample Size for the Training Set

Not applicable in the context of an AI/machine learning model where a "training set" is used to develop the algorithm. The Quo-Test A1c system is a biochemical assay, not an AI algorithm trained on data. Its "training" or calibration is based on manufacturer's procedures using reference calibrators traceable to international standards (NGSP/IFCC), as described in the "Calibration" section.

9. How the Ground Truth for the Training Set Was Established

As explained above, there's no "training set" in the AI sense. For the calibration of the device and its cartridges:

The Quo-Test A1C System is certified by the National Glycohemoglobin Standardization Program (NGSP) and International Federation of Clinical Chemistry and Laboratory Medicine (IFCC).
The Quo-Test Analyzer and A1C Test Cartridges have been calibrated using samples provided by the European Reference Laboratory (ERL) via the NGSP network.
Results obtained using the Quo-Test A1C System are traceable to the IFCC reference method.

This means the ground truth for the device's calibration (which would be analogous to "training" in an ML context) is established by highly standardized and internationally recognized reference methods and laboratories.

Summary

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February 16, 2019

EKF-diagnostic GmbH Karen Golomb Ebendorfer Chaussee 3 39179 Barleben Germany

Re: K180509

Trade/Device Name: Ouo-Test A1c System Regulation Number: 21 CFR 864.7470 Regulation Name: Glycosylated hemoglobin assay Regulatory Class: Class II Product Code: LCP, JJE Dated: November 2, 2018 Received: November 5, 2018

Dear Karen Golomb:

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. Although this letter refers to your product as a device, please be aware that some cleared products may instead be combination products. The 510(k) Premarket Notification Database located at https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm identifies combination product submissions. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part

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801 and Part 809); medical device reporting of medical device-related adverse events) (21 CFR 803) for devices or postmarketing safety reporting (21 CFR 4, Subpart B) for combination products (see https://www.fda.gov/CombinationProducts/GuidanceRegulatoryInformation/ucm597488.htm); good manufacturing practice requirements as set forth in the quality systems (OS) regulation (21 CFR Part 820) for devices or current good manufacturing practices (21 CFR 4, Subpart A) for combination products; and, if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21 CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to http://www.fda.gov/MedicalDevices/Safety/ReportaProblem/default.htm.

For comprehensive regulatory information about medical devices and radiation-emitting products, including information about labeling regulations, please see Device Advice

(https://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/) and CDRH Learn (http://www.fda.gov/Training/CDRHLearn). Additionally, you may contact the Division of Industry and Consumer Education (DICE) to ask a question about a specific regulatory topic. See the DICE website (http://www.fda.gov/DICE) for more information or contact DICE by email (DICE@fda.hhs.gov) or phone (1-800-638-2041 or 301-796-7100).

Sincerely,

Kellie B. Kelm -S

for Courtney H. Lias, Ph.D. Director Division of Chemistry and Toxicology Devices Office of In Vitro Diagnostics and Radiological Health Center for Devices and Radiological Health

Enclosure

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Indications for Use

510(k) Number (if known) K180509

Device Name Quo-Test A1c System

Indications for Use (Describe)

The Quo-Test A1c System is not intended for screening or diagnosis of diabetes or neonatal use. The device is intended for professional use in a clinical laboratory setting.

Type of Use (Select one or both, as applicable)

Prescription Use (Part 21 CFR 801 Subpart D)
Over-The-Counter Use (21 CFR 801 Subpart C)

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Quo-Test A1c System 510(k)

Section 5 - 510(k) Summary

510k Number

K180509

Introduction

In accordance with the requirements of 21 CFR 807.92, the following information provides sufficient detail to understand the basis for a determination of substantial equivalence.

I. Submitter

EKF-diagnostic GmbH Ebendorfer Chaussee 3 39179 Barleben Germany

Tel: +49 39203 511 0 Fax: +49 39203 511 171

Contact Person: Karen Golomb Phone: +1 (830) 249-072 Fax: +1 (830) 249-0851 Email: karengolomb@ekfdiagnostics.com

Secondary Contact: Jami Meeks Phone: +1 (407) 415-7196 Fax: +1 (830) 249-0851 Email: jamimeeks@ekfdiagnostics.com

Date prepared: February 13, 2019

II. Device Name

Proprietary Names:	Quo-Test A1c System
Common Names:	As above
Classification:	21 CFR 864.7470 – Glycosylated Hemoglobin Assay
	Class II
	Hematology
	Product Code: LCP
	21 CFR 862.2160 – Discrete photometric chemistry analyzer for clinical use
	Class I

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Chemistry

Product Code: JJE

III. Predicate Device

The Quo-Test A1c System is substantially equivalent to the currently marketed Alere Afinion HbA1c (Hb) Testing System, 510(k) number K151809.

IV. Device Description

V. Indications for Use

The Quo-Test A1c System is intended for the in vitro quantitative determination of glycated hemoglobin (%HbA1c) levels in venous whole blood samples (using K2EDTA and lithium heparin anticoagulants).

Measurement of percent glycated hemoglobin (%HbA1c) is effective for monitoring longterm glycemic control in individuals previously diagnosed with diabetes mellitus.

The Quo-Test A1c System is not intended for screening or diagnosis of diabetes or neonatal use. The device is intended for professional use in a clinical laboratory setting.

VI. Comparison with Predicate

1. Predicate device name(s): Alere Afinion HbA1c Testing System
1. Predicate 510(k) number(s): K151809.

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Similarities compared to the chosen (FDA cleared; marketed) predicate device(K151809)
Performance	Predicate DeviceAlere Afinion HbA1c Testing System	Candidate DeviceQuo-Test A1cSystem
Indications for use	Quantitative determination of glycatedhemoglobin (% hemoglobin A1c, %HbA1c) in human whole blood.	Same.
Analyte	Hemoglobin A1c	Same.
Sample preparation(pre-treatment)	None required	Same.
Automation	Fully automated.	Same.
Calibration procedure	Factory calibrated using whole bloodprovided by European ReferenceLaboratory, traceable to IFCC secondaryreference method.	Same.
Measurement range	4-15% glycated hemoglobin (% hemo-globin A1c, % HbA1c).	Same.
Cuvette storage	Refrigerated storage 2-8°C (36-46°F)until expiry date (12 months).Room temperature storage 15-25°C (59-77°F) 90 days.	Same.
Differences compared to the chosen (FDA cleared; marketed) predicate device (K151809)
Intended use	In vitro diagnostic use and point-of-caretesting.	In vitro diagnosticuse.
Method of detection(test methodology)	Boronate affinity reflectance.	Boronate affinityfluorescencequenching.
Sample volume	1.5 µL.	4 µL.
Sample type	Fingerprick capillary or venous wholeblood.	Venous wholeblood.
Cuvette reagentcomponents	Blue boronic acid conjugateMembrane tube- tube with apolyethersulfone membrane.Washing solution- morpholine bufferedsodium chlorideReconstitution reagent- HEPES bufferedsodium chloride with lysis andprecipitation agents.Sodium Azide is also present (< 0.1%).	Buffer (Water,AmmoniumChloride, SodiumDeoxycholateMonohydrate,Sodium Azide).
Cuvette components	Cartridge consists of the sampling deviceand the reagent container. The cartridgehas a barcode label with lot specific	Sampling device isseparate to thecartridge. Cartridgecontains reagent
	information and an ID area for the user torecord the sample ID.	latex-bound to metalbead. Barcode labelwith lot specificinformation present.
Quality control	2 level liquid control provided as separateitem.	2 level lyophilizedcontrol provided asseparate item.
Measuring time	3 minutes 20 seconds.	4 minutes.

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Performance Characteristics VII.

1. Analytical Performance

a. Precision/Reproducibility

20-day precision

Twenty-day precision testing was evaluated internally by the manufacturer according to CLSI EP05-A3, Evaluation of Precision Performance of Quantitative Measurement Methods; Approved Guideline-Second Edition. Three venous blood samples and two control solutions were tested in duplicate at two separate occasions per day over twenty days by one operator using three lots of cartridges across three different analyzers. Samples included three blood samples (High, Medium and Low A1C) which covered the clinically relevant range (5 – 12% DCCT) and the normal and abnormal controls.

Analyzerand Car-tridge lot	Wholebloodsample	Num-ber ofdays(N)	OverallMeanA1c, %		WithinRun	BetweenRun	BetweenDay	TotalPrecision
A	Low	20	5.26	SD	0.07	0.03	0.03	0.08
				CV, %	1.34	0.64	0.48	1.56
	Me-dium	20	8.20	SD	0.09	0.03	0.09	0.13
				CV, %	1.09	0.31	1.05	1.54
	High	20	10.39	SD	0.12	0.07	0.08	0.16
				CV, %	1.16	0.63	0.82	1.55
	NormalControl	20	6.95	SD	0.07	0.00	0.02	0.07
				CV, %	1.00	0.00	0.30	1.00
	Abnor-malControl	20	11.03	SD	0.10	0.04	0.05	0.12
				CV, %	0.95	0.34	0.46	1.11
B	Low	20	5.08	SD	0.07	0.05	0.03	0.09
				CV, %	1.39	0.96	0.59	1.79
	Medium	20	8.09	SD	0.10	0.03	0.07	0.13
				CV, %	1.22	0.34	0.90	1.55
	High	20	10.32	SD	0.09	0.07	0.08	0.14
				CV, %	0.87	0.68	0.81	1.37
	NormalControl	20	6.75	SD	0.06	0.00	0.04	0.07
				CV, %	0.94	0.00	0.55	1.06
		20	10.96	SD	0.10	0.05	0.02	0.12

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	AbnormalControl			CV, %	0.93	0.47	0.22	1.06
C	Low	20	5.00	SD	0.07	0.02	0.04	0.08
				CV, %	1.31	0.45	0.87	1.63
	Medium	20	8.01	SD	0.09	0.05	0.06	0.12
				CV, %	1.07	0.01	0.78	1.46
	High	20	10.19	SD	0.08	0.06	0.06	0.12
				CV, %	0.78	0.62	0.58	1.15
	NormalControl	20	6.59	SD	0.08	0.03	0.03	0.09
				CV, %	1.16	0.42	0.48	1.33
	AbnormalControl	20	10.77	SD	0.06	0.08	0.05	0.11
				CV, %	0.60	0.70	0.46	1.03

This data supports the claim that the Quo-Test A1c assay imprecision is ≤3 % CV.

b. Linearity

The purpose of this study was to demonstrate the linearity of the Quo-Test A1C assays across their reportable range: 4 – 15 % A1c. To establish a linear range, the specimens used in an initial experiment should cover a range 20 to 30 % wider than the anticipated analytical range. This allows specimens at the end points to be removed in a subsequent experiment if the initial experiment detects non-linearity.

This study followed the guidelines laid out in document CLSI EP6-A, Evaluation of the Linearity of Quantitative Measurement Procedures: A Statistical Approach; Approved Guideline (2003).

The study was carried out by Isala Ziekenhuis, Department of Clinical Chemistry, Zwolle, The Netherlands in August 2018.

Patient samples with a low HbA1c value of approximately 4.8% and a high HbA1c value of approximately 15.2% were mixed in incremental amounts to generate a series of samples over a broad HbA1c concentration range (n=11).

All testing was performed in accordance with the product package insert. Patient samples with a low A1c value and a high A1c value of approximately were mixed in the amounts given in table 1 to generate a series of samples over a broad A1c concentration range (n=11).

All samples were analysed fivefold.

		Achieved
Parameter	Acceptance	Lot 020482	Lot 0204842	Lot 020489
Correlation	$r^2 \geq 0.99$	0.999	0.999	1.000
Slope inthe range	0.98 - 1.02	0.9981	0.9872	1.001
Intercept	$\leq \pm 0.4 %A1c$	0.1427	0.1983	0.05292

Linear fit analysis for three cartridge lots.

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Acceptance criteria were achieved supporting a claim that the linear range for the Quo-Test assay is 4 - 15%A1C.

Traceability, Stability, Expected values (Controls, Calibrators) c.

Traceability

The Quo-Test A1C System is certified by the National Glycohemoglobin Standardization Program (NGSP) and International Federation of Clinical Chemistry and Laboratory Medicine (IFCC).

The Quo- Test Analyzer and A1C Test Cartridges have been calibrated using samples provided by the ERL via the NGSP network.

Results obtained using the Quo-Test A1C System are traceable to the IFCC reference method.

Stability

The stability of reconstituted quality controls when stored over a period of 16 days as recommended by the manufacturer at temperatures at 2 – 8°C was tested.

The quality control kit is manufactured for EKF-Diagnostics GmbH, Barleben by an OEM supplier (Canterbury Scientific Ltd, Christchurch, New Zealand).

Three EKF A1c Control Kits with each a Normal Control were used. The controls were reconstituted in accordance with the product instructions for use on Day 0 of the study as per the manufacturer's instruction, stored at 2-8°C for a 16-day period and tested on every second working day.

To ensure the total sample volume of 1000 µL from every Level of every lot 4 bottles of each control have been used which have been reconstituted at the same time and joined together to a sample pool.

All testing was performed in accordance with the product instructions for use and all cartridges and analysers suitably equilibrated to room temperature prior to use.

During the trial period the results obtained by the reconstituted quality controls were within the allowable deviation to the target value. The single CVs range from 0.50 % -3.37 %.

The Reconstituted Quality Controls are stable over a period of 16 days when stored as recommended at 2-8°C.

Expected values

A reasonable A1C goal for many nonpregnant adults is 7% (53 mmol/mol). Providers might reasonably suggest more stringent A1C goals (such as 6.5% [48 mmol/mol]) for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment (i.e., polypharmacy).

Appropriate patients might include those with short duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long life expectancy, or no significant cardiovascular disease. Less stringent A1C goals (such as 8% [64 mmol/mol]) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid

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conditions, or long-standing diabetes in whom the goal is difficult to achieve despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin.

American Diabetes Association. Standards of medical care in diabetes - 2018. Diabetes Care. 2018;41 (Suppl 1): S55–S64.

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d. Detection Limit

The claimed measuring range of 4.0-15.0% HbA1c for the Quo-Test A1c System is based on linearity. See section 1b above.

e. Analytical Specificity
The study was designed to assess the effects of some of the most common endogenous and exogenous interfering substances on the Quo-Test A1c assay. The design of the study followed the CLSI guideline Interference testing in Clinical Chemistry CLSI document CLSI EP07 - A2.

Substance	Highest Concentration tested where no interferencewas observed
Bilirubin, unconjugated	20 mg×dL-1
Bilirubin, conjugated	30 mg×dL-1
Creatinine	30 mg×mL-1
Triglycerides	1500 mg×dL-1
Uric Acid	20 mg×dL-1
Ascorbic Acid (Vitamin C)	3 mg×dL-1
Glucose	1000 mg×dL-1
Cholesterol	500 mg×dL-1
RF IgA	200 IU/mL
RF IgG	80 IU/mL
RF IgM	200 IU/mL
Acetaminophen	20 mg×dL-1
Caffeine	30 mg×dL-1
Dopamine	13 mg×dL-1
Glybenclamide	20 mg×dL-1
Hydroxyzine dihydrochloride	30 mg×dL-1
Ibuprofen	40 mg×dL-1
Metformin	5.1 mg×dL-1
Acetylsalicylic Acid	50 mg×dL-1
Salicylic Acid	50 mg×dL-1
Tetracycline	4 mg×dL-1
Tolazamide (Tolamide, Tolinase)	100 mg×dL-1
Tolbutamide (Oramide, Orinase)	100 mg×dL-1

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Hemoglobin variants

A hemoglobin variant study was performed using venous whole blood samples collected in K2 EDTA tubes spread across the analytical measurement range (4.6-11.6 % HbA1c). The Quo-Test A1C Test was found to be unaffected by the following hemoglobin variants:

HbAS (≤ 40 % S), HbAC (≤ 34 % C), HbAD (≤ 41 % D), HbAJ (≤ 51 % J), HbDD (≤ 95 % D), ß-thalassemia (≤ 5.7 % A2) and elevated fetal hemoglobin (≤ 11 % F).

The Quo-Test showed no interference from labile glycated hemoglobin and carbamylated hemoglobin (≤ 12.9%).

Assay Cut-off f.
Not applicable.
g. Stability
Real time studies were performed to verify that Quo-Test cartridges can be stored at 2 - 8 °C for 25 months. The study evaluated the performance of the Quo-Test cartridges when stored at the recommended storage conditions (2 - 8 °C) using real-time intervals up to a period of 25 months.

Performance of the test were monitored by testing three blood samples, which covered the relevant clinical range (5 – 11% A1C), and the normal and abnormal kit controls at various time points.

This protocol followed the CLSI guidelines EP25-A Evaluation of stability of in vitro diagnostic devices: approved guidelines.

All testing has been performed in accordance to the product IFU and all cartridges and analysers suitably equilibrated to room temperature prior to use. Each cartridge lot was measured on all three devices. Each of the five samples have been measured n=3 times on each of the three Quo-Test analysers at five interval time points over a 15-month period. Fresh whole blood and fresh reconstituted Controls were used at each time of the measurement.

The study confirmed a shelf life of twelve months for the Quo-Test cartridges when stored at the recommended temperature of 2-8°. In addition, it could be shown that the kits are still operational for at least three months after the expiry date.

h. Calibration
The Quo-Test A1C System is certified by the National Glycohemoglobin Standardization Program (NGSP) and International Federation of Clinical Chemistry and Laboratory Medicine (IFCC).

The Quo- Test Analyzer and A1C Test cartridges have been calibrated using samples provided by the European Reference Laboratory (ERL) via the NGSP network.

Results obtained using the Quo-Test A1C System are traceable to the IFCC reference method.

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i. Quality Control

The Quo-Test A1C Control Kit is a two-level, lyophilized control consisting of human blood, preservatives and stabilizers. The controls are formulated to enhance shelf life. Two levels are provided, one in the region of a normal patient response (4 - 7% A1C) and one in the region of an abnormally high patient sample (~10% A1C). A dropper bottle containing distilled water to reconstitute the controls is also provided. The two Control solutions require target values and an acceptable range. The method used for value assignment was to run each lot of controls with at least 3 different lots of Quo-Test A1C Test cartridges. During manufacture, the cartridge lots are calibrated to give NGSP/IFCC aligned results using standards supplied by the European reference Laboratory. The target values assigned to the Controls are therefore traceable to the NGSP/IFCC. The acceptable range for results produced with these controls was defined as being 3 standard deviations away from the mean.

Component	Composition	Amount
Level 1 Control	Lyophilised, screened (HIV-1, HIV-2,Hepatitis B surface antigen, Hepatitis CAntibody & Syphilis) human blood withHbA1c within normal non-diabetic range.Contains < 0.005% Potassium Cyanide(KCN) as a preservative.	2 x 0.25 ml(when reconstituted)
Level 2 Control	Lyophilised, screened (HIV-1, HIV-2,Hepatitis B surface antigen, Hepatitis CAntibody & Syphilis) human blood withHbA1c within diabetic range for abnormalContains < 0.005% Potassium Cyanide(KCN) as a preservative.	2 x 0.25 ml(when reconstituted)
Water to reconstitute A1Clyophilised controls	Water	1 x1 ml

Although the Controls are manufactured from Human blood, the level of A1C present in the Controls (particularly the abnormal control) has been artificially altered. Tests have been carried out to assess the level of matrix effects potentially increased by this manipulation and found to have limited to no effect when using the Quo-Test A1C System.

Human sourced materials are used in the manufacture of this product. Each donor unit was (and will be in the future) tested for hepatitis B surface antigen (HbsAg), antibodies to hepatitis C (HCV) and antibodies to Human Immunodeficiency virus (HIV-1 and HIV-2), HIV-1 antigen and Syphilis and were all found to be negative. Because no test method can offer complete assurance that HIV, Hepatitis B or C viruses, or other infectious agents are absent, these products should be handled as potentially infectious i.e. with the same precautions used with patient specimens.

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The Control kit is manufactured on behalf of EKF Diagnostics by an OEM supplier (Canterbury Scientific Ltd, Christchurch, New Zealand).

On July 11, 2017, the Federal Register published a list of class II devices that are exempt from premarket notification. The Quo-Test A1c Control Kit is in the list of exempted class II devices.

2. Method Comparison Studies

Method Comparison

Method comparison studies were performed according to Protocol EKF-A1C-MC-01 to support the substantial equivalence of the Quo-Test A1C System with other legally marketed HbA1c test devices. Venous specimens from a total of 424 subjects across three clinical sites were tested with the Quo-Test system. To ensure that HbA1c values in the low end of the measuring range were included, 115 normal subjects (27.1%) were included.

The K2EDTA venous whole blood specimens were forwarded to an NGSP-certified reference laboratory (Diabetes Diagnostic Laboratory, Columbia. MO) and tested with the Tosoh 8 analyzer to provide reference method values. Matrix equivalence with lithium heparin anti-coagulated whole blood was performed on 150 subjects at a single site. IRB approval was obtained prior to initiating the studies.

A total of 209 male and 215 female subjects, ranging from 21 to 89 years of age, provided 423 EDTA venous samples and 149 heparin venous samples. HbA1c values ranged from 4.5% to 14.6% when tested in the NGSP-certified reference laboratory. Summary results for all subjects tested are provided in Table 1a below. Since the intended use population does not include "normal" subjects, the data were also calculated for only subjects with diabetes (Table 1b).

Site #	Blood Type	n	Slope	95% CI	Intercept	95% CI	R2
1	K2EDTA Venous	149*	0.962	0.950 ~ 0.975	0.070	-0.031 ~ 0.170	0.993
	Heparin Venous	149*	0.961	0.947 ~ 0.975	0.092	-0.017 ~ 0.200	0.992
2	K2EDTA Venous	118	0.969	0.949 ~ 0.989	0.044	-0.096 ~ 0.184	0.988
3	K2EDTA Venous	156	0.960	0.947 ~ 0.972	0.143	0.033 ~ 0.253	0.993
TOTAL	K2EDTA Venous	423	0.964	0.956 ~ 0.972	0.084	0.010 ~ 0.147	0.993

Overall Results Summary, All Subjects

One missing sample was above the AMR (> 15% HbA1c) in the Quo-Test A1C System

Site #	Blood Type	n	Slope	95% CI	Intercept	95% CI	R2
1	K2EDTA Venous	102*	0.961	0.943 ~ 0.979	0.085	-0.074 ~ 0.244	0.991
	Heparin Venous	102*	0.969	0.950 ~ 0.988	0.020	-0.146 ~ 0.186	0.990
2	K2EDTA Venous	70	0.964	0.938 ~ 0.991	0.089	-0.124 ~ 0.303	0.987
3	K2EDTA Venous	136	0.956	0.942 ~ 0.971	0.180	0.050 ~ 0.310	0.992
TOTAL	K2EDTA Venous	308	0.959	0.949 ~ 0.969	0.130	0.042 ~ 0.219	0.991

Overall Results Summary, Diabetes Subjects

One missing sample was above the AMR (> 15% HbA1c) in the Quo-Test A1C System

Matrix Comparison

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1.1 K₂EDTA versus Lithium Heparin Venous Blood

A comparison between K2EDTA and lithium heparin venous blood, both tested with the Quo-Test A1C System, was performed at Site 1 (Figure 7a).

Image /page/14/Figure/2 description: The image is a scatter plot comparing K2EDTA versus Lithium Heparin Venous Blood. The x-axis represents Quo-Test K2EDTA, %HbA1c, and the y-axis represents Quo-Test Heparin, %HbA1c. The data points are clustered tightly around a linear regression line, which is described by the equation y = 0.9960x + 0.0408, with an R-squared value of 0.9937 and a sample size of n = 149.

K₂EDTA versus Heparin linear regression, y = 0.9960x + 0.0408, R² = 0.9937, n = 149.

Conclusions, Matrix Comparison 1.2

In conclusion, 149 paired K2EDTA and heparin samples agreed closely, and lithium heparin or K2EDTA can be used interchangeably in the Quo-Test A1C System.

Matrix Comparison

Comparison	Slope	Intercept	R²
Quo-Test Venous K₂EDTA vs Heparin	0.9960	0.0408	0.9937

VIII. Conclusion

The submitted information in this premarket notification is complete and supports a substantial equivalence decision.

Regulation Number and Section

§ 864.7470 Glycosylated hemoglobin assay.

(a)
Identification. A glycosylated hemoglobin assay is a device used to measure the glycosylated hemoglobins (A1a , A1b , and A1c ) in a patient's blood by a column chromatographic procedure. Measurement of glycosylated hemoglobin is used to assess the level of control of a patient's diabetes and to determine the proper insulin dosage for a patient. Elevated levels of glycosylated hemoglobin indicate uncontrolled diabetes in a patient.(b)
Classification. Class II (performance standards).