Use of Electronic Clinical Decision Support and Hard Stops to Decrease Unnecessary Thyroid Function Testing

Dalal, Sonia; Bhesania, Siddharth; Silber, Steven H.; Mehta, Parag

doi:10.1136/bmjquality.u223041.w8346

Cited by 15 publications

(7 citation statements)

References 15 publications

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“…One strategy to limit unnecessary thyroid assays in hospitalized patients with no prior thyroid dysfunction would be to implement reflex testing (automatically generated FT 4 for abnormal TSH results) on a widened TSH reference interval (0.05-10 mIU/L). [19][20][21][22] Although this strategy would curtail unneeded FT 4 tests, it may not limit inessential TSH tests. Additionally, if used indiscriminately, any reflex test risks missing cases, such as central hypothyroidism.…”

Section: Discussionmentioning

confidence: 99%

<p>Low Yield of Thyroid-Function Tests in Adult Hospitalized Patients — A Retrospective Analysis</p>

Dogra¹,

Paudel²,

Panthi³

et al. 2020

IJGM

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Background: In the US, serum thyroid-stimulating hormone (TSH) and thyroxine measurements are the fourth-and tenth-commonest laboratory tests ordered, respectively. Diagnosis of thyroid disorder requires clinical suspicion supported by laboratory values. However, in the setting of acute illness, both the clinical and laboratory pictures can be confounded. Objective: To study clinical outcomes and derangement patterns of inpatient thyroidfunction tests. Design: This retrospective study was conducted at an academic center on admissions aged ≥18 years and TSH tests performed over a 1-year period. Admissions with active pregnancy and/or prior thyroid-related diagnosis were excluded. Main Outcomes: Clinical outcomes were divided based on new diagnosis of thyroid-related disorder, newly prescribed thyroxine replacement, or antithyroid drugs/ endocrinology referrals, or both. In order to analyze the derangement patterns of abnormal TSH, only the results of the first test ordered were considered (as some admissions had multiple TSH tests ordered). Results: A total of 7,204 admissions aged ≥18 years had TSH tests done. Of these, 1,912 were excluded. Of the 5,292 admissions with no prior thyroid disorder or active pregnancy, 183 (3.46%) were assigned a new diagnosis of thyroid-related disorder, 54 (1.02%) received treatment/referral, and 46 (0.87%) received both a new diagnosis and treatment/referral. Based on the TSH results (reference range 0.42-4.0 mIU/L) of the 5,292 admissions, 4,312 (81.5%) and 980 (18.5%) admissions were flagged normal and abnormal, respectively. Of the 980 admissions with one or more abnormal TSH results, 21 (2.14%) had first ordered TSH <0.05 mIU/L, 855 (87.25%) admissions had first TSH result between 0.05-10 mIU/L, and lastly 104 (10.61%) were >10 mIU/L. Conclusion: There is low value in testing inpatients for thyroid disorders, and testing comes at significant expense to the health-care system.

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Section: Discussionmentioning

confidence: 99%

<p>Low Yield of Thyroid-Function Tests in Adult Hospitalized Patients — A Retrospective Analysis</p>

Dogra¹,

Paudel²,

Panthi³

et al. 2020

IJGM

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“…These tools may be even more valuable, but more difficult to implement, when established guidelines are unclear. When integrated electronically, structured note templates or ordering alerts within the electronic medical record system may facilitate practice patterns, as was shown in one study regarding the ordering of unnecessary serum T3 and T4 concentrations [33]. Although excessive ordering notifications can cause “alert fatigue,” if used properly, it can have significant impact in increasing the value of healthcare.…”

Section: Discussionmentioning

confidence: 99%

Endocrinology practice patterns of hypothyroidism and osteoporosis management in a U.S. tertiary academic medical center

Shim

Lin

Dashiell-Earp

et al. 2019

Clin Diabetes Endocrinol

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Background The major published clinical guidelines for the management of hypothyroidism and osteoporosis are not uniformly consistent and may be a significant contributor to variability of clinical care delivered by endocrinologists, in addition to other factors, such as physician experience, physician and patient perceptions, and patient comorbidities. The purpose of this study was to assess practice patterns of hypothyroidism and osteoporosis within an academic endocrine clinic. Methods A retrospective medical record review of the first 200 adult patients ( n = 100 with primary hypothyroidism and n = 100 with osteoporosis or osteopenia) seen by an endocrinologist beginning January 2, 2017at a large U.S. urban tertiary academic medical center was performed. Data were collected regarding patient demographics, clinic visit type, patterns of ordering laboratory tests and imaging, and choice of pharmacologic treatment. Results Most patients with hypothyroidism (99%) had a serum thyroid stimulating hormone concentration measured. Other thyroid indices measured included serum total thyroxine (10%), serum free thyroxine [T4] (82%), serum free T4 index (6%), serum total triiodothyronine [T3] (9%), and serum free T3 (12%). Forty-eight percent also had serum thyroid antibodies checked. A variety of thyroid hormone supplements were used to treat hypothyroidism, including levothyroxine (83%), levothyroxine and liothyronine combination (8%), and desiccated thyroid extract (6%). In regards to patients with osteoporosis, mean duration of all pharmacologic therapy combined was 73.4 ± 81.9 months. For those with more than one bone density (DXA) scans (64%), the mean time interval between two consecutive DXA scans was variable (mean 32.0 ± 24.7 [SD] months). Sixty eight percent of the patients had bone turnover markers assessed within 7 months of the visit. Conclusions This study reports a real-world experience of endocrinology practice patterns at a large U.S. academic healthcare system. For the common diagnoses of hypothyroidism and osteoporosis, there are opportunities for increased standardization of care, particularly regarding the ordering of laboratory testing and radiologic studies. Identifying areas with significant practice variability may improve the quality and health outcomes and reduce the cost of care for patients with these conditions. Increased understanding regarding the reasons behind ordering various studies may help physician and patients further align their goals.

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“…8 In many hospitals, TSH is included in emergency department laboratory panels and hospital admission order sets (sometimes as a preselected default), which can significantly influence prescriber ordering. 4,6,7,9 Hardwick et al conducted structured interviews with primary care providers to explore the factors contributing to high thyroid testing variability. Among the potential contributing factors identified were fear of a missed diagnosis, as well as the complexity and poor integration of electronic health records, which makes repeat testing easier than requesting outside records.…”

Section: Why You Might Think Ordering Tsh Routinely Is Helpfulmentioning

confidence: 99%

“…Although most thyroid disease is mild and managed in the outpatient setting, inpatient thyroid testing is common, with evidence suggesting that 21%-100% of internal medicine admissions receive thyroid testing. [4][5][6][7]…”

Section: Introductionmentioning

confidence: 99%

“…Severe manifestations of thyroid disease are rare, with an annual incidence of 0.2 per 100,000 2 for thyroid storm and 1.08 per 1,000,000 3 for myxedema coma in adults. Although most thyroid disease is mild and managed in the outpatient setting, inpatient thyroid testing is common, with evidence suggesting that 21%‐100% of internal medicine admissions receive thyroid testing 4‐7 …”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Things We Do for No Reason™: Routine Thyroid-Stimulating Hormone Testing in the Hospital

Wootton

Bates

2020

J Hosp Med

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Inspired by the ABIM Foundation's Choosing Wisely® campaign, the “Things We Do for No Reason™” (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

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Use of Electronic Clinical Decision Support and Hard Stops to Decrease Unnecessary Thyroid Function Testing

Cited by 15 publications

References 15 publications

<p>Low Yield of Thyroid-Function Tests in Adult Hospitalized Patients — A Retrospective Analysis</p>

<p>Low Yield of Thyroid-Function Tests in Adult Hospitalized Patients — A Retrospective Analysis</p>

Endocrinology practice patterns of hypothyroidism and osteoporosis management in a U.S. tertiary academic medical center

Things We Do for No Reason™: Routine Thyroid-Stimulating Hormone Testing in the Hospital

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