Analysis of current thyroid function test ordering practices

Reducing unnecessary free thyroid hormone testing by the reinforcement of a reflexive algorithm in an outpatient environment

BACKGROUND

Thyroid dysfunction is one of the most common endocrine disorders. Thyroid function tests, including TSH, Free T4, and Free T3, are essential for diagnosis and patient management. Current guidelines recommend TSH as the first-line test, with additional testing for Free T4 and Free T3 only when TSH is abnormal or in specific clinical scenarios. Despite guideline recommendations, inappropriate ordering of free hormone tests is prevalent, leading to increased healthcare costs, diagnostic inefficiencies, and potential patient burden. In this study, we aimed to assess thyroid function testing utilization in the Saskatoon Health Region and identify opportunities to enhance test appropriateness.

METHODS

A retrospective analysis of thyroid function test utilization was conducted in the Saskatoon Health Region to identify gaps in guideline adherence. Inappropriate Free T4 and Free T3 testing was defined as tests ordered with TSH results in the laboratory reference range. Interventions were developed, including reinforcing the reflexive testing algorithm in outpatient settings and restricting free hormone testing to pre-approved specialists. Metrics for evaluation included testing volume trends, physician satisfaction, and cost savings.

RESULTS

Pre-intervention analysis revealed significant increases in thyroid function testing volumes from 2016 to 2019: TSH orders increased by 34.5 %, Free T4 by 36.4 %, and Free T3 by 18.8 %. A substantial proportion of tests involved normal TSH ordered in combination with Free T4 and/or Free T3, which is unnecessary. Compared to baseline volumes, post-intervention Free T4 and Free T3 testing volumes decreased by approximately 60 % and 40 %, respectively.

CONCLUSION

Implementing and reinforcing a reflexive thyroid testing algorithm substantially reduced inappropriate Free T4 and Free T3 testing. Utilization management improved diagnostic efficiency, reduced unnecessary healthcare costs, and minimized patient harm.

Revisiting the Environmental Impact of Inappropriate Clinical Laboratory Testing: A Comprehensive Overview of Sustainability, Economic, and Quality of Care Outcomes

BACKGROUND

The use of laboratory resources has seen a substantial increase in recent years, driven by automation and emerging technologies. However, inappropriate use of laboratory testing, encompassing both overuse and underuse, poses significant challenges.

CONTENT

This review explores the complex interplay between patient safety, economic, and environmental factors-known as the "triple bottom line" or "3Ps" for people, profit, and planet-associated with inappropriate use of laboratory resources. The first part of the review outlines the impact of inappropriate laboratory testing on patient safety and economic outcomes. Then the review examines the available literature on the environmental impact of laboratory activities. Several practical solutions for mitigating the environmental impact of laboratories are discussed. Finally, this review emphasizes how decreasing unnecessary laboratory testing results in cost savings and environmental benefits, as evidenced by interventional studies, without compromising patient safety.

SUMMARY

The implementation of sustainable practices in laboratories can create a virtuous circle in which reduced testing enhances cost-efficiency, reduces the environmental footprint, and ensures patient safety, thereby benefiting the 3Ps. This review highlights the critical need for appropriate laboratory resource utilization in achieving sustainability in healthcare.

Polyethylene glycol thyroid-stimulating hormone (PEG-TSH) testing in the management of pediatric thyroid dysfunction

PURPOSE

The polyethylene glycol (PEG) methodology is used for investigating incongruities in laboratory assays, such as thyroid-stimulating hormone (TSH) measurements. The aim of the study is to investigate the practical application of PEG-TSH testing in cases of discrepancies between elevated TSH and normal free thyroxine (FT4) levels.

METHODS

A real-life observational study conducted in a tertiary medical center. The hospital's electronic database was queried for TSH tests performed in pediatric patients between 2015 and 2023. Of those, PEG-TSH were identified. Patients' clinical and biochemical characteristics and PEG-TSH-guided management were assessed.

RESULTS

In total, 2949 TSH tests were performed in 891 children and adolescents for various indications. Among them were 61 (2.1%) PEG-TSH results, mean age 7.1 ± 5.3 years, of 38 patients (4.3%), comprised of 16 with congenital hypothyroidism, 16 with subclinical hypothyroidism, and 6 with Hashimoto thyroiditis. Both the TSH and the PEG-TSH levels of patients with congenital hypothyroidism were higher than those of the other two groups (P = 0.021 and P = 0.009, respectively), with no group differences in FT4 levels. Spearman's correlation analysis revealed a strong association between TSH and PEG-TSH levels: r = 0.871, P < 0.001. In nearly one-half of the cases, clinical decisions made by clinicians (decreasing the dose or not initiating L-thyroxine treatment) were affected by the PEG-TSH results.

CONCLUSION

Our findings support PEG-TSH testing for determining appropriate TSH levels and avoid unnecessary thyroid hormone treatment among children and adolescents. We propose the suitability of managing their clinical condition based upon age-appropriate clinical parameters and FT4 levels when their PEG-TSH levels are within the normal range.

Trends and Components of Thyroid Status Evaluation in Commercially Insured Adults in the United States, 2006-2020

CONTEXT

Thyroid-stimulating hormone (TSH) is one of the most ordered laboratory tests.

OBJECTIVE

Determine trends of TSH testing rates and components of thyroid function testing.

METHODS

This was a retrospective analysis of adults 18-64 years old without evidence of thyroid disease with at least 365 days of continuous enrollment between 2006 and 2020 in the IBM MarketScan Claims Database. The main outcome measures were trends of TSH tests/1000 eligible patient-months stratified by age, sex, and region and composition of thyroid function testing.

RESULTS

Among 67 353 280 patients meeting eligibility criteria, we identified 25 606 518 TSH tests and 15 138 211 patients with ≥1 TSH test. Patients contributing an episode of TSH testing were most commonly 45-54 years old (29.8%) and female (63.6%). TSH testing rates remained consistent throughout the study period with 11.4 and 11.7 TSH tests/1000 person-months in the first and last study months, respectively (mean 12.2 TSH tests/1000 person-months). TSH testing rates dropped sharply in the spring of 2020 (4.2 TSH tests/1000 person-months). Females showed a nearly 2-fold higher rate of TSH testing than males (16.1 TSH tests/1000 person-months vs 8.6 TSH tests/1000 person-months). TSH testing rates increased with age (8.2 TSH tests/1000 person-months among individuals 18-34 years old vs 15.4 TSH tests/1000 person-months among individuals 55-64 years old). No difference in TSH testing rates was noted between regions. Thyroid function testing episodes included only TSH in most cases (70.8%).

CONCLUSION

TSH testing rates among commercially insured individuals without known thyroid disease appears stable over time, with higher frequency in females and with increasing age.

Reducing Inappropriate Simultaneous Ordering of Heparin Antibody and Serotonin Release Assays

INTRODUCTION

A 4T score with intermediate or high probability of heparin-induced thrombocytopenia prompts ordering of anti-platelet 4 heparin complex. If positive, a serotonin release assay (SRA) is recommended to confirm diagnosis. Despite these recommendations, overtesting of both anti-platelet 4 and SRA is highly prevalent.

METHODS

This was a quality improvement initiative using two forms of clinical decision support across 11 acute care hospitals. First, a 4T calculator was incorporated into anti-platelet 4 orders. Second, a Best Practice Advisory fired when anti-platelet 4 and SRA were ordered simultaneously, prompting the provider to remove the SRA order. Data were analyzed by a quasi-experimental interrupted time series linear regression comparing weekly average laboratory tests per 1,000 patient-days pre- and postintervention.

RESULTS

Average ordering frequency of anti-platelet 4 changed from 0.508 to 0.510 per 1,000 patient-days (0.5%, p = 0.42) without significant slope or level differences. Average ordering frequency of SRA decreased from 0.430 to 0.289 per 1,000 patient-days (32.8%, p < 0.001) with a significant level difference of -0.128 orders per 1,000 patient-days (-31.2%, p < 0.05).

CONCLUSION

A simultaneous Best Practice Advisory was effective in reducing SRA orders, but not anti-platelet 4 orders.

A Multicenter Retrospective Evaluation of Specialized Laboratory Investigations in the Workup of Pediatric Patients With New-Onset Supraventricular Tachycardia

INTRODUCTION

Specialized laboratory evaluation of supraventricular tachycardia in children may occur, but the utility is unknown. The study objectives are to assess the type, frequency, and results of specialized laboratory testing performed in pediatric patients presenting with new-onset supraventricular tachycardia. We hypothesized that when specialized laboratory testing occurs (particularly for cardiac failure, toxicologic, inflammatory, and thyroid diseases), the results are generally within normal limits.

METHODS

This is a retrospective descriptive study using an electronic health record database (TriNetX, Inc). We collected and evaluated the following data of subjects aged younger than 18 years with a first-time supraventricular tachycardia diagnosis: demographics, diagnostic codes, deaths, and laboratory codes/results (natriuretic peptide B, natriuretic peptide B prohormone N-terminal, troponin I, toxicology testing, inflammatory markers, and thyroid studies).

RESULTS

A total of 621 subjects (524 [84.4%] without laboratory testing, 97 [15.6%] with laboratory testing) were included. Thyroid studies (65 [10.5%]) were the most frequent laboratory study performed followed by cardiovascular specific studies (35 [5.6%]), inflammatory markers (21 [3.4%]), and toxicology tests (10 [1.6%]) (P = .002). Obtained laboratory testing was more frequent with older subjects, females, and need for emergency, hospital, and critical care services.

DISCUSSION

Cardiac-specific and noncardiac laboratory testing is frequently ordered for pediatric patients who present with supraventricular tachycardia. Thyroid studies were the most common laboratory testing ordered, but abnormal results only occurred in less than a quarter of subjects. These findings may highlight a quality improvement opportunity for emergency nurses and practitioners in the practice of obtaining laboratory tests to better reflect high-value evidence-based care for this vulnerable population.

Investigating Investigation (Ab)Use: Thyroid Function Test Audit in a Tertiary Care Teaching Institute in Eastern India

An essential component of contemporary health care is laboratory testing. As the utilization of diagnostic tests grow, there is also an increase in the scrutiny of such tests for its effectiveness, balance of cost and over- utilization. Thyroid dysfunction is common across all age groups and is associated with a number of comorbid states. The thyroid function tests (TFTs) are very important for the diagnosis and monitoring of such patients. The guidelines recommend serum thyroid stimulating hormone (TSH) as the single most reliable test to diagnose all common forms of hypothyroidism and hyperthyroidism, except in few cases. This study was conducted to study the investigation requesting pattern of TFTs. Our results showed that TFT panel was ordered in almost equal numbers (35.58%) as single test of TSH (41.27%). Subclinical thyroid disease was diagnosed in 22.1% of cases and the rest were excluded as having any thyroid dysfunction. Over 2/3rd of all requests were for women. An important conclusion from our study was that, the essentiality of lab tests is a decision entirely in the hands of the treating physician keeping in mind the cost and best outcome for patients. Hospitals can develop strategic protocols for ordering laboratory tests keeping resources, need and patient satisfaction and outcomes optimal.

Artificial intelligence and thyroid disease management: considerations for thyroid function tests

Artificial intelligence (AI) is transforming healthcare and offers new tools in clinical research, personalized medicine, and medical diagnostics. Thyroid function tests represent an important asset for physicians in the diagnosis and monitoring of pathologies. Artificial intelligence tools can clearly assist physicians and specialists in laboratory medicine to optimize test prescription, tests interpretation, decision making, process optimization, and assay design. Our article is reviewing several of these aspects. As thyroid AI models rely on large data sets, which often requires distributed learning from multi-center contributions, this article also briefly discusses this issue.

Endocrinal dysfunction in children with Down syndrome

Down syndrome (DS) is the most common genetic disorder in live-born infants. Children with DS are at increased risk of numerous endocrinal comorbidities. The information contained in this article will provide pediatricians with a narrative overview of different presentations, diagnoses, and management recommendations of various endocrinal disorders in children with DS. We systematically searched PubMed, Embase, Google Scholar, MEDLINE, EBSCO, and Science Direct, and potentially relevant articles were identified and retrieved from electronic and print journals.

Exploratory analysis of the associations between urinary phytoestrogens and thyroid hormones among adolescents and adults in the United States: National Health and Nutrition Examination Survey 2007-2010

Phytoestrogens are naturally plant-derived compounds that could bind to estrogen receptors and mimic estrogenic effects. Previous studies showed a positive association between phytoestrogens and hypothyroidism; however, little is known on phytoestrogens and thyroid hormones. This study was designed to investigate the associations between urinary phytoestrogens and thyroid hormone levels. Based on the US National Health and Nutrition Examination Survey (NHANES) 2007-2010, 4103 participants were recruited in this cross-sectional study. Linear regression models and multiple linear regressions models were applied to examine the relationships between urinary phytoestrogens and thyroid hormone levels. Urinary O-desmethylangolensin (O-DMA) was found to be correlated with serum FT₄ levels in the female 20-60-year-of-age group (β=0.018, 95% CI: 0.006, 0.031). Higher enterolactone (ENT) levels were significantly positively associated with TSH levels in the 12-19-year-of-age female group (β=0.196, 95% CI: 0.081, 0.311). In the male group, enterodiol (END) was significantly positively correlated with TSH and TT₃ in the 12-19-year-of-age group, respectively (TT₃: β=3.444, 95% CI: 0.150, 6.737; TSH: β=0.104, 95% CI: 0.005, 0.203). However, equol (EQU) levels were negatively associated with TT₄ (12-19-year-of-age: β=- 0.166, 95% CI: - 0.279, - 0.034; 20-60-year-of-age: β=- 0.132, 95% CI: - 0.230, - 0.034). Our study provided epidemiological evidence that urinary phytoestrogens were powerfully associated with thyroid hormone levels. The results also supported that phytoestrogens acted as endocrine disruptors. It is imperative and important to pay attention to the intake of phytoestrogens.

Routine T4 No More? Reducing Excess Thyroid Hormone Testing at a Pediatric Tertiary Care Hospital

OBJECTIVES

To promote resource stewardship in thyroid hormone testing at a pediatric tertiary care hospital.

STUDY DESIGN

Quality improvement approaches generated 3 change ideas that were implemented simultaneously in the hospital electronic medical record: (1) a reflex free thyroxine (fT4), whereby fT4 is automatically reported if the thyroid-stimulating hormone is outside the normal range; (2) a forced-function for thyroid hormone ordering, whereby a provider must select an appropriate indication for ordering fT4 or triiodothyronine (T3); and (3) a clinical decision support message displayed at the time of ordering thyroid function tests. Laboratory data were audited to determine the mean number of fT4 and T3 tests performed per week as well as indications for testing.

RESULTS

The mean number of fT4 and T3 tests processed per week decreased from 154 ± 21 and 11 ± 7, respectively, in the preintervention period, to 107 ± 12 (30% reduction) and 4 ± 3 (66% reduction) postintervention. These reductions were sustained for the full 20-week assessment period. Process and balancing measures revealed no unintended adverse consequences. Approximate cost savings were $43 000 per year.

CONCLUSIONS

We describe the successful implementation of electronic medical record-based interventions (reflex fT4, forced-function selection of indication, decision support text) leading to sustained improvements in healthcare use, with significant associated cost-savings.

The effect of galvanization and potassium iodide iontophoresis of the throat and larynx on thyroid parameters: a randomized controlled trial

Few studies have assessed the application and side effects of potassium iodide (KI) iontophoresis. Using a double-blinded randomized controlled trial with a 1:1 parallel-group, we investigated the effect of galvanization and the KI iontophoresis in the throat and larynx on three thyroid parameters. A total of 50 healthy volunteers with normal TSH, FT₃, and FT₄ levels and lacking focal changes in the thyroid ultrasonography were subjected to 10 electrotherapy treatments. The TSH, FT₃, and FT₄ levels were determined prior to the 10 electrotherapeutic treatments (T1), 2-weeks after treatment (T2) and 6-months after treatment (T3). At T2 and T3, both groups had normal levels of TSH, FT₃, and FT₄. Regarding the change of TSH, FT₃, and FT₄ levels between T1 vs. T2 and T1 vs. T3, no significant differences between the galvanization and iontophoresis groups were found. However, both groups had lower levels of all three hormones at T3. Together, these data indicate that KI iontophoresis does not affect thyroid hormone levels in the short- nor long-term. Additional follow-up studies with larger groups are required to better confirm the safety of galvanization and iontophoresis procedures in the pharynx and larynx.

Trial registration ClinicalTrials.gov (NCT04013308; URL: www.clinicaltrials.gov). Day of first registration 09/07/2019.

Estimated change in prevalence of abnormal thyroid-stimulating hormone levels in China according to the application of the kit-recommended or NACB standard reference interval

BACKGROUND

Both the kit-recommended and United States National Academy of Clinical Biochemistry (NACB) standard thyroid-stimulating hormone (TSH) reference intervals (RIs) are used to determine thyroid dysfunction in clinical practice and epidemiological surveys in China. However, a number of kit-recommended RIs were derived from the European or United States reference population.

METHODS

A nationally representative cross-sectional study with 78,470 enrolled participants aged 18 years or older from China was performed. Serum concentrations of thyroid hormones, TSH, thyroid antibodies (by Roche Diagnostics), and urine iodine concentration (UIC) were measured.

FINDINGS

The abnormal TSH weighted prevalence was 15.33% (95% CI, 14.24% to 16.49%) according to the kit-recommended RI and 6.89% (6.46% to 7.34%) according to the NACB standard RI. The NACB standard prevalence of abnormal TSH was associated with an absolute change in abnormal TSH prevalence of -11.20% (-12.23% to -10.18%) among women. When estimating the proportion of supranormal TSH levels according to background characteristics, the NACB standard definition decreased the prevalence by more than 10% in some categories, with the highest absolute difference of -13.92% (-15.52% to -12.33%) observed among the elderly, -12.85% (-13.68% to -12.02%) among those with UIC ≥300 μg/L, and -12.15% (-13.02% to -11.28%) among non-smokers. For subnormal TSH, with the highest absolute difference of 3.17% (2.74% to 3.61%) observed among regular smokers, 3.11% (2.49% to 3.74%) among the elderly, and 2.53% (2.29% to 2.77%) among those with BMI <25.

INTERPRETATION

For adults in China, the NACB standard RI of TSH reveals a lower estimated prevalence of supranormal TSH levels than the kit-recommended RI. Because of the public health significance of overt and subclinical hypothyroidism and the very large population base in China, the TSH RI should be further assessed.

FUNDING

National Health Commission of the People's Republic of China and National Natural Science Foundation of China.

Reducing free thyroid hormone testing through multiple Plan-Do-Study-Act cycles

OBJECTIVES

Free thyroid hormones (fT4 and fT3) are one of the most commonly ordered laboratory tests and often ordered when not clinically meaningful. Based on this, many studies have sought to identify strategies to reduce inappropriate fT4 and fT3 testing. The goal of the current study was to implement a quality improvement (QI) framework to identify an optimal approach to reducing inappropriate free thyroid hormone testing through multiple change ideas and Plan-Do-Study-Act (PDSA) cycles. The aim was to reduce fT4 and fT3 30% from baseline at a large tertiary hospital within 12 months.

METHODS

The Model for Improvement Framework was used to implement a total of 3 change ideas in the first and second PDSA cycles. Change ideas included implementation and refinement of a free thyroid hormone forced function reflex system, modifications to test requisitions/order-entry interfaces, and a TSH-only option. Process and balancing measures were evaluated to fine-tune the change interventions. Data was continuously monitored pre and post interventions to assess progress, impact and potential errors.

RESULTS

In the first PDSA cycle, laboratory testing of fT4 was decreased by 24% and fT3 by 18%. Soliciting physician feedback and assessing balancing measures was important in refining the approach. In the second PDSA cycle, fT4 was decreased by an additional 16% and fT3 by 29%. An audit of the process showed that phone calls to the laboratory to add-on free thyroid hormones did not increase after the second PDSA, averaging 2 calls per month.

CONCLUSIONS

To achieve optimal reductions in free thyroid hormone testing, multiple PDSA cycles were required alongside assessing process and balancing measures. Overall, fT4 and fT3 testing was decreased by 39% and 47%, respectively.

Optimization of the Order Menu in the Electronic Health Record Facilitates Test Patterns Consistent With Recommendations in the Choosing Wisely Initiative

OBJECTIVES

Thyroid and rheumatologic autoimmune testing are areas where evidence-based guidance from specialty organizations and Choosing Wisely support utilizing screening tests for autoimmune and thyroid disorders prior to more specialized testing. Adjustment of the orderable options in the electronic health record (EHR) can influence ordering patterns without requiring manual review or additional effort by the clinician.

METHODS

The menu was adjusted to reflect recommendations from Choosing Wisely to favor screening tests that automatically reflex to specialized testing on primary care providers' preference lists. Effectiveness was evaluated by reviewing total orders for individual tests.

RESULTS

Shifts in ordering from individual screening tests (antinuclear antibody and thyrotropin) to ones that reflexed to specialized testing were observed in parallel with significant reductions in the corresponding specialized testing.

CONCLUSIONS

Optimization of the EHR laboratory ordering menu can be used to shift ordering patterns toward Choosing Wisely recommendations.