Interventions to improve symptomatology in patients with hypothyroidism and persistent symptoms: A systematic review

BACKGROUND

Levothyroxine (LT4) monotherapy is the standard treatment for hypothyroidism; however, 10-15% of patients have persistent hypothyroid symptoms despite normalizing thyroid hormone levels with LT4. This study aims to summarize the best available evidence on interventions to improve symptomatology in patients with hypothyroidism and persistent symptoms.

METHODS

A systematic search was conducted in March 2022 for randomized controlled trials and observational studies on interventions for adult patients with persistent hypothyroid symptoms despite biochemical euthyroidism on thyroid hormone replacement.

RESULTS

A total of 277 articles were reviewed and seven fulfilled the inclusion criteria. 455 participants were included. Most intervention participants were female (78.6%) with a mean age of 47.5 (±2.8) years. Five clinical trials evaluating ginger (vs. starch), L-carnitine (vs. placebo), combination LT4 and liothyronine (LT3) (vs. LT4 or placebo), and surgery for patients with serum antithyroid peroxidase (TPO Ab) titers greater than 1000 IU/ml (vs. LT4) found inconsistent improvement in hypothyroidism related symptoms and general health. The two clinical trials with the largest improvement in fatigue scores were the use of ginger and surgery. One observational study comparing thyroidectomy vs observation found no significant difference on general health. Lastly, another observational study evaluating combination LT4/LT3 (vs. LT4 monotherapy) found improvement in fatigue and quality of life. There were 31 (12%) adverse events in the intervention group and 18 (10.8%) in the comparator group.

CONCLUSIONS

There is no high-quality evidence supporting any intervention for persistent symptoms in hypothyroidism. Available evidence, limited by the risk of bias, inconsistency, and heterogeneity, suggests that some persistent symptoms, particularly fatigue, could improve with ginger and thyroidectomy.

Patient Characteristics and the Extent to Which Clinicians Involve Patients in Decision Making: Secondary Analyses of Pooled Data

BACKGROUND

The occurrence of shared decision making (SDM) in daily practice remains limited. Various patient characteristics have been suggested to potentially influence the extent to which clinicians involve patients in SDM.

OBJECTIVE

To assess associations between patient characteristics and the extent to which clinicians involve patients in SDM.

METHODS

We conducted a secondary analysis of data pooled from 10 studies comparing the care of adult patients with (intervention) or without (control) a within-encounter SDM conversation tool. We included studies with audio(-visual) recordings of clinical encounters in which decisions about starting or reconsidering treatment were discussed.

MAIN MEASURES

In the original studies, the Observing Patient Involvement in Decision Making 12-items (OPTION12 item) scale was used to code the extent to which clinicians involved patients in SDM in clinical encounters. We conducted multivariable analyses with patient characteristics (age, gender, race, education, marital status, number of daily medications, general health status, health literacy) as independent variables and OPTION12 as a dependent variable.

RESULTS

We included data from 1,614 patients. The between-arm difference in OPTION12 scores was 7.7 of 100 points (P < 0.001). We found no association between any patient characteristics and the OPTION12 score except for education level (p = 0.030), an association that was very small (2.8 points between the least and most educated), contributed mostly by, and only significant in, control arms (6.5 points). Subanalyses of a stroke prevention trial showed a positive association between age and OPTION12 score (P = 0.033).

CONCLUSIONS

Most characteristics showed no association with the extent to which clinicians involved patients in SDM. Without an SDM conversation tool, clinicians devoted more efforts to involve patients with higher education, a difference not observed when the tool was used.

HIGHLIGHTS

Most sociodemographic patient characteristics show no association with the extent to which clinicians involve patients in shared decision making.Clinicians devoted less effort to involve patients with lower education, a difference that was not observed when a shared decision-making conversation tool was used.SDM conversation tools can be useful for clinicians to better involve patients and ensure patients get involved equally regardless of educational background.

Glucagon-Like Peptide-1 Receptor Agonists and Thyroid Cancer: A Narrative Review

Background: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are highly effective medications for the treatment of type 2 diabetes and obesity. Pharmacological studies in rodents support an association between the use of GLP-1 RAs and the development of medullary thyroid cancer (MTC) resulting in a black box warning for these agents in patients at risk for this condition. Yet, the association between GLP-1 RAs and non-MTC remains controversial. Excessive worry about unproven thyroid cancer risk might lead to underutilizing GLP-1 RAs in patients who could otherwise experience substantial benefits. Unwarranted concerns about thyroid cancer could lead to unnecessary thyroid cancer screening and harms from overdiagnosis. Summary: The body of evidence assessing the association between GLP-1 RA use and thyroid cancer spans a wide range of methodologies, including basic and translational research investigating biological plausibility; randomized trials assessing clinical efficacy and providing the strongest evidence for causality; observational studies providing real-life outcome evaluation in larger populations but with limited evaluation of covariates or dependable outcome definitions; and pharmacovigilance studies that provide postmarketing assessments of a safety signal but do not address causality. There is biological plausibility supporting an association between GLP-1 RA and MTC in rodents, which is less clear for non-MTC in humans. Clinical evidence from randomized trials and associated meta-analysis suggest thyroid cancer as a rare event making effect estimates imprecise but without conclusive and consistent evidence of increase risk in those receiving GLP-1 RA. Observational studies at higher risk of bias also show low event rates for thyroid cancer, with effect estimates that are inconsistent among different studies. Pharmacovigilance studies consistently show a signal of increased reporting of thyroid cancer in patients treated with GLP-1 RA. Conclusions: Evidence from randomized controlled trials indicates occurrence of thyroid cancer is infrequent in individuals exposed to GLP-1 RA. Observational studies at higher risk of bias yield inconsistent results. Overall there is no conclusive evidence of elevated thyroid cancer risk. These findings can help clinicians when addressing patient's concerns about a potential yet unproven link between GLP-1 RA therapy and thyroid cancer.

Thyroid Ultrasound Appropriateness Identification Through Natural Language Processing of Electronic Health Records

Objective

To address thyroid cancer overdiagnosis, we aim to develop a natural language processing (NLP) algorithm to determine the appropriateness of thyroid ultrasounds (TUS).

Patients and Methods

Between 2017 and 2021, we identified 18,000 TUS patients at Mayo Clinic and selected 628 for chart review to create a ground truth dataset based on consensus. We developed a rule-based NLP pipeline to identify TUS as appropriate TUS (aTUS) or inappropriate TUS (iTUS) using patients' clinical notes and additional meta information. In addition, we designed an abbreviated NLP pipeline (aNLP) solely focusing on labels from TUS order requisitions to facilitate deployment at other health care systems. Our dataset was split into a training set of 468 (75%) and a test set of 160 (25%), using the former for rule development and the latter for performance evaluation.

Results

There were 449 (95.9%) patients identified as aTUS and 19 (4.06%) as iTUS in the training set; there are 155 (96.88%) patients identified as aTUS and 5 (3.12%) were iTUS in the test set. In the training set, the pipeline achieved a sensitivity of 0.99, specificity of 0.95, and positive predictive value of 1.0 for detecting aTUS. The testing cohort revealed a sensitivity of 0.96, specificity of 0.80, and positive predictive value of 0.99. Similar performance metrics were observed in the aNLP pipeline.

Conclusion

The NLP models can accurately identify the appropriateness of a thyroid ultrasound from clinical documentation and order requisition information, a critical initial step toward evaluating the drivers and outcomes of TUS use and subsequent thyroid cancer overdiagnosis.

Defining inappropriate thyroid biopsy?-Proposed definition based on clinical evidence and stakeholder engagement

PURPOSE

Identify factors that can be used to assess the appropriateness of a thyroid biopsy and propose a pathway to define inappropriate thyroid biopsies in practice.

METHODS

We identified factors utilized in clinical guidelines and existing literature to determine the clinical indications for a thyroid biopsy. Subsequently, we assembled a multidisciplinary panel of experts, including patients, clinicians, researchers, and quality experts, to integrate these factors and develop a pathway for assessing the appropriateness of thyroid biopsies.

RESULTS

Through literature review and stakeholder engagement, we identified multiple factors to determine if a thyroid biopsy is necessary: ultrasound risk assessment, presence of compressive symptoms and/or clinical suspicion of high-risk thyroid cancer, life expectancy, comorbidity burden, surgical risk, personal risk factors for thyroid cancer, thyroid function levels, local resources and medical expertise and patient values and preferences. We proposed a multiple-tier classification for the appropriateness of thyroid biopsy that begins with ultrasound findings (e.g., size, thyroid cancer risk) and encompasses the evaluation of additional patient-specific factors.

CONCLUSION

Assessment of the appropriateness of a thyroid biopsy is possible. Although, thyroid nodule ultrasound risk assessment is a pivotal factor for this assessment, additional factors should be considered (e.g., life expectancy, personal risk factors for thyroid cancer, patient preferences). Yet, additional efforts are needed to operationalize the objective implementation of these factors in clinical practice.

NeuroEditor: a tool to edit and visualize neuronal morphologies

The digital extraction of detailed neuronal morphologies from microscopy data is an essential step in the study of neurons. Ever since Cajal's work, the acquisition and analysis of neuron anatomy has yielded invaluable insight into the nervous system, which has led to our present understanding of many structural and functional aspects of the brain and the nervous system, well beyond the anatomical perspective. Obtaining detailed anatomical data, though, is not a simple task. Despite recent progress, acquiring neuron details still involves using labor-intensive, error prone methods that facilitate the introduction of inaccuracies and mistakes. In consequence, getting reliable morphological tracings usually needs the completion of post-processing steps that require user intervention to ensure the extracted data accuracy. Within this framework, this paper presents NeuroEditor, a new software tool for visualization, editing and correction of previously reconstructed neuronal tracings. This tool has been developed specifically for alleviating the burden associated with the acquisition of detailed morphologies. NeuroEditor offers a set of algorithms that can automatically detect the presence of potential errors in tracings. The tool facilitates users to explore an error with a simple mouse click so that it can be corrected manually or, where applicable, automatically. In some cases, this tool can also propose a set of actions to automatically correct a particular type of error. Additionally, this tool allows users to visualize and compare the original and modified tracings, also providing a 3D mesh that approximates the neuronal membrane. The approximation of this mesh is computed and recomputed on-the-fly, reflecting any instantaneous changes during the tracing process. Moreover, NeuroEditor can be easily extended by users, who can program their own algorithms in Python and run them within the tool. Last, this paper includes an example showing how users can easily define a customized workflow by applying a sequence of editing operations. The edited morphology can then be stored, together with the corresponding 3D mesh that approximates the neuronal membrane.

Ablation techniques or active surveillance compared to surgical resection in patients with low-risk papillary thyroid cancer: a systematic review and meta-analysis

BACKGROUND

The global prevalence of thyroid cancer is on the rise. About one-third of newly diagnosed thyroid cancer cases comprise low-risk papillary thyroid cancer (1.5 cm or more minor). While surgical removal remains the prevailing approach for managing low-risk papillary thyroid cancer (LPTC) in patients, other options such as active surveillance (AS), radiofrequency ablation (RFA), microwave ablation (MWA), and laser ablation (LA) are also being considered as viable alternatives. This study evaluated and compared surgical thyroid resection (TSR) versus non-surgical (NS) methods for treating patients with LPTC.

METHODS

The study encompassed an analysis of comparisons between surgical thyroid resection (TSR) and alternative approaches, including active surveillance (AS), radiofrequency ablation (RFA), microwave ablation (MWA), or laser ablation (LA). The focus was on patients with biopsy-confirmed low-risk papillary thyroid cancer (LPTC) of less than 1.5 cm without preoperative indications of local or distant metastasis. The primary outcomes assessed were recurrence rates, disease-specific mortality, and quality of life (QoL). Data were collected from prominent databases, including Cochrane Database, Embase, MEDLINE, and Scopus, from inception to June 3rd, 2020. The CLARITY tool was utilized to evaluate bias risk. The analysis involved odds ratios (OR) with 95% confidence intervals (CI) for dichotomous outcomes, as well as mean differences (MD) and standardized mean differences (SMD) for continuous outcomes. The study is registered on PROSPERO under the identifier CRD42021235657.

RESULTS

The study incorporated 13 retrospective cohort studies involving 4034 patients. Surgical thyroid resection (TSR), active surveillance (AS), and minimally invasive techniques like radiofrequency ablation (RFA), microwave ablation (MWA), and laser ablation (LA) were performed in varying proportions of cases. The analysis indicated that specific disease mortality rates were comparable among AS, MWA, and TSR groups. The risk of recurrence, evaluated over different follow-up periods, showed no significant differences when comparing AS, RFA, MWA, or LA against TSR. Patients undergoing AS demonstrated better physical health-related quality of life (QoL) than those undergoing TSR. However, no substantial differences were observed in the overall mental health domain of QoL when comparing AS or RFA with TSR. The risk of bias was moderate in nine studies and high in four.

CONCLUSION

Low-quality evidence indicates comparable recurrence and disease-specific mortality risks among patients with LPTC who underwent ablation techniques or active surveillance (AS) compared to surgery. Nevertheless, individuals who opted for AS exhibited enhanced physical quality of life (QoL). Subsequent investigations are warranted to validate these findings.

Clinician feedback using a shared decision-making tool for the evaluation of patients with thyroid nodules-an observational study

BACKGROUND

We pilot-tested an encounter conversation aid to support shared decision making (SDM) between patients with thyroid nodules and their clinicians.

OBJECTIVE

Characterize the clinician feedback after providing care to patients with thyroid nodules using a tool to promote SDM conversations during the clinical encounter, and evaluate how clinicians used the tool during the visit.

METHODS

Mixed method study in two academic centers in the U.S., including adult patients presenting for evaluation of thyroid nodules and their clinicians. We thematically analyzed interviews with clinicians after they used the SDM tool in at least three visits to characterize their feedback. Additionally, investigators evaluated visits recordings to determine the extent to which clinicians engaged patients in the decision-making process (OPTION score, scale 0 to 100, higher levels indicating higher involvement), the tool's components used (fidelity), and encounter duration. Using a post-visit survey, we evaluated the extent to which clinicians felt the tool was easy to use, helpful, and supportive of the patient-clinician collaboration.

RESULTS

Thirteen clinicians participated in the study and used the SDM tool in the care of 53 patients. Clinicians thought the tool was well-organized and beneficial to patients and clinicians. Clinicians noticed a change in their routine with the use of the conversation aid and suggested it needed to be more flexible to better support varying conversations. The median OPTION score was 34, the fidelity of use 75%, and the median visit duration 17 min. In most encounters, clinicians agreed or strongly agreed the tool was easy to use (86%), helpful (65%), and supported collaboration (62%).

CONCLUSION

Clinicians were able to use a SDM tool in the care of patients with thyroid nodules. Although they wished it were more flexible, they found on the whole that its use in the clinical encounter was beneficial to patients and clinicians.

Real Practice Assessment of Persistent Symptoms After Initiation of Levothyroxine

OBJECTIVE

Levothyroxine (LT4) is the standard treatment for hypothyroidism. However, certain patients experience persistent symptoms even after achieving euthyroid status with LT4 therapy. We aimed to determine the frequency of persistent or new symptoms in patients with hypothyroidism after initiating LT4.

METHODS

This retrospective study included patients with hypothyroidism who started on LT4 between January 2017 and December 2019 at Mayo Clinic in Rochester, Minnesota, USA. Five hundred patient charts were randomly selected for review. Patients with at least 1 documented follow-up encounter after LT4 initiation were evaluated for ≤3 follow-up visits regarding their biochemical status and symptoms.

RESULTS

We included 356 patients, a majority of whom were female (66.6%), white (92.3%), and obese (71.9%), with an average age of 59.5 years. At the baseline visit, approximately one-half of the patients (177/356, 47.7%) reported hypothyroid symptoms, with fatigue being the most common symptom. During the follow-up periods, we observed that 17.8% (28/157), 17.9% (19/106), and 19.3% (11/57) of patients had normal thyroid stimulating hormone (TSH) values but persistent symptoms, while 12.3% (19/156), 19.9% (16/107), and 8.9% (5/56) had normal TSH values but new symptoms. Overall, during each respective follow-up period, 26.7% (42/157), 27.3% (29/106), and 28% (16/57) of patients experienced persistent or new symptoms alongside normal TSH values, with fatigue being the most constant symptom.

CONCLUSION

Our findings indicate that approximately 1 in every 4 patients with hypothyroidism receiving LT4 therapy and achieving normal TSH levels experience persistent or new hypothyroid symptoms. The cause of these symptoms remains unclear, emphasizing the need for a better understanding of their underlying causes and the development of effective management strategies.

Linking QKD Testbeds across Europe

Quantum-key-distribution (QKD) networks are gaining importance and it has become necessary to analyze the most appropriate methods for their long-distance interconnection. In this paper, four different methods of interconnecting remote QKD networks are proposed. The methods are used to link three different QKD testbeds in Europe, located in Berlin, Madrid, and Poznan. Although long-distance QKD links are only emulated, the methods used can serve as a blueprint for the secure interconnection of distant QKD networks in the future. Specifically, the presented approaches combine, in a transparent way, different fiber and satellite physical media, as well as common standards of key delivery interfaces. The testbed interconnections are designed to increase the security by utilizing multipath techniques and multiple hybridizations of QKD and post-quantum cryptography (PQC) algorithms.

Appropriateness of Levothyroxine Prescription: A Multicenter Retrospective Study

CONTEXT

Levothyroxine is one of the most prescribed medications in the United States.

OBJECTIVE

This study explores the appropriateness of levothyroxine prescriptions.

METHODS

A retrospective multicenter study was conducted on adult patients who were prescribed levothyroxine for the first time between 2017 and 2020 at three academic centers in the United States. We classified each case of levothyroxine initiation into one of three mutually exclusive categories: appropriate (clinically supported), indeterminate (clinically unclear), or nonevidence based (NEB, not clinically supported).

RESULTS

A total of 977 participants were included. The mean age was 55 years (SD 19), there was female (69%) and White race predominance (84%), and 44% had possible hypothyroid symptoms. Nearly half of the levothyroxine prescriptions were considered NEB (528, 54%), followed by appropriate (307, 31%) and indeterminate (118, 12%). The most common reason for NEB prescription was an index thyrotropin (TSH) value of less than 10 mIU/L without previous TSH or thyroxine values (131/528, 25%), for appropriate prescription, was overt hypothyroidism (163/307, 53%), and for an indeterminate prescription was a nonconfirmed subclinical hypothyroidism with TSH greater than or equal to 10 mIU/L (no confirmatory testing) (51/118, 43%). In multivariable analysis, being female (odds ratio [OR]: 1.3; 95% CI, 1.0-1.7) and prescription by a primary care provider (OR: 1.5; 95% CI, 1.2-2.0) were associated with NEB prescriptions.

CONCLUSION

There is a considerable proportion of NEB levothyroxine prescriptions. These results call for additional research to replicate these findings and to explore the perspective of those prescribing and receiving levothyroxine.

Extracting Thyroid Nodules Characteristics from Ultrasound Reports Using Transformer-based Natural Language Processing Methods

The ultrasound characteristics of thyroid nodules guide the evaluation of thyroid cancer in patients with thyroid nodules. However, the characteristics of thyroid nodules are often documented in clinical narratives such as ultrasound reports. Previous studies have examined natural language processing (NLP) methods in extracting a limited number of characteristics (<9) using rule-based NLP systems. In this study, a multidisciplinary team of NLP experts and thyroid specialists, identified thyroid nodule characteristics that are important for clinical care, composed annotation guidelines, developed a corpus, and compared 5 state-of-the-art transformer-based NLP methods, including BERT, RoBERTa, LongFormer, DeBERTa, and GatorTron, for extraction of thyroid nodule characteristics from ultrasound reports. Our GatorTron model, a transformer-based large language model trained using over 90 billion words of text, achieved the best strict and lenient F1-score of 0.8851 and 0.9495 for the extraction of a total number of 16 thyroid nodule characteristics, and 0.9321 for linking characteristics to nodules, outperforming other clinical transformer models. To the best of our knowledge, this is the first study to systematically categorize and apply transformer-based NLP models to extract a large number of clinical relevant thyroid nodule characteristics from ultrasound reports. This study lays ground for assessing the documentation quality of thyroid ultrasound reports and examining outcomes of patients with thyroid nodules using electronic health records.

Radiofrequency ablation for thyroid nodules in Ecuador: a cross-sectional study

OBJECTIVES

To describe the demographic characteristics and clinical outcomes following the first cohort of patients with Bening Thyroid Nodule (BTN) and (Papillary Thyroid Microcarcinoma) (PTMC) treated with Radiofrequency Ablation (RFA)in Ecuador.

METHODS

Single-center, cross-sectional study. We included adults undergoing RFA for BTN and PTMC between July 2019 and May 2022. Descriptive statistics and the Wilcoxon signed-rank test were used to compare some pre- and post-intervention outcomes.

RESULTS

We included 44 patients with 36 BTNs and eight PTMCs. The median age was 45.80 years (IQR 16-79 years), and most patients had normal thyroid function (72.72%). The median follow-up time was 7.80 months (IQR1.0-34.0). Nodules were primarily solid (43.21%) or predominantly solid (56.81%). The pre-RFA median volume in the benign lesions group was 10.30 ml (IQR 1.86-18.97). After ablation, the 1-month, 3-month, 6-month, and 12-month median volumes were 6.90 (IQR 0.48-10.15; p < 0.01) mL, 5.72 (IQR 0.77-7.25; p = 0.045); 0.98 (IQR 0.25-3.64; p < 0.01), and 0.11 (IQR 0.07-11.26; p = 0.026), respectively. The volume rate reduction was 47.20%, 72.20%, 74.00%, and 96.20% at 1, 3, 6, and 12-month follow-ups, respectively. The pre-RFA median volume in the PTMC group was 0.25 ml (IQR 0.19-0.48). After ablation, the 1-month, 3-month, and 6-month mean volumes were 0.19 (range 0.12-0.31; p = 0.120) mL, 0.10 (IQR 0.05-0.15; p = 0.13), and 0.01 (IQR 0.005-0.04; p = 0.364), respectively.

CONCLUSIONS

In this first report from Ecuador, we found that RFA may be a feasible alternative for treating benign and malignant thyroid nodules in the short term. Long-term data are needed to evaluate oncologic outcomes in PTMC patients.

Physical Examination of the Thyroid: Accuracy in Detecting Thyroid Nodules and Frequency of Additional Findings

OBJECTIVE

Thyroid palpation is a common clinical practice to detect thyroid abnormalities. However, its accuracy and potential for additional findings remain unclear. This study aimed to assess the diagnostic accuracy of physical exams in detecting thyroid nodules.

METHODS

A retrospective observational study was conducted on a random sample of adult patients who underwent their first-time thyroid ultrasound between January 2015 and September 2017, following a documented thyroid physical exam. The study assessed the performance of thyroid palpation in detecting 1 or multiple thyroid nodules, as well as the proportion of additional findings on ultrasounds due to false positive thyroid palpation.

RESULTS

We included 327 patients, mostly female (65.1%), white (84.1%), and treated in a primary care setting (54.4%) with a mean age of 50.8 years (SD 16.9). For solitary thyroid nodules, the physical exam had a sensitivity of 20.3%, specificity of 79.1%, an accuracy of 68.5%, negative predictive value of 81.8%, and positive predictive value of 17.6%. For detecting a multinodular goiter, physical exams demonstrated a sensitivity of 10.8%, specificity of 96.5%, accuracy of 55.4%, negative predictive value of 53.9, and positive predictive value of 73.9%. Among 154 cases with palpable nodules, 60% had additional nodules found in subsequent thyroid ultrasound.

CONCLUSION

Thyroid physical exam has limited diagnostic performance and leads to additional findings when followed by a thyroid ultrasound. Future efforts should be directed at improving the accuracy of thyroid physical exams or re-evaluating its routine use.

Drivers of Thyroid Ultrasound Use: A Retrospective Observational Study

OBJECTIVE

Excessive use of thyroid ultrasound (TUS) contributes to the overdiagnosis of thyroid nodules and thyroid cancer. In this study, we evaluated drivers of and clinical trajectories following TUS orders.

METHODS

We conducted a retrospective review of 500 adult patients who underwent an initial TUS between 2015 and 2017 at Mayo Clinic in Rochester, MN. A framework was employed to classify the indication for TUS, and it was characterized as inappropriate when ordered without a guideline-based indication. Medical records were reviewed for up to 12 months following the TUS, and clinical outcomes were evaluated.

RESULTS

The mean age mean age (SD) was 53.6 years (16.6), 63.8% female, and 86.6% white. TUS orders were triggered by incidental findings on unrelated imaging (31.6%), thyroid symptoms (20.4%), thyroid abnormalities on routine physical examination (17.2%), and thyroid dysfunction workup (11.8%). In females and males, the most common reason were incidental findings on imaging (female, 91/319, 28.5% and male, 67/181, 37.0%). In primary care practice, TUS orders were mostly triggered by symptoms (71/218, 32.5%), while thyroid dysfunction workup was the primary reason in endocrinology (28/100, 28.0%). We classified 11.2% (56/500) TUS orders as likely to have been ordered inappropriately based on current guidelines. Finally, 119 patients (119/500, 23.8%) had a thyroid biopsy with 11.8% had thyroid cancer (14/119. 11.8%).

CONCLUSIONS

Incidental findings on imaging, symptoms, and routine physical exam findings in asymptomatic patients were the most prevalent drivers of TUS. Furthermore, 1 in 10 TUS were likely inappropriately ordered based on current practice guidelines.

Understanding diagnostic conversations in clinical practice: A systematic review

OBJECTIVE

Summarize frameworks to understand diagnostic conversations and assessments of diagnostic conversations in practice.

METHODS

We systematically searched MEDLINE, Scopus, Cochrane, and other databases from inception to July 2022 for reports of diagnostic conversations. Two authors independently reviewed studies for eligibility, assessed methodological quality with the mixed methods appraisal tool and extracted information related to study characteristics, frameworks and components evaluated in assessments of diagnostic conversations and results.

RESULTS

Eight studies were included. One study reported an empiric framework of diagnostic conversations that included the following components: identifying the problem that requires diagnosis, obtaining information, and delivering the diagnosis and treatment plan. Thematic analyses highlighted communication between patients and clinicians as central in diagnostic conversations as it allows a) patient's presentation of their symptoms which guide subsequent diagnostic steps, b) negotiation of the significance of the patient's symptoms through conversation and c) introducing and resolving diagnostic uncertainty.

CONCLUSION

Despite the importance of diagnostic conversation only one empiric framework described its components. Additionally, limited available evidence suggests patients can have an important role in the diagnostic process that expands beyond patients as an information source.

PRACTICE IMPLICATIONS

Patients should be included as active partners in co-development of diagnostic plans of care.

Overuse of thyroid ultrasound

PURPOSE OF REVIEW

Thyroid ultrasound (TUS) is a common diagnostic test that can help guide the management of patients with thyroid conditions. Yet, inappropriate use of TUS can lead to harmful unintended consequences. This review aims to describe trends in the use and appropriateness of TUS in practice, drivers and consequences of inappropriate use, and potential solutions to decrease overuse.

RECENT FINDINGS

TUS use has increased in the U.S. and is associated with increased diagnosis of thyroid cancer. Between 10-50% of TUSs may be ordered outside of clinical practice recommendations. Patients who receive an inappropriate TUS and are incidentally found to have a thyroid nodule may experience unnecessary worry, diagnostic interventions, and potential overdiagnosis of thyroid cancer. The drivers of inappropriate TUS use are not yet fully understood, but it is likely that a combination of clinician, patient, and healthcare system factors contribute to this problem.

SUMMARY

Inappropriate TUS is a factor leading to the overdiagnosis of thyroid nodules and thyroid cancer, resulting in increased healthcare costs and potential harm to patients. To effectively address the overuse of this diagnostic test, it is necessary to gain a deeper understanding of the frequency of inappropriate TUS use in clinical practice and the factors that contribute to it. With this knowledge, interventions can be developed to reduce the inappropriate use of TUS, leading to improved patient outcomes and more efficient use of healthcare resources.

Implementation strategies to support ultrasound thyroid nodule risk stratification: A systematic review

BACKGROUND

Ultrasound risk stratification can improve the care of patients with thyroid nodules by providing a structured and systematic approach for the evaluation of thyroid nodule features and thyroid cancer risk. The optimal strategies to support implementation of high quality thyroid nodule risk stratification are unknown. This study seeks to summarise strategies used to support implementation of thyroid nodule ultrasound risk stratification in practice and their effects on implementation and service outcomes.

METHODS

This is a systematic review of studies evaluating implementation strategies published between January 2000 and June 2022 that were identified on Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane, Scopus, or Web of Science. Screening of eligible studies, data collection and assessment for risk of bias was completed independently and in duplicate. Implementation strategies and their effects on implementation and service outcomes were evaluated and summarised.

RESULTS

We identified 2666 potentially eligible studies of which 8 were included. Most implementation strategies were directed towards radiologists. Common strategies to support the implementation of thyroid nodule risk stratification included: tools to standardise thyroid ultrasound reports, education on thyroid nodule risk stratification and use of templates/forms for reporting, and reminders at the point of care. System based strategies, local consensus or audit were less commonly described. Overall, the use of these strategies supported the implementation process of thyroid nodule risk stratification with variable effects on service outcomes.

CONCLUSIONS

Implementation of thyroid nodule risk stratification can be supported by development of standardised reporting templates, education of users on risk stratification and reminders of use at the point of care. Additional studies evaluating the value of implementation strategies in different contexts are urgently needed.

Determinants for Thyroid Hormone Replacement Therapy in Subclinical Hypothyroidism: A Multicenter Electronic Health Records-Based Study

Background: The frequency and factors associated with thyroid hormone replacement therapy among patients with subclinical hypothyroidism (SCH) remain uncertain. Methods: In this electronic health records-based observational cohort study, we included adults diagnosed with SCH from four academic centers (the United States and Mexico) from January 1, 2016, to December 31, 2018. We aimed to identify the determinants of thyroid hormone replacement therapy for SCH and the frequency of treated SCH. Results: A total of 796 patients (65.2% women) had SCH, and 165 (20.7%) were treated with thyroid hormone replacement therapy. The treated group was younger [51.0 (standard deviation {SD} 18.3) vs. 55.3 (SD 18.2) years, p = 0.008] and had a higher proportion of women (72.7% vs. 63.2%, p = 0.03) compared with the untreated group. Only 46.7% of patients in the treated group and 65.6% in the untreated group had confirmatory thyroid function tests (TFTs) before the decision to start thyroid hormone replacement therapy was made. There was no difference in the frequency of thyroid autoimmunity evaluation, but a positive thyroid autoimmunity test was more frequent in the treated group compared with the untreated group (48.2% vs. 20.3%, p < 0.001). In a multivariable logistic regression model, female sex (odds ratio [OR] = 1.71 [CI 1.13-2.59], p = 0.01) and index thyrotropin (TSH) level (OR = 1.97 [CI 1.56-2.49], p < 0.001 for every SD [2.75 mIU/L] change) were associated with higher odds of treatment. Conclusions: Among patients with SCH, female sex and index TSH level were associated with higher odds of treatment. Moreover, in our population, the decision to treat or not to treat SCH was often based on only one set of abnormal TFTs, and thyroid autoimmunity assessment was underused.

Thyroid Cancer Risk Communication in Patients with Thyroid Nodules

The objective of this study is to evaluate thyroid cancer risk clinician-patient communication among patients receiving usual counseling and counseling enhanced by a conversation aid. A secondary analysis of clinical visit recordings and post-visit surveys obtained during a trial assessing the impact of a conversation aid for patients with thyroid nodules was conducted. We assessed how thyroid cancer risk was communicated, different risk communication strategies between groups, and predictors of accurate cancer risk perception. Fifty-nine patients were analyzed. Most were women (90%) and middle-aged (median 57 years). A verbal description of thyroid cancer risk was present most frequently (83%) and was more frequent in the conversation aid than the usual care group (100% vs. 63%, p < 0.001). A numerical description using percentages was present in 41% of visits and was more frequent in the conversation aid group (59% vs. 19%, p = 0.012). Natural frequencies (7%) and positive/negative framing (10%) were utilized less commonly. Uncertainty about risks was not discussed. No predictors of accurate risk perception were identified. Clinicians most commonly present a verbal description of thyroid cancer risk. Less commonly, natural frequencies, negative/positive framing, or uncertainty is discussed. Clinicians caring for patients with thyroid nodules should be aware of different strategies for communicating thyroid cancer risk.

Artificial Intelligence in Thyroidology: A Narrative Review of the Current Applications, Associated Challenges, and Future Directions

Background: The use of artificial intelligence (AI) in health care has grown exponentially with the promise of facilitating biomedical research and enhancing diagnosis, treatment, monitoring, disease prevention, and health care delivery. We aim to examine the current state, limitations, and future directions of AI in thyroidology. Summary: AI has been explored in thyroidology since the 1990s, and currently, there is an increasing interest in applying AI to improve the care of patients with thyroid nodules (TNODs), thyroid cancer, and functional or autoimmune thyroid disease. These applications aim to automate processes, improve the accuracy and consistency of diagnosis, personalize treatment, decrease the burden for health care professionals, improve access to specialized care in areas lacking expertise, deepen the understanding of subtle pathophysiologic patterns, and accelerate the learning curve of less experienced clinicians. There are promising results for many of these applications. Yet, most are in the validation or early clinical evaluation stages. Only a few are currently adopted for risk stratification of TNODs by ultrasound and determination of the malignant nature of indeterminate TNODs by molecular testing. Challenges of the currently available AI applications include the lack of prospective and multicenter validations and utility studies, small and low diversity of training data sets, differences in data sources, lack of explainability, unclear clinical impact, inadequate stakeholder engagement, and inability to use outside of the research setting, which might limit the value of their future adoption. Conclusions: AI has the potential to improve many aspects of thyroidology; however, addressing the limitations affecting the suitability of AI interventions in thyroidology is a prerequisite to ensure that AI provides added value for patients with thyroid disease.

Financial Toxicity in the Clinical Encounter: A Paired Survey of Patient and Clinician Perceptions

Objective

To compare the agreement between patient and clinician perceptions of care-related financial issues.

Patients and Methods

We surveyed patient-clinician dyads immediately after an outpatient medical encounter between September 2019 and May 2021. They were asked to separately rate (1-10) patient's level of difficulty in paying medical bills and the importance of discussing cost issues with that patient during clinical encounters. We calculated agreement between patient-clinician ratings using the intraclass correlation coefficient and used random effects regression models to identify patient predictors of paired score differences in difficulty and importance of ratings.

Results

58 pairs of patients (n=58) and clinicians (n=40) completed the survey. Patient-clinician agreement was poor for both measures, but higher for difficulty in paying medical bills (intraclass correlation coefficient=0.375; 95% CI, 0.13-0.57) than for the importance of discussing cost (-0.051; 95% CI, -0.31 to 0.21). Agreement on difficulty in paying medical bills was not lower in encounters with conversations about the cost of care. In adjusted models, poor patient-clinician agreement on difficulty in paying medical bills was associated with lower patient socioeconomic status and education level, whereas poor agreement on patient-perceived importance of discussing cost was significant for patients who were White, married, reported 1 or more long-term conditions, and had higher education and income levels.

Conclusion

Even in encounters where cost conversations occurred, there was poor patient-clinician agreement on ratings of the patient's difficulty in paying medical bills and perceived importance of discussing cost issues. Clinicians need more training and support in detecting the level of financial burden and tailoring cost conversations to the needs of individual patients.

Collaborative Diagnostic Conversations Between Clinicians, Patients, and Their Families: A Way to Avoid Diagnostic Errors

Objective

To identify the components of the collaborative diagnostic conversations between clinicians, patients, and their families and how deficiencies in these conversations can lead to diagnostic errors.

Patients and Methods

We purposively selected 60 video recordings of clinical encounters that included diagnosis conversations. These videos were obtained from the internal medicine, and family medicine services at Mayo Clinic's campus in Rochester, Minnesota. These clinical encounters were recorded between November 2017, and December 2021, during the conduct of studies aiming at developing or testing shared decision-making interventions. We followed a critically reflective approach model for data analysis.

Results

We identified 3 components of diagnostic conversations as follows: (1) recognizing diagnostic situations, (2) setting priorities, and (3) creating and reconciling a diagnostic plan. Deficiencies in diagnostic conversations could lead to framing issues in a way that sets diagnostic activities off in an incorrect or undesirable direction, incorrect prioritization of diagnostic concerns, and diagnostic plans of care that are not feasible, desirable, or productive.

Conclusion

We identified 3 clinician-and-patient diagnostic conversation components and mapped them to potential diagnostic errors. This information may inform additional research to identify areas of intervention to decrease the frequency and harm associated with diagnostic errors in clinical practice.

Patient feedback receiving care using a shared decision making tool for thyroid nodule evaluation-an observational study

PURPOSE

To characterize the feedback of patients with thyroid nodules receiving care using a shared decision making (SDM) tool designed to improve conversations with their clinicians related to diagnostic options (e.g. thyroid biopsy, ultrasound surveillance).

METHODS

Investigators qualitatively analyzed post-encounter interviews with patients to characterize their feedback of a SDM tool used during their clinical visits. Additionally, investigators counted instances of diagnostic choice awareness and of patients' expression of a diagnostic management preference in recordings of clinical encounters of adult patients presenting for evaluation of thyroid nodules in which the SDM tool was used.

RESULTS

In total, 53 patients (42 (79%) women); median age 62 years were enrolled and had consultations supported by the SDM tool. Patients were favorable about the design of the SDM tool and its ability to convey information about options and support patient-clinician interactions. Patients identified opportunities to improve the tool through adding more content and improve its use in practice through training of clinicians in its use. There was evidence of diagnostic choice awareness in 52 (98%) of these visits and patients expressed a diagnostic management preference in 40 (76%).

CONCLUSION

User centered design including feedback from patients and real life observation supports the use of the SDM tool to facilitate collaboration between patients and clinicians.

Novel assessment of epigenetic imprinting biomarkers for the diagnosis of thyroid nodules

Caring for individuals with thyroid nodules requires accurate estimation of their risk of thyroid cancer; however, available diagnostic tools offer only imprecise estimates. Novel biomarkers might help to clarify thyroid cancer risk and facilitate more-accurate diagnostic decision-making, although limitations in this area continue to exist.

Development of Complementary Encounter and Patient Decision Aids for Shared Decision Making about Stroke Prevention in Atrial Fibrillation

Introduction

Decision aids (DAs) are helpful instruments used to support shared decision making (SDM). Patients with atrial fibrillation (AF) face complex decisions regarding stroke prevention strategies. While a few DAs have been made for AF stroke prevention, an encounter DA (EDA) and patient DA (PDA) have not been created to be used in conjunction with each other before.

Design

Using iterative user-centered design, we developed 2 DAs for anticoagulation choice and stroke prevention in AF. Prototypes were created, and we elicited feedback from patients and experts via observations of encounters, usability testing, and semistructured interviews.

Results

User testing was done with 33 experts (in AF and SDM) and 51 patients from 6 institutions. The EDA and PDA underwent 1 and 4 major iterations, respectively. Major differences between the DAs included AF pathophysiology and a preparation to meet with the clinician in the PDA as well as different language throughout. Content areas included personalized stroke risk, differences between anticoagulants, and risks of bleeding. Based on user feedback, developers 1) addressed feelings of isolation with AF, 2) improved navigation options, 3) modified content and flow for users new to AF and those experienced with AF, 4) updated stroke risk pictographs, and 5) added structure to the preparation for decision making in the PDA.

Limitations

These DAs focus only on anticoagulation for stroke prevention and are online, which may limit participation for those less comfortable with technology.

Conclusions

Designing complementary DAs for use in tandem or separately is a new method to support SDM between patients and clinicians. Extensive user testing is essential to creating high-quality tools that best meet the needs of those using them.

Highlights

First-time complementary encounter and patient decision aids have been designed to work together or separately.User feedback led to greater structure and different experiences for patients naïve or experienced with anticoagulants in patient decision aids.Online tools allow for easier dissemination, use in telehealth visits, and updating as new evidence comes out.

A Survey on the Management of Thyroid Eye Disease Among American and European Thyroid Association Members

Background: The thyroid eye disease (TED) treatment landscape is rapidly evolving. How new treatment options have impacted practice is unknown. Methods: We conducted a cross-sectional electronic survey of American and European Thyroid Association members between June 2 and June 30, 2021. The survey included TED questions about resources for its management, index cases for different severities and presentations of TED, barriers for the management of TED, and participants' concerns about TED. We classified respondents into three geographic categories: North America, Europe, or other regions. Results: Two hundred fifty-two eligible participants started the survey (15% response rate), and 227 completed it. Participants were mostly men (50.2%, 114/227), white (79.7%, 181/227), endocrinologists with a thyroid focus (66.1%, 150/227), practicing in a tertiary academic center (46.7%, 106/227), caring for 10 or more TED patients over the last 12 months (40.5%, 92/227), and reported not having a multidisciplinary TED clinic in their institution (52.8%, 120/227). The majority reported that new TED cases per annum have not changed in the past 10 years (47.5%, 108/227), and that TED patients are found in practice during the management of hyperthyroidism (41.8%, 95/227). For mild active TED, participants from Europe reported a higher use of selenium (73%[96/132] vs. 32%[20/62] of respondents from North America and 24%[8/33] of respondents from other regions). For moderate-to-severe active TED, there was a modest preference for teprotumumab as first-line therapy (37%, 23/62) among North American participants and intravenous (IV) steroids (73%[96/132], and 42%[14/33]) for participants from Europe and other regions, respectively. These treatment preferences did not change in patients with moderate-to-severe active TED with poorly controlled diabetes. In contrast, participants from the three geographic categories preferred IV steroids for optic neuropathy and women planning pregnancy. The three top "very important" concerns about TED management according to participants were: the cost of TED treatment (31.3%, 71/227), lack of effective TED treatments (19.8%, 45/227), and difficulty in predicting whether TED will develop (18.9%, 43/227). Conclusions: There is a marked geographic practice variation in the management of TED. Clinicians' concerns about TED management demand ongoing research on more effective treatment, TED predictive tools, and policy changes to improve the affordability of new TED therapies.

Appropriate Use of Telehealth Visits in Endocrinology: Policy Perspective of the Endocrine Society

OBJECTIVE

This work aims to guide clinicians practicing endocrinology in the use of telehealth (synchronous patient-clinician visits conducted over video or telephone) for outpatient care.

PARTICIPANTS

The Endocrine Society convened a 9-member panel of US endocrinologists with expertise in telehealth clinical care, telehealth operations, patient-centered care, health care delivery research, and/or evidence-based medicine.

EVIDENCE

The panel conducted a literature search to identify studies published since 2000 about telehealth in endocrinology. One member extracted a list of factors affecting the quality of endocrine care via telehealth from the extant literature. The panel grouped these factors into 5 domains: clinical, patient, patient-clinician relationship, clinician, and health care setting and technology.

CONSENSUS PROCESS

For each domain, 2 or 3 members drew on existing literature and their expert opinions to draft a section examining the effect of the domain's component factors on the appropriateness of telehealth use within endocrine practice. Appropriateness was evaluated in the context of the 6 Institute of Medicine aims for health care quality: patient-centeredness, equity, safety, effectiveness, timeliness, and efficiency. The panel held monthly virtual meetings to discuss and revise each domain. Two members wrote the remaining sections and integrated them with the domains to create the full policy perspective, which was reviewed and revised by all members.

CONCLUSIONS

Telehealth has become a common care modality within endocrinology. This policy perspective summarizes the factors determining telehealth appropriateness in various patient care scenarios. Strategies to increase the quality of telehealth care are offered. More research is needed to develop a robust evidence base for future guideline development.

PSAT377 Minimally Invasive Treatment Modalities or Active Surveillance Compared to Surgery for Patients with Small Papillary Thyroid Cancer: A Systematic Review and Meta-Analysis

Background

The incidence of thyroid cancer is increasing worldwide. A third of new thyroid cancer cases are small papillary thyroid cancer (1.5 cm or less in size). Although surgical intervention is the most common management option for patients with small papillary thyroid cancer (SPTC), active surveillance (AS), radiofrequency ablation (RFA), laser ablation (LA), and microwave ablation (MWA) are also considered as management alternatives. This study aimed to assess the comparative effectiveness of surgical (TS) vs. non-surgical management options for patients with SPTC.

Methods

We included studies comparing any type of TS versus AS, LA, RFA, or MWA in patients with a biopsy-proven SPTC of less than 1.5 cm without evidence of preoperative local or distant metastasis. The outcomes of interest were risk of recurrence of thyroid cancer, disease-specific mortality, and quality of life (QoL). All outcomes were measured at the longest follow-up. Literature search used Cochrane Database, Embase, and MEDLINE from inception to June 3rd, 2020. The CLARITY tool was used to assess the risk of bias. For dichotomous outcomes, we calculated odds ratios (OR) and their corresponding 95% confidence intervals (CI) using random-effects models. We estimated mean differences (MD) and standardized mean differences (SMD) based on predetermined criteria for continuous outcomes. PROSPERO (CRD42021235657).

Results

We included 14 retrospective cohort studies consisting of 6457 patients. TS, AS, RFA, MWA, and LA therapies were performed in 67.50% (n=4291), 21.03% (n=1337), 7.53% (n=479), 2.49% (n=255), and 1.27% (n=81) of cases, respectively. Disease-specific mortality (mean follow-up ranged from 37.5 to 120.0 months) was not different between patients who underwent TS versus AS. There was no data on mortality for the other noninvasive approaches. The risk of recurrence (mean follow-up ranged from 17.0 to 49.2 months) was not different when comparing LA, RFA, AS, or MWA against TS. The overall physical health domain of QoL (mean follow-up ranged from 10.8 to 29.6 months) was increased in patients who underwent AS (SMD: 0.23 95%CI 0.09; 0.37, k=2, I2=0.00%) compared to TS, but it was no different when comparing MWA or RFA versus TS. In addition, there were no differences in the overall mental health domain of QoL comparing AS or RFA vs TS. The risk of bias was considered moderate in nine studies and high in five studies.

Conclusion

Low evidence quality suggests equal risk of recurrence and mortality between SPTC patients who underwent minimally invasive treatment modalities or active surveillance compared to surgery. However, physical QoL was better in SPTC patients who underwent AS. Further studies are needed to confirm these results and draw robust conclusions.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

PSUN158 INTENSIVE VS. CONVENTIONAL BLOOD PRESSURE GOALS IN OLDER PATIENTS WITH TYPE 2 DIABETES: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Hypertension is a major cardiovascular risk factor that affects over 50% of individuals with type 2 diabetes. Lowering blood pressure to reduce the risk of micro- and macrovascular complications of diabetes is a strong recommendation advocated by contemporary clinical practice guidelines, however, proposed goals for older patients with diabetes are heterogeneous and rely on indirect evidence as they are frequently underrepresented in clinical trials. Herein, the optimal blood pressure goal and its associated risks remain uncertain in this population.

Objective

To assess the effect of intensive vs conventional blood pressure goals on patient important outcomes in older adults with type 2 diabetes.

Methods

A comprehensive search was performed using MEDLINE, Embase, Web of Science, Scopus, Cochrane Central Register of Controlled trials, and Cochrane Database of Systematic Reviews, from database inception to March 2021. Randomized controlled trials comparing intensive vs conventional blood pressure goals in adults over 60 years of age with type 2 diabetes were included. Screening and data extraction were performed independently and in duplicate. Modified Mantel-Haenszel meta-analyses were conducted to estimate odds ratios (OR) for dichotomous outcomes and mean differences for continuous outcomes, alongside 95% confidence intervals (CIs). (PROSPERO registration number: CRD42019126078)

Results

Seven trials fulfilled our inclusion criteria.A 19% risk reduction (OR 0.81; 95% CI 0.69 to 0.95; I2= 8%; p= 0.35) in the occurrence of major adverse cardiovascular events (MACE) and 37% risk reduction (OR 0.63; 95% CI 0.51 to 0.79; I2= 0%; p= 0.56) in the occurrence of fatal or non-fatal stroke was documented in the intensive treatment group. There were no differences in the occurrence of all-cause mortality, cardiovascular mortality, non-fatal myocardial infarction, and peripheral vascular disease. Data regarding treatment adverse effects and microvascular outcomes were scarcely reported among included studies.

Conclusion

In summary, our analysis provides evidence that intensive blood pressure goals in older patients with diabetes are associated with a lower risk of stroke and MACE. Nevertheless, data are very scarce regarding microvascular diabetes outcomes and treatment safety. Given that an intensive approach would increase the number of medications, cost, adverse events and probably decrease adherence, treatment of hypertension in this population should be conducted with a shared decision making approach that makes sense from an intellectual, emotional, and practical basis.

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

PSAT243 Late Versus Early Administration of Radioiodine Therapy for Patients with Differentiated Thyroid Cancer: A Systematic Review and Meta-analysis

Background

Radioiodine (RAI) therapy is an important adjuvant therapy for differentiated thyroid carcinoma (DTC) patients. Several studies have demonstrated the efficacy of RAI in reducing the risk of thyroid cancer recurrence and mortality; however, the ideal timing to initiate RAI after surgery is debatable. This systematic review and meta-analysis evaluates the risk of achieving excellent response and mortality when comparing late administration versus early administration of RAI in patients with DTC.

Methods

We searched Medline, Embase, Scopus, and Cochrane Database from inception to April 2021 to identify experimental and observational studies that evaluated the impact of different timings of RAI after surgery (<3 months vs. >3 months, <6 months vs. >6 months, <9 months vs. >9 months) on the risk of excellent response and thyroid-specific mortality in DTC patients with low, intermediate, and high risk of recurrence. We used random-effects model to pool dichotomous variables with odd ratios (OR) and their confidence intervals (95%CI). The risk of bias was evaluated using the Newcastle Ottawa Scale. PROSPERO Protocol ID CRD42021267036.

Results

We included 12 retrospective cohort studies with 34,833 patients. The majority of participants were female (78.00%) and the mean age ranged from 39.70 (± 3.40) to 51.60 (± 1.70) years. In patients with low-to-intermediate risk of recurrence, there were no differences in excellent response (OR 0.76, 95%CI: 0.34-1.68, I²: 78.00%, n=1099) and mortality risk (OR 1.00, 95%CI: 0.84-1.19, I²: 0.00%, n=21450) in the late group (>3 months) compared to the early group (<3 months). The same outcomes were obtained for DTC patients who underwent RAI at 6 months (excellent response, OR 1.26, 95%CI: 0.94-1.69, I²: 0.00%, n=880) and at 9 months cut-offs (excellent response, OR 0.78, 95%CI: 0.32-1.91, I²: 0.00%, n=597; mortality, OR 1.28, 95%CI: 0.74-2.23, I²: 0.00%, n=327). Regarding DTC patients with high risk of recurrence, there were no differences in excellent response (OR 0.82, 95%CI: 0.61-1.11, I²: 0.00%, n=720) and mortality risk (OR 1.04, 95%CI: 0.74-1.47, I²: 62.50, n=10426) in the late group (>3 months) when compared to the early group (<3 months). Similarly for patients who underwent RAI at 6 months cut-off (excellent response, OR 1.04, 95%CI: 0.64-1.68, I²: 58.90%, n=72). However, mortality risk was higher in the late group (>6 months) when compared to the early group (<6 months) (OR 6.55, 95%CI: 2.92-14.67, I²: 0.00%, n=198). The risk of bias was considered moderate in 7 studies and high in 5.

Conclusions

Low-to-moderate quality of evidence suggests increased mortality with delayed RAI (>6 months) in DTC patients with high risk of recurrence. The timing of RAI for other risk categories has little or no effect. Further experimental studies are needed to confirm these results and draw robust conclusions.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

ABLE to support patient financial capacity: A qualitative analysis of cost conversations in clinical encounters

OBJECTIVE

To explore how costs of care are discussed in real clinical encounters and what humanistic elements support them.

METHODS

A qualitative thematic analysis of 41 purposively selected transcripts of video-recorded clinical encounters from trials run between 2007 and 2015. Videos were obtained from a corpus of 220 randomly selected videos from 8 practice-based randomized trials and 1 pre-post prospective study comparing care with and without shared decision making (SDM) tools.

RESULTS

Our qualitative analysis identified two major themes: the first, Space Needed for Cost Conversations, describes patients' needs regarding their financial capacity. The second, Caring Responses, describes humanistic elements that patients and clinicians can bring to clinical encounters to include good quality cost conversations.

CONCLUSION

Our findings suggest that strengthening patient-clinician human connections, focusing on imbalances between patient resources and burdens, and providing space to allow potentially unexpected cost discussions to emerge may best support high quality cost conversations and tailored care plans.

PRACTICE IMPLICATIONS

We recommend clinicians consider 4 aspects of communication, represented by the mnemonic ABLE: Ask questions, Be kind and acknowledge emotions, Listen for indirect signals and (discuss with) Every patient. Future research should evaluate the practicality of these recommendations, along with system-level improvements to support implementation of our recommendations.

Intensive vs. conventional blood pressure goals in older patients with type 2 diabetes: a systematic review and meta-analysis

PURPOSE

Assess the effect of intensive vs conventional blood pressure goals on patient-important outcomes in older adults with type 2 diabetes.

METHODS

A comprehensive search was performed using electronic databases. Randomized controlled trials comparing intensive vs conventional blood pressure goals in adults over 60 years of age with type 2 diabetes were included. Events were evaluated using a modified Mantel-Haenszel meta-analysis with Peto's method. Study selection and data extraction were performed independently and in duplicate.

RESULTS

Seven trials were included. A 19% risk reduction (OR 0.81; 95% CI 0.69-0.95; I² = 8%; p = 0.35) in the occurrence of major adverse cardiovascular events (MACE) and 37% risk reduction (OR 0.63; 95% CI 0.51-0.79; I² = 0%; p = 0.56) in the occurrence of fatal or non-fatal stroke was documented in the intensive treatment group. There were no differences in the occurrence of all-cause mortality, cardiovascular mortality, non-fatal myocardial infarction, and peripheral vascular disease. Data regarding treatment adverse effects and microvascular outcomes was scarce.

CONCLUSIONS

Intensive blood pressure goals in older patients with diabetes were associated with a lower risk of stroke and MACE, but not with all-cause mortality, cardiovascular mortality, non-fatal myocardial infarction, and peripheral vascular disease.

The design and development of an encounter tool to support shared decision making about preventing cardiovascular events

Patients at high risk for cardiovascular disease (CVD) tend to receive less intensive preventive care. Clinical practice guidelines recommend shared decision making (SDM) to improve the quality of primary CVD prevention. There are tools for use during the clinical encounter that promote SDM, but, to our knowledge, there are no SDM encounter tools that support conversations about available lifestyle and pharmacological options that can lead to preventive care that is congruent with patient goals and CVD risk. Using the best available evidence and human-centered design (iterative design in the context of ultimate use with users), our team developed a SDM encounter tool, CV Prevention Choice. Each subsequent version during the iterative development process was evaluated in terms of content, usefulness, and usability by testing it in real preventive encounters. The final version of the tool includes a calculator that estimates the patient's risk of a major atherosclerotic CVD event in the next 10 years. Lifestyle and medication options are presented, alongside their pros, cons, costs, and other burdens. The risk reduction achieved by the selected prevention program is then displayed to support collaborative deliberation and decision making. A U.S. multicenter trial is estimating the effectiveness of CV Prevention Choice in achieving risk-concordant CV prevention while identifying the best strategies for increasing the adoption of the SDM encounter tool and its routine use in practice.

Enrolling people of color to evaluate a practice intervention: lessons from the shared decision-making for atrial fibrillation (SDM4AFib) trial

Background

Trial recruitment of Black, indigenous, and people of color (BIPOC) is key for interventions that interact with socioeconomic factors and cultural norms, preferences, and values. We report on our experience enrolling BIPOC participants into a multicenter trial of a shared decision-making intervention about anticoagulation to prevent strokes, in patients with atrial fibrillation (AF).

Methods

We enrolled patients with AF and their clinicians in 5 healthcare systems (three academic medical centers, an urban/suburban community medical center, and a safety-net inner-city medical center) located in three states (Minnesota, Alabama, and Mississippi) in the United States. Clinical encounters were randomized to usual care with or without a shared decision-making tool about anticoagulation.

Analysis

We analyzed BIPOC patient enrollment by site, categorized reasons for non-enrollment, and examined how enrollment of BIPOC patients was promoted across sites.

Results

Of 2247 patients assessed, 922 were enrolled of which 147 (16%) were BIPOC patients. Eligible Black participants were significantly less likely (p < .001) to enroll (102, 11%) than trial-eligible White participants (185, 15%). The enrollment rate of BIPOC patients varied by site. The inclusion and prioritization of clinical practices that care for more BIPOC patients contributed to a higher enrollment rate into the trial. Specific efforts to reach BIPOC clinic attendees and prioritize their enrollment had lower yield.

Conclusions

Best practices to optimize the enrollment of BIPOC participants into trials that examined complex and culturally sensitive interventions remain to be developed. This study suggests a high yield from enrolling BIPOC patients from practices that prioritize their care.

Trial registration

ClinicalTrials.gov (NCT02905032).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08399-z.

Treatment burden and perceptions of glucose-lowering therapy among people living with diabetes

AIMS

Address treatment burden and general perceptions of pharmacological treatment in patients with diabetes.

METHODS

We surveyed adult patients with diabetes cared for in a tertiary academic medical center about: i) knowledge about the impact of glucose-lowering medication use on diabetes control and complications, ii) common beliefs about natural medicine and insulin use, iii) attitudes towards glucose-lowering medications, iv) burden of treatment, v) general knowledge of diabetes pharmacological treatment, and vi) perceptions of shared decision-making.

RESULTS

Two hundred-four participants completed the survey. While most (90%) agreed that adherence to medication would control diabetes and improve quality of life, 30-40% were not certain that it would translate to fewer disease complications. About one of three thought medications could be harmful (29.4%). Over 50% agreed or was unsure that natural remedies were as good/better than prescribed medications. About 30% acknowledged difficulties taking their diabetes medications and monitoring blood glucose, and over 50% were concerned about treatment costs. Nearly 30% denied receiving a detailed explanation from their clinician regarding their disease and is treatment.

CONCLUSIONS

Our results highlight the importance of patient education regarding pharmacological treatment for diabetes, and eliciting sources of distress and treatment burden among patients with diabetes.

Clinician Agreement on the Classification of Thyroid Nodules Ultrasound Features: A Survey of 2 Endocrine Societies

CONTEXT

Thyroid nodule risk stratification allows clinicians to standardize the evaluation of thyroid cancer risk according to ultrasound features.

OBJECTIVE

To evaluate interrater agreement among clinicians assessing thyroid nodules ultrasound features and thyroid cancer risk categories.

DESIGN, SETTING, AND PARTICIPANTS

We surveyed Endocrine Society and Latin American Thyroid Society members to assess their interpretation of composition, echogenicity, shape, margins, and presence of echogenic foci of 10 thyroid nodule cases. The risk category for thyroid cancer was calculated following the American College of Radiology-Thyroid Imaging Reporting & Data System (ACR-TIRADS) framework from individual responses.

MAIN OUTCOMES AND MEASURES

We used descriptive statistics and Gwet's agreement coefficient (AC1) to assess the primary outcome of interrater agreement for ACR-TIRADS risk category. As secondary outcomes, the interrater agreement for individual features and a subgroup analysis of interrater agreement for the ACR-TIRADS category were performed (ultrasound reporting system, type of practice, and number of monthly appraisals).

RESULTS

A total of 144 participants were included, mostly endocrinologists. There was moderate level of agreement for the absence of echogenic foci (AC1 0.53, 95% CI 0.24-0.81) and composition (AC1 0.54, 95% CI 0.36-0.71). The agreement for margins (AC1 0.24, 95% CI 0.15-0.33), echogenicity (AC1 0.34, 95% CI 0.22-0.46), and shape assessment (AC1 0.42, 95% CI 0.13-0.70) was lower. The overall agreement for ACR-TIRADS assessment was AC1 0.29, (95% CI 0.13-0.45). The AC1 of ACR-TIRADS among subgroups was similar.

CONCLUSIONS

This study found high variation of judgments about ACR-TIRADS risk category and individual features, which poses a potential challenge for the widescale implementation of thyroid nodule risk stratification.

Shared decision making process measures and patient problems

OBJECTIVES

Purposeful SDM posits four modes of shared decision making (SDM). The use of each mode depends on the type of problem of care that is being addressed. We sought to identify how current observer-based SDM measures apply to each mode of Purposeful SDM.

METHODS

Four coders, working independently, evaluated 192 items pertaining to 12 observer-based SDM process measures. They classified the items into 6 themes that vary across Purposeful SDM modes and then into one of the four modes (weighing, negotiating, problem-solving, developing insight). Disagreements were resolved by consensus.

RESULTS

The items were classified as pertaining to the following themes: problem (28), roles/participation (84), options (62), preferences (21), decision (15), and evaluation (6). They were then classified as pertaining particularly to the SDM modes of weighing (54), negotiating (5), problem-solving (0), and developing insight (0) modes, with 191 items applying broadly to all modes of Purposeful SDM.

CONCLUSIONS

Observer-based SDM measures describe behaviors pertinent to all modes but lack items sensitive to behaviors particular to some modes of SDM.

PRACTICE IMPLICATIONS

New or revised observer-based measures of the SDM process could help estimate the extent to which the appropriate SDM mode is being used to address the patient's problem.

Rates of, and factors associated with, switching among generic levothyroxine preparations in commercially insured American adults

IMPORTANCE

Some practice guidelines warn against generic L-thyroxine preparation switching.

OBJECTIVE

To examine the rates of generic L-thyroxine preparation switching within one year of initiating L-thyroxine, and to examine factors associated with switching.

DESIGN AND SETTING

Retrospective study using national data from a large administrative claims database from January 2008 through November 2018.

PATIENTS

Medicare or commercially insured adults (≥18 years) who filled a generic L-thyroxine preparation.

MAIN OUTCOME MEASURES

At least one switch from one generic L-thyroxine preparation to another within 1 year of L-thyroxine initiation defined by prescription fills.

RESULTS

From January 2008 to November 2018, we included 483,390 patients who initiated generic L-thyroxine: mean (SD) age was 61.4 years (15.2), 75.2% were female, 72.6% were white. Within 1 year of initiating therapy, 98,013 (20%) switched to another L-thyroxine generic preparation at least once. In a multivariate logistic regression analysis, factors associated with switching included the number of pharmacies visited to fill L-thyroxine (>2 vs 1 adjusted OR [aOR] 7.15, 95% confidence interval [CI] 6.97-7.34), age ≥75 vs. <45 years (aOR 1.29, 95% CI 1.26-1.33), history of thyroid surgery (aOR 1.22, 95% CI 1.13-1.31), and first L-thyroxine fill date in 2018 vs. 2008 (aOR 3.32, 95% CI 3.14-3.51).

CONCLUSIONS AND RELEVANCE

One in five patients switched among generic L-thyroxine manufacturers within one year of treatment initiation. Generic L-thyroxine switching occurred more often when more pharmacies were used to fill L-thyroxine. Given existing guideline recommendations, additional studies should clarify the impact of generic L-thyroxine switching on thyroid hormone values.

Effect of metformin on microvascular outcomes in patients with type 2 diabetes: A systematic review and meta-analysis

AIMS

Examine the efficacy of metformin compared to placebo or other glucose-lowering medications on microvascular outcomes in patients with Type 2 Diabetes Mellitus (T2DM).

METHODS

MEDLINE, EMBASE, Web of Science, and Scopus were searched from database inception to March 2020. We included randomized clinical trials of patients with T2DM receiving metformin compared with another active glucose-lowering treatment or placebo in which a microvascular outcome was assessed. The risk of bias was assessed using the Cochrane Risk of Bias tool. Microvascular complications included kidney-related outcomes, retinopathy, and peripheral neuropathy. An inverse-weighted variance random-effect meta-analysis was performed to estimate drugs effect over microvascular disease. PROSPERO (CRD42019120365).

RESULTS

Nineteen RCTs (n = 18,181) were included. Metformin increased estimated glomerular filtration rate (eGFR) by a mean difference (MD) of 1.08 (95% CI 0.84 to 1.33 ml/min/1.73 m²) after 24 weeks. No effect was found on urinary albumin-creatinine ratio, serum creatinine, and end-stage kidney disease; Patient-important outcomes regarding kidney disease, retinal outcomes, peripheral neuropathy or quality of life were not assessed by any of the included studies and could not be analyzed.

CONCLUSIONS

There is no evidence of clinically significant beneficial effect of metformin therapy as compared to other glucose-lowering medications or placebo on the examined microvascular complications.

Association Between Generic-to-Generic Levothyroxine Switching and Thyrotropin Levels Among US Adults

IMPORTANCE

Switching among generic levothyroxine sodium products made by different manufacturers typically occurs at the pharmacy and may affect serum thyrotropin (TSH) levels.

OBJECTIVE

To compare TSH levels between patients who continued taking the same sourced generic levothyroxine product and those who switched.

DESIGN, SETTING, AND PARTICIPANTS

This comparative effectiveness research study with 1:1 propensity matching used data from OptumLabs Data Warehouse, a national administrative claims database linked to laboratory test results. Adults aged 18 years or older were included if they filled a generic levothyroxine prescription between January 1, 2008, and June 30, 2019, and had a stable drug dose, the same drug manufacturer, and a normal TSH level (0.3-4.4 mIU/L) for at least 3 months before either continuing to take the same product or switching among generic levothyroxine products (index date). Patients were excluded if they were pregnant, had diagnosed hypopituitarism or hyperthyroidism, or had a medical condition or used medications that could affect thyrotropin levels. They were also excluded if they filled a prescription for other forms of thyroid replacement therapy between 6 months before the index date and when the first TSH level was obtained 6 weeks to 12 months after the index date. Data were analyzed from December 1, 2019, to November 24, 2021.

MAIN OUTCOMES AND MEASURES

Proportion of individuals with a normal (0.3-4.4 mIU/L) or markedly abnormal (<0.1 or >10.0 mIU/L) TSH level using the first available laboratory result 6 weeks to 12 months after the index date. A propensity score model was developed to minimize confounding using logistic regression with the binary outcome of continuing the same sourced levothyroxine product vs switching generic levothyroxine. Covariates were demographics, comorbidities, and baseline TSH level. The balance among the treatment groups was evaluated by comparing standardized mean differences of baseline covariates between the groups.

RESULTS

A total of 15 829 patients filled generic levothyroxine (mean [SD] age, 58.9 [14.6] years; 73.4% [11 624] were women; 4.5% [705] were Asian, 10.2% [1617] were Black, 11.4% [1801] were Hispanic, and 71.4% [11 295] were White individuals); of these patients, 56.3% [8905] received a daily levothyroxine dose of 50 μg or less. A total of 13 049 patients (82.4%) continued taking the same sourced preparation, and 2780 (17.6%) switched among generic levothyroxine preparations. Among 2780 propensity-matched patient pairs, the proportion of patients with a normal TSH level after the index date was 82.7% (2298) among nonswitchers and 84.5% (2348) among switchers (risk difference, -0.018; 95% CI, -0.038 to 0.002; P = .07). The proportion of patients with a markedly abnormal TSH level after the index date was 3.1% (87) among nonswitchers and 2.5% (69) among switchers (risk difference, 0.007; 95% CI, -0.002 to 0.015; P = .14). The mean (SD) TSH levels after the index date were 2.7 (2.3) mIU/L among nonswitchers and 2.7 (3.3) mIU/L among switchers (P = .94).

CONCLUSIONS AND RELEVANCE

Results of this comparative effectiveness research study suggest that switching among different generic levothyroxine products was not associated with clinically significant changes in TSH level. These findings conflict with the current guideline recommendation that warns clinicians about potential changes in TSH level associated with switching among levothyroxine products sourced from different manufacturers.

Development and pilot testing of a conversation aid to support the evaluation of patients with thyroid nodules

OBJECTIVE

To support patient-centred care and the collaboration of patients and clinicians, we developed and pilot tested a conversation aid for patients with thyroid nodules.

DESIGN, PATIENT AND MEASUREMENTS

We developed a web-based Thyroid NOdule Conversation aid (TNOC) following a human-centred design. A proof of concept observational pre-post study was conducted (TNOC vs. usual care [UC]) to assess the impact of TNOC on the quality of conversations. Data sources included recordings of clinical visits, post-encounter surveys and review of electronic health records. Summary statistics and group comparisons are reported.

RESULTS

Sixty-five patients were analysed (32 in the UC and 33 in the TNOC cohort). Most patients were women (89%) with a median age of 57 years and were incidentally found to have a thyroid nodule (62%). Most thyroid nodules were at low risk for thyroid cancer (71%) and the median size was 1.4 cm. At baseline, the groups were similar except for higher numeracy in the TNOC cohort. The use of TNOC was associated with increased involvement of patients in the decision-making process, clinician satisfaction and discussion of relevant topics for decision making. In addition, decreased decisional conflict and fewer thyroid biopsies as the next management step were noted in the TNOC cohort. No differences in terms of knowledge transfer, length of consultation, thyroid cancer risk perception or concern for thyroid cancer diagnosis were found.

CONCLUSION

In this pilot observational study, using TNOC in clinical practice was feasible and seemed to help the collaboration of patients and clinicians.

Association between maternal thyroid function and risk of gestational hypertension and pre-eclampsia: a systematic review and individual-participant data meta-analysis

BACKGROUND

Adequate maternal thyroid function is important for an uncomplicated pregnancy. Although multiple observational studies have evaluated the association between thyroid dysfunction and hypertensive disorders of pregnancy, the methods and definitions of abnormalities in thyroid function tests were heterogeneous, and the results were conflicting. We aimed to examine the association between abnormalities in thyroid function tests and risk of gestational hypertension and pre-eclampsia.

METHODS

In this systematic review and meta-analysis of individual-participant data, we searched MEDLINE (Ovid), Embase, Scopus, and the Cochrane Database of Systematic Reviews from date of inception to Dec 27, 2019, for prospective cohort studies with data on maternal concentrations of thyroid-stimulating hormone (TSH), free thyroxine (FT₄), thyroid peroxidase (TPO) antibodies, individually or in combination, as well as on gestational hypertension, pre-eclampsia, or both. We issued open invitations to study authors to participate in the Consortium on Thyroid and Pregnancy and to share the individual-participant data. We excluded participants who had pre-existing thyroid disease or multifetal pregnancy, or were taking medications that affect thyroid function. The primary outcomes were documented gestational hypertension and pre-eclampsia. Individual-participant data were analysed using logistic mixed-effects regression models adjusting for maternal age, BMI, smoking, parity, ethnicity, and gestational age at blood sampling. The study protocol was registered with PROSPERO, CRD42019128585.

FINDINGS

We identified 1539 published studies, of which 33 cohorts met the inclusion criteria and 19 cohorts were included after the authors agreed to participate. Our study population comprised 46 528 pregnant women, of whom 39 826 (85·6%) women had sufficient data (TSH and FT₄ concentrations and TPO antibody status) to be classified according to their thyroid function status. Of these women, 1275 (3·2%) had subclinical hypothyroidism, 933 (2·3%) had isolated hypothyroxinaemia, 619 (1·6%) had subclinical hyperthyroidism, and 337 (0·8%) had overt hyperthyroidism. Compared with euthyroidism, subclinical hypothyroidism was associated with a higher risk of pre-eclampsia (2·1% vs 3·6%; OR 1·53 [95% CI 1·09-2·15]). Subclinical hyperthyroidism, isolated hypothyroxinaemia, or TPO antibody positivity were not associated with gestational hypertension or pre-eclampsia. In continuous analyses, both a higher and a lower TSH concentration were associated with a higher risk of pre-eclampsia (p=0·0001). FT₄ concentrations were not associated with the outcomes measured.

INTERPRETATION

Compared with euthyroidism, subclinical hypothyroidism during pregnancy was associated with a higher risk of pre-eclampsia. There was a U-shaped association of TSH with pre-eclampsia. These results quantify the risks of gestational hypertension or pre-eclampsia in women with thyroid function test abnormalities, adding to the total body of evidence on the risk of adverse maternal and fetal outcomes of thyroid dysfunction during pregnancy. These findings have potential implications for defining the optimal treatment target in women treated with levothyroxine during pregnancy, which needs to be assessed in future interventional studies.

FUNDING

Arkansas Biosciences Institute and Netherlands Organization for Scientific Research.

Effect of Shared Decision-Making for Stroke Prevention on Treatment Adherence and Safety Outcomes in Patients With Atrial Fibrillation: A Randomized Clinical Trial

Background Guidelines promote shared decision-making (SDM) for anticoagulation in patients with atrial fibrillation. We recently showed that adding a within-encounter SDM tool to usual care (UC) increases patient involvement in decision-making and clinician satisfaction, without affecting encounter length. We aimed to estimate the extent to which use of an SDM tool changed adherence to the decided care plan and clinical safety end points. Methods and Results We conducted a multicenter, encounter-level, randomized trial assessing the efficacy of UC with versus without an SDM conversation tool for use during the clinical encounter (Anticoagulation Choice) in patients with nonvalvular atrial fibrillation considering starting or reviewing anticoagulation treatment. We conducted a chart and pharmacy review, blinded to randomization status, at 10 months after enrollment to assess primary adherence (proportion of patients who were prescribed an anticoagulant who filled their first prescription) and secondary adherence (estimated using the proportion of days for which treatment was supplied and filled for direct oral anticoagulant, and as time in therapeutic range for warfarin). We also noted any strokes, transient ischemic attacks, major bleeding, or deaths as safety end points. We enrolled 922 evaluable patient encounters (Anticoagulation Choice=463, and UC=459), of which 814 (88%) had pharmacy and clinical follow-up. We found no differences between arms in either primary adherence (78% of patients in the SDM arm filled their first prescription versus 81% in UC arm) or secondary adherence to anticoagulation (percentage days covered of the direct oral anticoagulant was 74.1% in SDM versus 71.6% in UC; time in therapeutic range for warfarin was 66.6% in SDM versus 64.4% in UC). Safety outcomes, mostly bleeds, occurred in 13% of participants in the SDM arm and 14% in the UC arm. Conclusions In this large, randomized trial comparing UC with a tool to promote SDM against UC alone, we found no significant differences between arms in primary or secondary adherence to anticoagulation or in clinical safety outcomes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: clinicaltrials.gov. Identifier: NCT02905032.

Cardiovascular outcomes and rates of fractures and falls among patients with brand-name versus generic L-thyroxine use

PURPOSE

To compare cardiovascular outcomes and rates of fractures and falls among patients with persistent brand-name versus generic L-thyroxine use.

METHODS

Retrospective, 1:1 propensity-matched longitudinal study using a national administrative claims database to examine adults (≥18 years) who initiated either brand or generic L-thyroxine between 2008 and 2018, censored at switch or discontinuation of L-thyroxine formulation or disenrollment from the health plan. Main outcome measures included rates of hospitalization for atrial fibrillation, myocardial infarction, congestive heart failure, stroke, spine and hip fractures, and rate of falls in the outpatient or inpatient setting. Hospitalizations for pneumonia were used as a negative control.

RESULTS

195,046 adults initiated treatment with L-thyroxine between 2008 and 2017: 87% generic and 13% brand formulations. They were mostly women (76%), young (94.6% under age 65), white (66%), and 47% had baseline thyroid stimulating hormone levels between 4.5 and 9.9 mIU/L. Among 35,667 propensity-matched patients, there were no significant differences between patients treated with brand versus generic L-thyroxine in atrial fibrillation (HR 0.96, 0.58-1.60), myocardial infarction (HR 0.66, 0.39-1.14), congestive heart failure (HR 1.30, 0.78-2.16), stroke (0.72, 0.49-1.06), spine (HR 0.87, 0.38-1.99) and hip fractures (HR 0.86, 0.26-2.82), or fall outcomes (HR 1.02, 0.14-7.32). Hospitalization rates for pneumonia (used as negative control) did not differ between groups (HR 0.85, 0.61-1.19). There were no interactions between brand versus generic L-thyroxine, these outcomes, and thyroid cancer, age, or L-thyroxine dose subgroups.

CONCLUSIONS

We found no significant differences in cardiovascular outcomes and rates of falls and fractures for patients who filled brand versus generic L-thyroxine.