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Adoption of TSH Reflex algorithm in an Italian clinical laboratory

A few days ago, someone mentioned TSH Reflex - and in general we didn't know what was meant. So it is lucky that this paper has just been published.

Note the emphasis on costs.

Note that there are many possible interpretations. Fewer requests for FT4 and FT3 because they never get done even if asked? (We do not know if that happens in Italy.)

Ann Ig. 2017 Jul-Aug;29(4):317-322. doi: 10.7416/ai.2017.2158.

Adoption of TSH Reflex algorithm in an Italian clinical laboratory.

Caldarelli G1, Troiano G2, Rosadini D2, Nante N3.

Author information

1 Laboratory Medicine Functional Area, "Misericordia" Hospital of Grosseto, Italy.

2 Post Graduate School of Public Health, University of Siena, Italy.

3 Post Graduate School of Public Health, University of Siena, Italy - Health Service Research Laboratory, University of Siena, Italy.



TSH Reflex is an automated diagnostic algorithm which follows the rule "If ... then", in which the initial determination of TSH is followed by the determination of fT4, and possibly of fT3, if TSH is not within the reference limits. The aim of our study was to evaluate the results of the introduction and implementation of the test "TSH Reflex", which started in late 2013 in the hospital of Grosseto, comparing the requests of thyroid hormones for external patients, in 2012, 2014 and 2015.


In our study we analyzed the number of thyroid tests prescribed in 2012, 2014 and 2015 and we calculated the increase in prescription of "TSH Reflex" from 2014 to 2015; the prescriptive appropriateness, after the introduction of the "TSH Reflex", through the ratios TSH/FT4, TSH/FT3 and the ratio "TSH Reflex"/TSH. Finally we calculated the total spending for the reagents in 2012, 2014 and 2015 and the consequent savings in euros (the costs of the reagents did not change during that time).


Requests for TSH decreased by 4.6% in 2014, compared to 2012 and by 5.4% in 2015 compared to 2014, with a 9.8% reduction in 2015 compared to 2012. The requests for FT4 decreased by 11.5%, comparing 2014 with 2012, by 5.3% comparing 2015 with 2014, with a 16.2% reduction in 2015 compared to 2012. The requests for FT3 decreased by 13.3% in 2014 compared to 2012 and by 8.4% in 2015 compared to 2014, with a 20.6% reduction in 2015 compared to 2012. The appropriateness, evaluated the indicator TSH/FT4, increased by 7.6%, comparing 2014 with 2012, and remained unchanged in 2015. In 2012 71,134 euros were spent, 63,998 euros in 2014, 60,055 euros in 2015, resulting in a saving of € 11,079 in 2015 compared to 2012. The spending for "TSH Reflex" should be subtracted (1,964 Euros in 2015) from the previous savings.


The improvement of the efficiency and the prescriptive appropriateness was better in 2014, the first year of implementation of the "TSH Reflex". The overall assessment suggests that the 2014 results are attributable to the letters that general practitioners received in December 2013, with a temporary increase of the use of the test. We need further analyses with the same indicators in order to assess the possibility of additional improvements in the future.


Clinical laboratory; Cost effectiveness; TSH Reflex

PMID: 28569340


6 Replies

Still puzzled.If it means : TSH normal do not do further tests , where does the cost for "TSH reflex " come from?


The other side of the coin - if TSH is out of range, then positively do further tests.


I must have missed the original comment. I can't help with your puzzlement I'm afraid. I googled the phrase "TSH reflex algorithm" and came up with this


Wasn't there a thread a while ago about laboratories being given the responsibility for follow-up tests as a cost-cutter?

Is this the start of a trend?


It most certainly does look like the start of a trend.

The very title of that paper ends with "... to Decrease Unnecessary Thyroid Function Testing". The aim of medicine is supposed to be to make people well not reduce number of tests - the reason for which is so obviously money. Had the title ended "... to Improve Diagnosis of Patients" it might have been more acceptable.

Of course we do not want money to pour from the NHS into the coffers of test manufacturers. But we want proper investigation that is not curtailed on the basis of TSH alone.

Ironically, in that paper it says:

There are specific medical conditions where a full set of TFTs are useful: this includes symptomatic patients who have previously been diagnosed with hyper/hypothyroidism, patients prescribed thyroid medication, patients with atrial fibrillation, the geriatric population, psychiatric patients, and in AML.8 Thus, in these patients, a full TFT panel is needed. Moreover, only fT3 and fT4, without a TSH, are needed in cases of primary hypothyroidism.

So their implementation of reflex and hard stops actually excludes most of the people on this forum! But we know that the underlined sentence is positively turned upside down in the context of the UK.


Sorry, I need to re-read that. It'll have to be tomorrow now.

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Yes, I had missed that comment. And thank you for posting.

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