REDUCING INAPPROPRIATE SERUM T3 LABORATORY TEST ORDERING IN PATIENTS WITH TREATED HYPOTHYROIDISM

[helvella]

Another paper imploring doctors NOT to order T3 tests.

Their reason is claimed to be: may reduce inappropriate monitoring practices, decrease costs, and improve utilization of limited healthcare resources

Given that the biggest burdens of doing blood tests is probably on the doctor ordering, the phlebotomist doing the blood draw, the lab interacting with the blood sample and returning results, and any follow-up, the marginal cost (or burden) of doing T3 at the same time as TSH (or, for that matter, many other blood tests) is probably a vanishingly small amount.

The inappropriateness for an individual can only be judged after the test. Otherwise, it is simply an assumption that a T3 test would add nothing and hence be inappropriate.

I'd also point out that as written, it would also declare block and replace patients as inappropriate for T3 tests. It does say the alert appears when the patient is on levothyroxine without regard as to why.

When a test is newly developed, it is claimed to do wonderful things. What happened between then and now which makes it such an awful test to order?

Note the prejudging implicit in the title. They KNOW which tests would be inappropriate without even knowing the patient exists.

Endocr Pract. 2019 Aug 14. doi: 10.4158/EP-2019-0215. [Epub ahead of print]

REDUCING INAPPROPRIATE SERUM T3 LABORATORY TEST ORDERING IN PATIENTS WITH TREATED HYPOTHYROIDISM.

Sue LY1, Kim JE2, Oza H3, Chong T4, Woo HE5, Cheng EM6, Leung AM1.

Author information

1 From: 1Division of Endocrinology, Diabetes & Metabolism; Department of Medicine; University of California Los Angeles (UCLA) David Geffen School of Medicine and VA Greater Los Angeles Healthcare System.

2 Division of Endocrinology and Metabolism, University of California San Francisco School of Medicine.

3 UCLA Health Information Technology.

4 Department of Pathology, UCLA David Geffen School of Medicine.

5 Department of Medicine, UCLA David Geffen School of Medicine.

6 Department of Neurology, UCLA David Geffen School of Medicine.

Abstract

Objective: Choosing Wisely is a campaign of the American Board of Internal Medicine that aims to promote evidence-based practices to reduce unnecessary ordering of tests or procedures. As part of this campaign, the Endocrine Society advises against ordering a serum total or free triiodothyronine (T3) level when assessing levothyroxine dosing in hypothyroid patients. This study was performed to assess and reduce inappropriate laboratory ordering practices among providers who manage patients with hypothyroidism within a large U.S. academic health system. Methods: A best practice alert (BPA) in the health record was developed and implemented following the collection of baseline data. This alert consisted of a pop-up window that was triggered when a serum T3 laboratory test was ordered for patients prescribed levothyroxine. The alert required user acknowledgement before the serum T3 laboratory test could be ordered. Results: During the six-week period prior to launching the BPA, serum T3 tests were ordered a mean of 162.3 ± 15.4 [standard deviation] occurrences per 10,000 patients per week. Over a 15-week period following implementation of the BPA, the frequency of serum T3 orders steadily decreased and resulted in >44% fewer inappropriate tests being ordered. Conclusion: Although national societal guidelines recommend against ordering serum T3 concentrations while monitoring patients with hypothyroidism managed with levothyroxine, these laboratory tests are frequently ordered. Development of a triggered alert in the health record may reduce inappropriate monitoring practices, decrease costs, and improve utilization of limited healthcare resources for this common clinical condition. Abbreviations T3 = triiodothyronine; BPA = best practice alert; ATA = American Thyroid Association; U.S. = United States; TSH = thyroid stimulating hormone.

KEYWORDS:

hypothyroidism; thyroid diseases; thyroid dysfunction

PMID: 31412225

DOI: 10.4158/EP-2019-0215

ncbi.nlm.nih.gov/pubmed/314...

[greygoose]

Makes you sick, dunnit.

[MaisieGray in reply to greygoose]

Makes me want to smack them all very very soundly indeed, whilst shouting 'Don't be so b***dy stupid', in their collective ears.

[greygoose in reply to MaisieGray]

Oh, absolutely, that too. It's really unbelievable that these so-called 'experts' - presumably intelligent people - can be so thick. But, if you want to see stupidity in its pure state, come on a thyroid forum and read some of the things doctors have said.

[MaisieGray in reply to greygoose]

Yes, we really should be compiling a list of them all, but life's too short

[greygoose in reply to MaisieGray]

They have done some of that on the STTM site, and it's dismal reading.

[Hidden in reply to greygoose]

My TSH was very low and T3 and T4 high in range but I still felt hypo. By some miracle, they believed me and sent a referral request to the local endocrinology department (there were mistakes in the request, but that's another story. Sorted now, thankfully).

The request was refused on the grounds that my results were well within range. Which was of course the actual reason for sending the request in the first place!!!!

[greygoose in reply to Hidden]

lol

[shaws Administrator in reply to MaisieGray]

What about removing their thyroid glands for a while!!!!! They seem to have forgotten that we have disabling clinical symptoms. 'Symptoms?' you will hear them say "what's that?!.

Are we all to become the 'new' suffragetts?

en.wikipedia.org/wiki/Suffr...

[jimh111]

Thanks, I'll read it sometime. Full paper here journals.aace.com/doi/pdf/1... .

[kissemiss in reply to jimh111]

" However, as there is a subset of patients who may instead be treated with thyroid hormone formulations that contain T3, assessing serum T3 concentrations during monitoring is reasonable to ensure against T3 excess; this monitoring method has been suggested, but not recommended, by the ATA (14), although monitoring using T3 is difficult in patients taking T3 due to fluctuations during the day and the short half-life of T3 ."

When I had my last blood test (recommended by a high up endo) I was told from now on we only need to measure "tsh" because.. and he quoted the above text.... "due to fluctuations during the day and the short half-life of T3".

I have been on t3 only for about 20 years.

[jimh111 in reply to kissemiss]

It is more difficult to monitor hormone levels for patients on T3. Tough, it still should be done, being difficult is not an excuse to use something easy to measure, especially when it is not so useful. I have my blood taken about half-way between L-T3 doses, this will give a very rough idea of my average fT3 levels.

The text 'assessing serum T3 concentrations during monitoring is reasonable to ensure against T3 excess' gives the game away. Serum fT3 should be monitored as a guide to whether there is excess or insufficient treatment (in conjunction with symptoms and clinical assessment). Their only concern is to worry about excess treatment, no consideration given to insufficient treatment.

They also fail to point out TSH fluctuates considerably during the day and even more so through the menstrual cycle.

[Greekchick]

UGH - enough said about that. Thanks for posting, helvella.

[diogenes Remembering]

You know, when I read this I simply scratch my head (rather than feeling somewhat ill). Do these people ever properly read the literature? It really makes me wonder at the bovine lack of intelligence and curiosity to discover what is actually being found out, that destroys their position. This ostrich attitude (heads in sand) seems to hardwired into these peoples' socalled brains. Nothing but nothing will move them. Truly they'll have to retire and die before sense and objectivity can prevail (or perhaps new prejudices). However, as I've discovered many times, medics in the US pay absolutely no attention to work done and conclusions made elsewhere in the world and will intellectually steal ideas to their own benefit when they get round to repeating the work and claim the discoveries as their own achievement. For them if they believe the sun rises in the west, then it does so, period and dissenters are simply seeing things backwards until perhaps magically all is quietly reversed. On the contrary, all of us are the same human stock and behave in the same way, no matter what flag we live under.

[Greekchick in reply to diogenes]

👍🏻👍🏻👍🏻

[shaws Administrator in reply to diogenes]

How awful it is that they 'dare' to steal others' research findings. Don't forget Big Pharma is out to make profits (it seems to me) and if we're made well then there's no need for 'additional prescriptions' if we only have to take thyroid hormones to be well again (proper ones that suit an individual).

[Margo in reply to shaws]

Spot on shaws , well said!

[Baobabs]

Last time I had blood tests in Saudi it was decided T3 was not necessary despite me having to take T3 as well as T4 for Hashi’s and I have private med cover. I fought like hell to have it done, even thought I may be chopped into pieces, put in a bath of acid and effectively got rid of. There really is no hope for any of us!

[FarmerDJ]

Feeling happy that I live in the UK. When doing TSH and T4 tests, how is not doing T3 at the same time going to save money, especially as peoples private health insurance should be covering any cost.. crazy.

[humanbean]

It seems to be a growing trend in medicine. Keeping doctors ignorant about lots of different illnesses means less money needs to be spent on healthcare. If the herd are ill they can just be allowed to die. There's too many of them anyway, and a cull is overdue.

[Tongue firmly in cheek and being VERY sarcastic!]

[JGBH in reply to humanbean]

Indeed I agree with you. The cull is most important if one is over the age of 65 and has a few complex health issues! Just deny everything, it makes work easier and save lots of money and to hell with the miserable quality of life patients have before they pop their clogs! Not reassuring getting old and being ill in 2019 UK....

We have no choice it seems... so depressing and infuriating.

[Hidden in reply to humanbean]

The only thing is, it actually costs POTS and POTS of money to care for us poor souls while we are in the process of dying for lack of what they could so easily supply.

[humanbean in reply to Hidden]

I agree. There is no benefit to keeping people ill. I would guess that healthy people bring in more taxes, earn more, spend more, and help the economy.

[Angel_of_the_North in reply to humanbean]

The best ones to cull would be politicians and endos ...

[humanbean in reply to Angel_of_the_North]

Bloodthirsty - but justified!

[linda96]

Last year I had a look at the ABIM.

They were started on $10m of funding, but that was not enough apparently, and I think the funding eventually went up to about $60m. It would have been cheaper to cut out the Choose Wisely campaign and paid for the tests!

So what’s the REAL reason they don’t want T3 testing done, then eh?

Don’t test T3, don’t talk about it, .... don’t prescribe it, lose the memory that it exists... just take this little white pill of Levothyroxine..

...just who are they trying to kid??

[helvella Administrator]

Many cars, even today, have both a rev counter and a speedometer. That appears redundant and wasteful. After all, if you know your road speed, and which gear you are in, you can work out your revolutions per minute to quite a decent accuracy.

What a rev counter can do is help identify "bad things" - like clutch slipping, or the precise revs at which it misfires - or the exact point at which to change gear for optimum acceleration. (No, I am not a vehicle engineer of any sort, so these examples might not be the best!)

Funnily enough, rev counters are particualrly common in more expensive, smarter cars, the sort that consultant doctors might be expected to run.

A classic for carpenters, builders, and similar, is to measure right angles with a square, and the sides AND diagonals with a ruler. Good old Pythagorus shows us that will identify a room or box that is not actually square.

[Hidden in reply to helvella]

Good illustration!

[JGBH]

Thanks for this.... what depressing reading it makes.

[helvella Administrator]

And an abstract on Reflex and Reflective thyroid testing. It still ends up asserting that logic and maths dictates when FT4 and FT3 tests should be done. Without any consideration that if you only do one test, anything at all that upsets that result (biotin, various antibodies, lab mistakes) leaves the patient in a very bad place.

May I point out that the grounding of the Boeing 737 Max fleet was very largely due to the reliance on a single sensor? Anything wrong with that left the pilots in a situation which they could not understand sufficiently to even start to manage.

By the way, the ugly really is ugly.

Reflex TSH strategy: the good, the bad and the ugly

Mario Plebani / Luca Giovanella

Published Online: 2019-07-17 | DOI: doi.org/10.1515/cclm-2019-0625

degruyter.com/view/j/cclm.a...

(You just might be able to find the full paper somewhere. Even if not, the first page is just about readable in the link above - and it is only a short paper.)

[Hidden]

GRRRRRRRRR

[Gambit62]

suspect it would be okay if the GPs actually talked to and listened to their patients before doing the tests to ask if they were okay on the meds and then decided to order T3 where the answer was no but as it is extremely rare to speak to a patient on levo before actually doing routine monitoring tests it's rather worrying.

[DippyDame]

What!!

There is only one (sadly impossible) answer that I can see..."they" need to walk in our shoes and judge the issue through the soles of their feet because there seems little evidence that their (intelligent) brains operate in the expected place.

GRRRRRRRRR