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

[helvella]

Don't know about you, but the fundamental aim of this study seems grossly mis-placed.

The aim should be the best outcome for patients. That a best outcome might require changes to testing regimes is, in itself, fine. When the aim is "reduce", that will be the result.

We are living with the impact of reduced FT4 and minimal/rare FT3 testing in the UK. It is, in my book, impossible to assess the impact of reducing tests in the short term - such as in this paper. I mean, how many of us might have been diagnosed differently had we got FT4 and FT3 tests results from a long time ago? How much would full FT4 and FT3 testing contribute to the field of thyroidology?

Coming up with acronyms like PDSA doesn't hide the underlying fact that the aim is to save money.

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

JenniferTaher

Daniel R.Beriault

DrakeYip

ShafqatTahir

Lisa K.Hicks

Julie A.Gilmour

doi.org/10.1016/j.clinbioch...

Get Highlights

• Successfully decreased unnecessary fT4 and fT3 testing in a large tertiary hospital.

• Applying the Model for Improvement was pivotal in reducing fT4 and fT3 testing.

• Multiple plan-do-study-act (PDSA) cycles were required to achieve the project aim.

• Assessing balancing measures were important in refining change ideas.

• Post-implementation monitoring was vital in identifying implementation errors.

Abstract

Objectives

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

Methods

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

Results

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

Conclusions

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

Keywords

free thyroid hormones

reflexive testing

laboratory utilization

quality improvement

balancing measures

sciencedirect.com/science/a...

[Hidden]

"Free thyroid hormones (fT4 and fT3) are one of the most commonly ordered laboratory tests and often ordered when not clinically meaningful. Based on this, many studies have sought to identify strategies to reduce inappropriate fT4 and fT3 testing."

Why don't they try to "Identify strategies to reduce inappropriate TSH testing"? For example, when someone is on T3 only and has suppressed TSH that never changes?

[Hidden]

Must admit that whenever the doctor orders a Thyroid function test I add "TSH, T3, T4", otherwise they will only test TSH.

PS, Don't tell!

[DippyDame]

A Canadian study, so difficult to compare with UK testing protocols

By, "not clinically valuable" (first sentence) might we conclude that they do not/cannot correctly understand/ interprete test results... taking in- range to indicate "normal". A trap many in the UK have fallen into.

There can only be one conclusion and that is to save money....this seems to be the mantra amongst Health Boards - is it the same in Canada? I don't know but probably!

"Overall, FT4 and FT3 testing was decreased by 39% and 47%, respectively." Are they now diagnosing mainly by clinical evaluation as in pre testing days....or are more patients suffering from wrong diagnoses due to a cost cutting exercise.

Or is poor thyroid education in med schools behind this idea?

Had (since you ask) medics picked up on my clinical symptoms long time ago and combined those with FT4 and FT3 testing I may not have experienced decades of health issues, wrong diagnoses and wrong medication and treatments. Nobody suggested thyroid tests until I suspected the problem may lie there...it did, but the true nature of the problem was only revealed when I started to "dig" and, in my seventies, found the answers here TUK. Is this the future for even more young patients?

I may just be a cynical old woman but I'm left with the impression that this a load of tosh in the disguise of a cost cutting exercise. FT4 and FT3 tests are there for a good reason and interpreted correctly are vital for thyroid patients.

Economy before health!

My head may now be on the chopping block but like many of us I am incensed that so many patients are suffering - often for decades - from shockingly poor diagnoses and treatments. This paper does nothing to change that as far as I can see.

Until medics (as these authors) listen to the scientists then more tests will be removed... with obvious consequences.

Somebody set me straight if I'm wrong

Best...

DD

[helvella in reply to DippyDame]

I'd like to consider, if thyroid tests were entirely without cost, what regime would be appropriate?

(After all, we can measure our body weight, height, hair and eye colours, heart rate, to reasonable accuracy for effectively no cost. At least, no additional (incremental) cost if we have a scale/tape measure/eyes/watch.)

Then work back from that to try to assess how much loss there is at each step.

[DippyDame in reply to helvella]

Loss of patience (and/or patients) for a start!

[fuchsia-pink in reply to DippyDame]

Can't help but think back to the Thyroid Trust conference in London I attended in the dim and distant days before lock-down [see post about it] where the number of us who had had free T3 tested on the NHS was (just) exceeded by people who had only had it tested privately.

So the net result is not that free T3 isn't tested: it's that the patient has to step in to remedy the deficiencies of their health professionals.

Marvellous. Truly a step forward.

[DippyDame in reply to fuchsia-pink]

In order to improve my health I had to take control....my GP at that time knew little about T3 but she did test...once. She was interested in my findings but sadly moved to another area.

Now my practice is no longer allowed to test T3.

I asked to see an endo whose knowledge was riddled with holes. He tested TT3...

and was not conversant with hormone resistance.

Man flew to the moon, surely accurate testing is not impossible.

Oh! But the test results need to be correctly analysed....and how much easier and cheaper it is just to test TSH .

If the patient doesn't respond to basic levo protocol and recover then it must be something else.....exercise more, lose weight and eat a healthy diet.

If that fails it must be the patient's fault!

Sorry...poor testing is a very sore point!

Dr Ord, in the late 1800s had a better grip on things...

[tattybogle in reply to DippyDame]

I agree, there are not many branches of medicine where i would prefer to be treated using method's from decades ago. But i make an exception for thyroidology.

I wish no one had invented any blood test's ,if they are not going to use them properly. And then they'd have to figure it out by ........ LOOKING AT THE PATIENT......!!

[DippyDame in reply to tattybogle]

....and listening!

[birkie]

Hi again helvella ❤️

That post was interesting.. We're routinely told that their is no need to check T3 or T4 just TSH.... If this is the case why when I was rushed in to hospital in thyroid storm did the doctor request full thyroid pannle, T3, T4, TSH.. Then I was taken in again full pannle done again.. As I've said before on here my thyroid was very toxic and needed to be removed.. I attended the hospital many times before my op for bloods and the hospital always did T3, T4, TSH.. So if T3, T4 arnt relevant for our gp to do them.. why do doctors at the hospital requested full thyroid pannles..make no sense... I demand full pannle and bar one time I get a full thyroid pannle.. I'm not saying my GPS are pleased about it they always tell the fairytale about not needing T3 or T4 and TSH is all you need I say I've always had full thyroid pannle from the hospital so we will continue with it thank you... 😊

[diogenes Remembering]

I think reading between the lines, that this is an attempt to justify TSH-only testing as much as is possible. It is rather ripe of these authors to talk about FT3 testing in Canada, when the authorities there already are strictly opposed to such testing as a blanket restriction. Of course there will always be some doctors who test thyroid function in inappropriate circumstances but any drift towards TSH only in assessing therapy (what this study is actually promoting in a rather underhand way) is frankly disastrous and goes against the findings in modern literature. Ironically FT3 testing in therapy should be increased rather than decreased, with FT4 and TSH taking a significantly smaller role. This paper is another example of categorisation: treating a patient group as a statistical entity rather than dealing with the patient as an individual. Clinicians these days seem to have lost the idea for the need to practice medicine in a unique patient-doctor relationship. Rather a faceless imposition of a general idea on any one patent to decide whether or not to test. Diagnosis by the numbers, except they have even fewer numbers to examine, and the one they give most credence to is actually the most unreliable.

[diogenes Remembering]

I'd hate to be in their shoes when Prof Tania Smith gets on to them.

[helvella in reply to diogenes]

Am really looking forward to that!

[DippyDame in reply to helvella]

Me too!

[linda96]

This is coming from the Choose Wisely initiative, whether it says that or not. It’s the same mantra from them. CW was set up by the American Medical Association.

You have to ask why the AMA are sending out this message when

yesterday on Twitter, the President of the European Society for Endocrinology stated that you need Ft3 and ft4 results with symptoms in order to help patients.

Choose Wisely comes in all guises, they operate here in the UK, NZ and other countries. The initial seeding finance for CW was approx $60m. You have to ask why? When all they seem to be doing is advocating for less testing. Are they also for prOscribing medicines? Don’t know.

If the pharmaceutical companies are behind this AMA/CW initiative then we need a clear open dialogue, to find out why. If CW a ‘long game’ sales pitch for t4 then I’m sorry, but it has to stop.

CW also advocate for other tests not connected to thyroid to be culled. I have not seen CW advocate for tests to be added to test protocols.

[Marz in reply to linda96]

Before reading your post I was thinking that it was possible this was being influenced by Insurance Companies - who in turn seem to be influenced by Big Pharma. All in all nothing to do with health ... only the mighty dollar.

I was under the impression the cost of testing T4 and T3 was under a £ ...

[pennyannie in reply to Marz]

From memory T3 and T4 cost the same to process and a few years ago think it came out at around 91 pence for each one, though the hospital laboratory mine were sent to charged me around £34 for the pleasure and sent the results to my doctor, so I then had to grovel for the results - T3 was 25% through range against a T4 at 80% through with a TSH low / suppressed at around 0. 57 :

Yes, Graves Disease post RAI thyroid ablation in 2005. Oh, how I regret this treatment, though wasn't even offered an option, though well on the Carbimazole - hey ho !!

[Marz in reply to pennyannie]

Yes you are right about the costs - I remember Jim posting about them.

Hope you are OK now 🌻 - and well practised in taking control no doubt !!

[pennyannie in reply to Marz]

Yes thank you - I'm much improved and I'm now self medicating with NDT - in total control and no TSH - so be it :

[Hidden]

If a patient has definite hyper or hypothyroid symptoms, a TSH test on its own might help with initial diagnosis. It may also give an idea of how treatment is going in the early stages. But that seems about the limit of its usefulness without T3 and T4 being tested as well.

[TSH110]

PDSA is also an acronym for the Peoples’s Dispensary for Sick Animals it has an eerie irony about it but at least they try and make the animals better not worse!

[tattybogle in reply to TSH110]

I have wondered for years whether we would get more effective treatment from a vet. Come to think of it , i wonder if the cost of replacement hormones for animals has risen like T3 has ! It may be easier to get prescribed by pretending to be a horse. Neigh!

[DippyDame in reply to tattybogle]

Love it!

I've often thought the vet would do a better job.

[tattybogle in reply to DippyDame]

If you can lay your hand's on a pantomime horse costume i'm up for it!

[DippyDame in reply to tattybogle]

I knew a (late) vet prof. who would have been up for that too....he was full of fun.

[tattybogle in reply to DippyDame]

I think we may be onto something here . I've just googled 'hypothyroid horse' and found this...... "thyroid-function-and-dysfunction-horses-part-1-and-2-proceedings "

It mentions deiodinase enzymes , eating a kind of grass that causes Secondary Hypothyroidism, and best of all there is no commercially available TSH test ...yet!

and I've only read part one !!!

Right i'm off to find me a vet........clip clop ,, ,, ,, ,, ,, ,,

Ps sorry i still can't copy and paste a link, but my hooves are too big for the keyboard

Tat the Fire Horse

xx

[Marz in reply to tattybogle]

Racehorses also have a B12 injection before a race - so yet another reason to return as a horse ! Sheep too need B12 jabs as they get depressed !

[tattybogle in reply to Marz]

Mmm.... Will Endocrinologist's be offended if we asked to be referred for a second opinion...... from a vet!............ not going to lose any sleep over it though, as i gather from here most of em don't mind offending recalcitrant thyroid patients.

And i bet race horse Vets are trained in nutrition too.

[helvella in reply to tattybogle]

And is there a connection between equine thyroid issues and laminitis?

[tattybogle in reply to helvella]

Yes ,but guess what ....it's 'controversial'

[tattybogle in reply to tattybogle]

But , they give them thyroid hormones anyway because it seems to work...... hurrah for common sense!

[tattybogle]

Bravo!!! ....... just what we need ... LESS information on thyroid hormone levels.... do you have an address so we can send flowers to express our gratitude....NOT

[humanbean]

With TSH only I can't see how any patient with central hypothyroidism can ever be diagnosed. And what about those with thyroid hormone resistance? They will also be cut adrift and allowed to suffer.

[DippyDame]

Do they know anything about symptoms! Blue Moon as you say!

My long list didn't ring any bells with them even when I reached the stage that I could barely function....I was even offered a talking therapy. I politely gave that suggestion short shrift!

[DippyDame]

I gave up on medics and now self medicate

I found the best advice and guidance here.....without it I would most likely have followed my Grandmother's fate. Years in bed and some painkillers. The best they came up with was fibrositis - now fibromyalgia or CFS. - which researchers now consider to be the result of low T3.

Amazing what family (medical) history crops up when you try to join up the dots.

I doubt Granny's medics even considered a thyroid problem!

[jgelliss]

We can very easily remedy the thyroid testing with FT4 FT3 TSH with home testing kits . It would be financially a win win for all. If diabetics can self test at home the time has arrived for thyroid patients as well . This could solve thyroid patients stress/agony/ when begging Dr's for thyroid tests other than TSH.

If we can put man on the Moon /Mars we most certainly can have thyroid home test kits.

[helvella in reply to jgelliss]

In the early days of the motor car, they had few diagnostic tools. Just observations like "smoke", "petrol smell", "poor acceleration".

Then we started to see some diagnostic tools - rev counters, vacuum gauges, spark timing detectors, etc. But these were primarily garage tools for when something is wrong. (Though some did appear as permenent accessories.)

Gradually electronics were introduced which both detect and, to a large extent, manage numerous things happening. With the additional benefit of displaying warnings when things go wrong. Modern cars are chock full of sensors - tyre pressure, wheel spin, temperature, humidity, battery charging, even headlamp dipping and lane detection!

Although we are starting to see things like watches which can check pulse, etc., the basic biochemical tests are still regarded as exceptional diagnostic tools - to be done when things are wrong. Not for one moment wishing to see permanent internet connections for our bodies, the ability to run tests should be seen as opportunities - not costs.

We have seen the effective costs of Full Blood Count and various dip stick tests fall. Let us see some of the same invention applied to tests for monitoring thyroid disorders. (I do appreciate that it is not certain it would be possible. But there are numerous things to look at. I keep wondering about hyperspectral imaging.)

[jgelliss in reply to helvella]

Helvella I couldn't agree with you more . Opportunists over Cost. Even though cost would/could be lowered. Self testing thyroid home kits would be very beneficial for so many of us . We can cross reference our symptoms with serum instant home thyroid kits results . That would infect be a huge help for us thyroid patients as well as the Dr's.

If we can have heart monitors hooked up to phones for Dr's to read the heart monitors of their patients . Then thyroid home testing kits should not be much of a problem either.

[helvella in reply to jgelliss]

There are almost entirely useless home TSH tests - they just detect over or under 5 (or whatever the precise number). And home finger-prick tests. But the costs are significant.

But I am currently veering away from TSH, FT4 and FT3 and towards numerous other measurable "things" - not that I know what would be good to measure!

[jgelliss in reply to helvella]

Helvella I trust you will come up with great ideas . Your a *Great Think Tank*. All I know is many changes are needed . Dr's test TSH mainly and omit the very important markers FT3 FT4 that are so very telling . Patients shouldn't have to beg /plead from their Dr's to see a full picture of their thyroid panel.

[MichelleHarris]

When I look at the rarity that my TSH has been tested over the years never mind T4 and T3 they have got to be joking! I had Myxoedema and had put on 20 kgs, could hardly move and had to beg for them to do more tests to find out what should have been obvious to any doctor. This will mean more NHS neglect by arrogant well paid medics.

[helvella in reply to MichelleHarris]

I agree - my own FT4 has hardly ever been tested. FT3 only once - a recent private test.

There are, effectively, no savings to be made on my testing. Once a year TSH - at most. That being what they say I must have. (But my current surgery doesn't do anything to remind me, or to check before dispensing. Just went about two years without any testing at all.)

[tattybogle]

To continue your mechanical analogy, I find it simple to explain thyroid problems to my mechanical friends,

'My engines not running at full power and cant make it up hills anymore (and the thermostats buggered )

but the doctors will only check the fuel gauge ,and refuse absolutely to adjust the carburetor'

They understand the problem immediately !

So to improve our diagnostics toolkit i would like;

An instant home T3 test that i could use when i felt 'off ', not when i could afford it.

Really not bothered about TSH ,T4 - i think they just cause trouble !

For the Hospital, i'd like a T3 Tissue /organ scanner please, so there would at least be something useful to be found in the thyroidologits insulting room.

' Hyperspectral Imaging' ? sound's like a new age hippy idea to me. Is it like TM ?

[helvella in reply to tattybogle]

Hyperspectral imaging means, really, two things at the same time.

First, using light from infra-red up to ultra-violet.

Second, looking at only one very narrow range of wavelengths at a time.

Imagine having a light in your room which emits only a single colour. (Old yellow/orange street lamps were very close to this - sodium yellow.) And a dial to choose the colour.

Plus a camera.

Turn the light on and turn down to infra-red. Take a photo. Nudge the colour up a tiny bit. Take another picture. Repeat and repeat. Our eyes see three colours - but this technique would let us "see" maybe a hundred colours.

I have no idea what this would reveal about thyroid but I'd like to know!

Bear in mind that many compounds fluoresce under ultra-violet light. We might find that produces interesting results.

This is one possible application - wound healing:

spectroscopyeurope.com/news...

[tattybogle in reply to helvella]

Ah! i understand now, i agree that looks interesting , for a minute there i thought you'd been eating psylocybe .

OK lets get one of them too !

I would also like to measure how fast my nails grow,

and the speed of muscle relaxation,

and the speed and intensity of reflexes,

sometimes i startle massively, and sometimes sometimes i'm like a corpse!

i'd also like to 'see' whats happening in the language centre in my brain when sometimes i can only manage 'on the ....behind the...... no ..... butter dish......... yes ....that '

[helvella in reply to tattybogle]

It seems to me that some of these things might be achievable without anything very sophisticated. For example, make some indelible marks on a nail (e.g. permanent ink). Photograph the nails repeatedly over the next week or month (once a day).

Then analyse using some clever software to compare each day's photo with the next day.

Do something similar on skin and use video to show how quickly muscles relax.

In so many ways, our mobile phone have the potential to do many fancy tricks. Add in the fitness watch hardware and you really are doing amazing things.

[tattybogle in reply to helvella]

I can do the first one .

The rest will have to wait until i 've learned how to copy and paste.

[Hillwoman in reply to tattybogle]

I'm stealing your analogy - it's perfect!

[tattybogle in reply to Hillwoman]

I've had a look at yer car but there's plenty of petrol in your tank luv ....... so there's nothing wrong wiv yer engine. Have you tried Antidepressants or talking to it ?

[Hillwoman in reply to tattybogle]

🤣🤣