Suboptimal Thyroid Hormone Replacement is Associated with Worse Hospital Outcomes

[helvella]

Not saying this paper doesn't have its place. Of course it does, otherwise there is too much guesswork and assumption. But, I ask you, is anyone actually surprised by this?

The cost of treating (in terms of length of stay and/or readmission) must be vastly more than providing adequate levothyroxine. (I'm assuming that the number taking T3 or desiccated thyroid was a small proportion of those added to the study.)

That cost alone should

J Clin Endocrinol Metab. 2022 Apr 26;dgac215.

doi: 10.1210/clinem/dgac215. Online ahead of print.

Suboptimal Thyroid Hormone Replacement is Associated with Worse Hospital Outcomes

Matthew D Ettleson 1 , Antonio C Bianco 1 , Wen Wan 2 , Neda Laiteerapong 2

• PMID: 35472082

• DOI: 10.1210/clinem/dgac215

Abstract

Context: Many patients with hypothyroidism receive suboptimal treatment that may impact hospital outcomes.

Objective: To identify differences in hospital outcomes between patients with and without hypothyroidism.

Design: A retrospective cohort study, using the propensity score-based fine stratification method to balance covariates.

Setting: A large, US-based, commercial claims database from January 1, 2008 to December 31, 2015.

Participants: Participants included patients 64 years and younger who had a thyrotropin (TSH) level collected prior to a hospital admission. Covariates included age, sex, US region, type of admission, year of admission, and comorbidities.

Exposure: Clinical hypothyroidism, which was divided into 4 subgroups based on pre-hospitalization TSH level: low (TSH <0.40 mIU/L), normal (TSH 0.40 - 4.50 mIU/L), intermediate (TSH 4.51 - 10.00 mIU/L), and high (TSH >10.00 mIU/L).

Main outcomes measures: length of stay (LOS), in-hospital mortality, and readmission outcomes.

Results: A total of 43,478 patients were included in the final study population, of whom 8,873 had a diagnosis of hypothyroidism. Those with a high pre-hospitalization TSH level had a LOS that was 1.2 days longer (95% CI [1.1 - 1.3]; p = 0.003), a 49% higher risk of 30-day readmission (RR 1.49, 95% CI [1.20 - 1.85]; p <0.001), and 43% higher rate of 90-day readmission (RR 1.43, 95% CI [1.21 - 1.67]; p <0.001) compared to balanced controls. Patients with normal TSH levels exhibited decreased risk of in-hospital mortality (RR 0.46, 95% CI [0.27 - 0.79]; p = 0.004) and 90-day readmission (RR 0.92, 95% CI [0.85 - 0.99]; p = 0.02).

Conclusions: The results suggest that suboptimal treatment of hypothyroidism is associated with worse hospital outcomes, including longer LOS and higher rate of readmission.

Keywords: MarketScan; hospital outcomes; hypothyroidism; quality of care.

pubmed.ncbi.nlm.nih.gov/354...

Journal link - but there is a paywall:

academic.oup.com/jcem/advan...

[DippyDame]

Maybe I'm being really dense but if patients are being treated with suboptimal thyroid replacement treatment they must already be suffering from poor health and QOL... before whatever hospital treatment ensues.The hospital treatment could/ would increase their ill health so requiring longer LOS.

If it is known that they are undermedicated why not initiate correct medication!

Or do they mean that the undermedication was not picked up until they entered hospital?

Are TSH tests routinely carried out on or just before admission...

If not how does the hospital know?

Was this a "snap shot" cohort?

Do their med records state not only hypothyroid but also suboptimal replacement?

If so, why has the latter not been addressed?

8, 873 patients in this category!!

FT3 tests may have been more useful...

Demonstrates the need to improve thyroid treatments and diagnosing techniques in the general population to improve health ...and save money methinks!!

Sorry more questions than answers...

In my case....a little knowledge etc!

Brain gone numb!!

[helvella in reply to DippyDame]

It was a retrospective study.

Which I interpret as them doing TSH tests on admission but then ignoring them! Whether out of ignorance or some other reason.

It is, really, just plain daft. With the even worse downside that people actually suffered.

[TSH110 in reply to helvella]

It’s hardly rocket science why did they have to let people suffer to prove the blatantly obvious? I agree it is daft and plain cruel

[shaws in reply to DippyDame]

It just confirms what we all already know and are aware of how poor the 'experts' - endocrinolgost/GPs - seem to be in diagnosing and returning good health to patients who're hypothyroid. How my TSH of 100 was stated by GP as having nothing wrong with my blood test.

[nellie237]

"But, I ask you, is anyone actually surprised by this?" No, I shouldn't think so, but at least it opposes that guy (Is it Pearce in Newcastle? ) who writes papers stating that Hypo's shouldn't be treated until TSH is over 10-20, and goes on about it all being in our heads.

[TSH110 in reply to nellie237]

That’s true, so a good point, but why does anyone even listen to that fatuous, sexist, ageist? All the latest quality science is not behind him he’s the one that’s behind, stuck in his own little arrogant bubble, promoting an absolution of responsibility for treating hypothyroidism, which let’s face it mainly affects older women, the very group he advises leaving to rot untreated. Decent physicians are struck off but not the real experts in neglect and dereliction of duty they seem to rise to the top.

[Partner20 in reply to TSH110]

Mainly affects older women??? Large numbers of children, young people, and those in their thirties, forties and fifties are hypothyroid. Most hypo people I know were diagnosed long before they reached an "older" age. Fewer men are hypo, yes, but simply because hypothyroidism appears less likely to affect men, although I personally know of several men with this condition, my partner included. The more you mention it, the more people you discover have it too!

[TSH110 in reply to Partner20]

Statistically speaking it mainly affects older women - that’s a fact. I did not say it didn’t affect younger people or men. The work of Pearce is saying the elderly with TSH of 10 -20 do not require any treatment. The cruelty of this view is what I was highlighting in my comment, which you do not seem to have understood as your comment is completely irrelevant to the point was making

[Partner20 in reply to TSH110]

I was not referring to Pearce at all, but to your statement that hypothyroidism mainly affects older women. If you had read my reply this would have been clear. Your statement is not proven, and actually promotes the ridiculous idea that we are all elderly suffering women who are being badly treated by the NHS. This may well be the view reflected by those here on HU, but does a great disservice to the vast number of men, women of all ages, and children, too, who are hypothyroid, the majority of whom manage their condition well.

[TSH110 in reply to Partner20]

‘Hypothyroidism is found in about 2% of the UK population and in more than 5% of those over 60. Women are 5 to 10 times more likely to be affected than men. ‘

From NICE.

I’d like to know what figures are you are working from.

[mrskiki]

Interesting, I'm wondering if I may already have been developing thyroid problems when I had an op a couple of yrs ago, ended up with hyponatremia and iron levels dropping even after a drips for both, they couldn't work out why, as they thought I'd recover quickly. I doubt they tested thyroid though even though my arms looked like pincushions by end of week ? Think I'll write in and ask if they have a set of thyroid results anyway.

[helvella in reply to mrskiki]

Suggest you ask for all results in the relevant period - and specify you want the reference intervals (ranges) as well!

[mrskiki in reply to helvella]

Thanks, yes, good idea, I only ever had blood tests 20 years before that, same hospital but dermatology, they said all hormone levels normal, go away, but wouldn't tell me which of course in those days.

[SilverAvocado]

Something I always wonder about with these studies is where they find all these people with a TSH over 10. A TSH that high is fairly rare on the forum, though pops up occasionally.

An optimistic interpretation is that the patients lucky enough to have a nice, responsive TSH are getting better treatment already so don't find the forum. Meaning we end up self selecting as people with sluggish TSHs who struggle to find treatment.

But I'm more suspicious that high TSHs of that kind are just unusual, particularly in Hashimoto's sufferers. And maybe the high TSH peeps are actually a bit of a different population. (I've got no thyroid, so of course I've had a high TSH, so has a friend I've helped, but they've got congenital hypo).

[SilverAvocado in reply to SilverAvocado]

That was a bit long, so new post for a second point.

If I'm reading this correctly, patients with both a diagnosis of hypothyroid AND a TSH between 0.40 - 4.50 had considerably better outcomes than the non-hypothyroid controls? To me this is quite a surprising result that needs extra explanation.

Rereading more carefully, it actually doesn't technically say much of what I've interpreted above, though a lot of it is implied. The word 'population' is used strangely to refer to both those with a diagnosis of hypo and those without. The 'normal' TSH group may or may not include people who don't have a diagnosis of hypothyroid, which would rope in people with a healthy thyroid as well as many people with undiagnosed underactive thyroid.

But then who would a balanced control group be? It's a bit hard to really have a control for people who have a long term illness...

I searched for the full paper because I was interested to see if they unpacked the outcomes for the other TSH groups but I guess it is not available for free.

This is another one of a huge number of studies where the headline conclusions are useful to us. But the detail of how they got there contains a lot the forum would disagree with. For example divididing people up into TSH categories and then inferring some are well on hormone replacement and some aren't is a bit of a nightmare! I'm suspicious about what will end up happening to the low TSH group 😅

I do think it is good people are doing studies even for things that seem obvious, because we need to have a basket of evidence. And lots of people are doing studies with equally obviously unhelpful conclusions like that T3 is pointless, or people with sky high TSHs are doing just fine.