Thyroid Function Testing in the VA Ambulatory Clinic David Sanders Cost Conscious Medicine May 2017

Thyroid Function Screening? Controversial to screen asymptomatic non-pregnant adults No clinical trials have examined the benefits of screening USPSTF: Insufficient evidence to recommend screening general population

Whom to Test All patients with symptoms of hyper or hypothyroid Substantial hyperlipidemia Hyponatremia High serum CK Macrocytic Anemia Pericardial or pleural effusions Previous thyroid injury Hyponatremia Pituitary or hypothalamic disease History of autoimmune disease

Objective To evaluate whether TSH testing is over-utilized in the VA ambulatory setting

Methods Chart review of 49 patients seen consecutively by Resident D in the Bravo clinic at the LBVA from July 1 2016 – December 31st 2016 Laboratory tests are generally ordered prior to the patient coming to clinic Each patient was assessed if TSH was ordered for that visit Each clinic patient was assessed for one of the previously mentioned indications for testing

Results TSH ordered for 26/49 patients Of patients with TSH, testing was reasonably indicated in 9/26 patients Some indications that were found acceptable for those 9 patients Stiffness Unintended weight loss Weight gain High degree AV block Depression

Results Continued Thyroid testing was most often ordered for patients visiting clinic for routine health maintenance and without any specific symptoms or other indications for testing. Of the 17 patients who were unnecessarily tested 1 had an abnormal TSH

Cost of Testing According to Health Care Blue Book TSH costs $44. $44 x 26 patients underwent testing = $1,144 over 6 months total $44 x 17 patients unnecessarily tested = $748 over 6 months $748 x 2 = $1,496 per year, for unnecessary testing in one resident’s patient panel 0/17 times TSH result changed management

Conclusions TSH was often ordered as a part of routine screening for many patients visiting LBVA Bravo clinic This overutilization of the TSH test was costly and did not alter management