Decreasing Utilization of Screening Thyroid Function Testing in a Primary Care Practice: A Quality Improvement Project

From the 2022 HVPA National Conference

Sara Velayati MD (Long Island Community Hospital), Olga Karasik MD, FACP, Ravi Gupta MD, Zubin J Tharayil MD

Background

Although thyroid disorders are commonly encountered in the primary care setting, unnecessary thyroid function testing (TFT) may result in detecting clinically insignificant abnormalities, leading to possible unnecessary treatment, increased costs, patient anxiety, and unnecessary sub-specialty referrals. The role of screening for thyroid dysfunction is controversial; the United States Preventive Service Task Force (USPSTF) does not recommend routine screening for thyroid disease among nonpregnant asymptomatic adults (grade I recommendation). Currently, our primary care practice Brookhaven Family Medicine Clinic (BFMC), does not have a standardized process for thyroid function screening. We implemented a quality improvement project using a standardized process, utilizing a multidisciplinary approach and the USPSTF screening guideline for thyroid function testing, to decrease our screening TFT rates.

Objective

To develop and implement a standardized process, utilizing the USPSTF screening guideline, to decrease thyroid function screening in nonpregnant asymptomatic adults.

Methods

The records of BFMC patients 18 years of age and older who had a resident visit for a complete physical exam (CPE) or an annual wellness visit (AWV) during a six month period of 2019 were reviewed to assess: 1) if TFTs were ordered under those encounters and 2) if TFTs were ordered under CPE/AWV diagnosis codes. Residents, medical assistants, and attending physicians were educated on the thyroid screening guideline. Residents created a data collection form to track TFT orders for every qualifying encounter and, when applicable, reasons for ordering the TFT. Additionally, residents created a visual reminder, in the form of a laminated card, which was placed on every physician and medical assistant’s computer in the office. The study period took place from February 14, 2022, through March 25, 2022. The primary outcome was to decrease the number of unnecessary screening TFT (defined as TFT ordered under CPE/AWV diagnostic codes) ordered during resident CPE or AWV encounters.

Results

A retrospective review from July 1, 2019, through December 31, 2019, revealed 337 eligible resident encounters of patients without any history of thyroid disease. Among those, TFTs were ordered in 150 encounters (44.5%) and, in 74 of those encounters, TFTs were ordered under the CPE or AWV diagnosis codes (22.0% of all encounters). During the study period, there were 102 qualifying encounters. TFTs were ordered in 42 cases (41.2%) and, of those, there were 4 patients (3.9% of all encounters) who had TFT ordered under CPE or AWV.

Conclusions

Implementing a standardized process led to a significant decrease in utilization of screening thyroid function testing without clear indication during CPE/AWV encounters (22.0% to 3.9%).

Clinical Implications

While the overall rate of TFT orders did not change significantly (44.5% to 41.2%), our project showed a significant decrease in the documentation of TFT ordering under CPE/AWV encounters. This can be a result of two possible causes: 1) indicated TFT orders were incorrectly documented under CPE/AWV encounters; 2) unnecessary TFT were documented under other diagnoses for justification. Further studies can shed additional light on the process.

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