Free the T3: Implementation of Best Practice Advisory to Reduce Unnecessary Orders

From the 2022 HVPA National Conference

Da Wi Shin BE (NYC Health + Hospitals), Daniel Alaiev BBA, Nessreen Mestari MPA, Joseph Talledo BS, Hyung Cho MD, Mona Krouss MD


Thyroid function tests are commonly overused and amount to 1.6 billion dollars annually in health care spending in the United States. Although national guidelines recommend a thyroid-stimulating hormone (TSH) centered approach, clinicians often inappropriately order triiodothyronine (T3) and thyroxine (T4). This may be due to lack of knowledge or ease of ordering all three tests at once in premature anticipation of an abnormal TSH. Additionally, clinicians order free T3 rather than total T3, despite the American Thyroid Association’s recommendations to avoid free T3 due to its high rate of variability.


To study the effect of a best practice advisory (BPA) in reducing targeted T3 testing in both hypothyroidism and hyperthyroidism in inpatient and outpatient settings in a large safety net system.


BPAs were created for total T3 and free T3 orders. The BPA triggered upon order entry, and defaulted for the clinician to remove the test. An informational nudge was positioned at the top of the BPA, providing guidance from NYC H+H High Value Care Council. As free T3 is an unreliable test, its messaging was different from total T3 and encouraged clinicians not to order. Messaging for total T3 focused on not ordering for hypothyroidism, and ordering for hyperthyroidism only when TSH and free T4 levels did not correspond with clinical picture (low TSH but normal free T4 in someone with symptoms of hyperthyroidism).


For free T3, the BPA acceptance rate was 23.0% (982 of 4269). The inpatient BPA acceptance rate was 21.6% (347 of 1606), and outpatient BPA acceptance rate was 23.8% (635 of 2663). For total T3, the BPA acceptance rate was 21.0% (1083 of 5173). The inpatient BPA acceptance rate was 23.4% (460 of 1968) and outpatient BPA acceptance rate was 19.4% (623 of 3203).
In the inpatient setting, ordering frequency of free T3 decreased from 1.47 to 0.68 per 1000 patient days, and total T3 decreased from 1.65 to 0.68 per 1000 patient days. In the outpatient setting, ordering frequency of free T3 decreased from 1.61 to 0.75 per 1000 encounters, and total T3 decreased from 1.55 to 0.95 per 1000 encounters. All of these reductions were significant (p < 0.001) both when adjusting and not-adjusting for the temporal trends.


Overall, the initiative targeting inappropriate T3 testing proved successful across 11 hospitals and 70 ambulatory centers within a safety net setting. Our simplistic nudge approach was low effort, high impact, and can be generalizable to other institutions.

Clinical Implications

Development of a triggered alert in the health record may reduce inappropriate monitoring practices, decrease costs, and improve utilization of limited health-care resources for this common clinical condition.

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