Category: Thyroid

Monitor: 31

31 - THYROID FUNCTION TESTING IN HOSPITALIZED PATIENTS

Saturday, Apr 27
10:00 AM – 10:30 AM

Objective :

Determine the usefulness and cost-effectiveness of thyroid function testing (TFT) in hospitalized patients. 


Methods :

Single center, retrospective chart review of patients admitted to the general medical ward of a community hospital in a one-month period who underwent TFT. Indications for TFT and change in management based on TFT were analyzed. 


Results :

We identified 171 out of 1464 patients with TFT performed during hospitalization.  The mean age was 61.7 years (60% women); 83.6% were Caucasian.  The indications for TFT were undocumented in 1/3 of patients. In the rest, the indications for ordering TFT were dizziness 10.5%, cardiac arrhythmias 9.9%, TIA/stroke 7.6%, palpitations 7%, syncope/near syncope 7%, fatigue 7%, depression/anxiety 5.3%, history of thyroid disease 6.4% and miscellaneous 7%. Hypothyroidism was the most frequent pre-existing thyroid disorder (29.2%). TSH was most commonly ordered as a first test, which was abnormal in 42.7%. In patient with abnormal TSH, thyroid hormone levels were only obtained in 34.2% of patients. In patients with abnormal TSH levels, a concrete intervention was done in 30% of cases. An endocrine consult was obtained in 13.6%, and change or initiation of medications only occurred in 13.6% of patients with rest being deferred to outpatient follow up. 


Discussion :

Given the problems in interpretation of TFT in hospitalized patients, testing should only be done if there is a strong suspicion for a thyroidal illness. Our study yielded similar results as studies from other parts of the world showing that TFTs are routinely ordered without a warranted indication in most patients. Lack of documentation for ordering the tests also suggests low confidence in the testing itself. Additionally, abnormal TSH was not followed by measurement of thyroid hormones. Moreover, abnormal TFT did not result in significant change in management in most cases.  When extrapolated to a one-year period, cost of TSH testing would amount  to around $197,820 in our facility. In addition, incorrectly analyzed abnormal TFT can trigger unnecessary workup as well as management, which is likely to be expensive and sometimes detrimental. 


Conclusion :

Thyroid function testing in hospitalized patients without any hard indication has not only limited clinical value but is also not cost effective and can be potentially harmful. Thus, to practice evidence based and cost-conscious care, providers should be educated about the actual indications for TFT in hospitalized patients and how to properly interpret its result.

SHORT URL FUNCTION-->

Mehrunissa Kazim

Internal Medicine Resident
Saint Vincent Hospital
Worcester, Massachusetts

I am a PGY-3 Internal Medicine Resident at Saint Vincent Hospital in Worcester, MA. I finished my medical school in Islamabad, Pakistan and soon after decided to pursue a career in medicine in the United States. My interest in Endocrinology started after my first rotation in Endocrine and it continued to grow throughout my years of residency. I am fascinated by the various pathologies in this field and hence plan to pursue a career in Endocrinology.

Carolina ISABEL. Perez Carrion

Internal Medicine Resident
Saint Vincent Hospital
Worcester, Massachusetts

I'm an Internal Medicine PGY-3 at St. Vincent hospital in Worcester, Massachusetts. I started my medical training in Ecuador where I finished my medical school in 2012. I then moved to the US and did research in non-invasive brain stimulation to then start residency in internal medicine. I am interested in pursuing a career in Endocrinology. Since the beginning of my intern year I have been interested in endocrine pathology, specially thyroid pathology. I became an AACE member this year and look forward to become a clinical endocrinologist and a researcher in the field.

Trivedi Nitin

Division Director, Endocrinology
Saint Vincent Hospital
Shrewsbury, Massachusetts

Dr. Nitin Trivedi is an Associate Professor of Medicine at the University of Massachusetts Medical School and one of the Associate Program Directors in the Internal Medicine Residency Program at Saint Vincent Hospital in Worcester, MA. He is board certified in Internal Medicine and Endocrinology. He is a fellow of American College of Physicians and American Association of Clinical Endocrinologists. He has served as the President of the New England Chapter of American Association of Clinical Endocrinologists. He has received the Gilbert E. Levinson Award for the best resident voted by the faculty members and the John J Mckeever Medical Educator Award from the Department of Medicine at Saint Vincent Hospital. His research interests include management of diabetes in hospitalized patients and insulin pump use in type 2 diabetes.
Dr. Trivedi earned his medical degrees from MGM Medical College in Indore, India and completed his Internal Medicine Residency at Saint Vincent Hospital and Endocrinology Fellow at Brown Medical School. He has worked as a Research Fellow in the section of Islet Transplantation and Cell Biology at Joslin Diabetes Center, Harvard Medical School in Boston. He was an Assistant Professor at Brown Medical School from 2004 -2005.
He has authored several publications and abstracts.

Selected Bibliography:
1. Suzuki K, Bonner-Weir, Trivedi N, Yoon KH, Lock JH, Colton CK, Weir GC: Survival and function of macroencapsulated syngeneric islets transplanted into Streptozotocin diabetic mice. Transplantation 1998;66:21-28.
2. Trivedi N, Mithal A, Sharma AK, Mishra SK, Trivedi B, Daughaday WH. Nonislet tumor induced
hypoglycemia with acromegaloid facial and acral swelling. Clinical Endocrinology (Oxf.)
1995;42:433-435.
3. Trivedi N, Suzuki K, Bonner-Weir S, Hollister-Lock J, Weir GC: Islet number in an immunobarrier required to cure diabetes in mice. Transplantation Proceedings 1997;29-21-2143.
4. Trivedi N, Steil GM, Colton CK, Bonner Weir S, Weir GC: Improved vascularization on planar diffusion devices following continuous infusion of vascular endothelial growth factor. Cell Transplantation 1999;8:673-689.
5. Steil GM, Trivedi N, Jonas JC, Hasenkemp WM, Sharma A, Bonner Weir, Weir GC. Enhanced beta-cell function with normal islet gene expression following Adaptation of B-cell mass to substrate oversupply. Am J Physiology 2001;280:E788-E796.
6. Trivedi N, Keegan M, Steil GM, Hollister-Lock J, Hasenkemp WM, Colton CK, Bonner-Weir S, Weir GC. Islets in alginate macrobeads reverse diabetes despite minimal acute insulin secretory responses. Transplantation 2001;27:203-211.
7. Omer A, Duvivier-Kaul, Trivedi N, Wilmot K, Bonner-Weir S, Weir GC. Survival and maturation of microencapsulated porcine neonatal pancreatic cell clusters transplanted into immunocompetent diabetic mice. Diabetes 2003;52(1):69-75
8. Xu G, Kaneto H, Laybutt DR, Duvivier VF, Trivedi N, Suzuma K, Kiong GL, Weir GC, Bonner-Weir S. Downregulation of GLP-1 and GIP receptor expression by hyperglycemia: Possible contribution to impaired incretin effect in diabetes. Diabetes 2007;56(6):1551-8.

9. Vyas A, Fillipon N. Lynn, Vyas P, Vijayakrishnan R, Trivedi N. Successful treatment of thyroid storm in a patient with methimazole-induced toxicity. Endocrine Practice 2010;16673-675.
10. Chhabra L, Liti B, Kuraganti G, Kaul S, Trivedi N. Challenges in the management of Type 2 Diabetes Mellitus and Cardiovascular Risk Factors in Obese Subjects: What is the Evidence and What are the Myths? Int J Endocrinol Endocrinology 2013; Article ID 856793: 10 pages.
11. Alang N, Trivedi N. Secure email communication between patients and physicians is associated with better glycemic control. R I Med J (2013). 2014 Jan 3;97(1):15.
12. Sahni P, Trivedi A, Omer AO, Trivedi N. Adrenal incidentaloma: Are they getting work up appropriately? J Community Hospital Perspective 2016;6(5):32913. Doi:10.3402/jchimp.v6.32913.





Gurbir Gill

Mehrunissa Kazim

Internal Medicine Resident
Saint Vincent Hospital
Worcester, Massachusetts

I am a PGY-3 Internal Medicine Resident at Saint Vincent Hospital in Worcester, MA. I finished my medical school in Islamabad, Pakistan and soon after decided to pursue a career in medicine in the United States. My interest in Endocrinology started after my first rotation in Endocrine and it continued to grow throughout my years of residency. I am fascinated by the various pathologies in this field and hence plan to pursue a career in Endocrinology.