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Impact of an Interprofessional Collaborative Quality Improvement Initiative to Decrease Inappropriate Thyroid

Alyssa B Bradshaw1, Alex K Bonnecaze2, Cynthia A Burns2

  • 1Wake Forest Baptist Health, Winston-Salem, NC, USA.

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|November 1, 2021
PubMed
Summary

A quality improvement initiative reduced inappropriate thyroid-stimulating hormone (TSH) and free T4 lab orders in acute care settings, leading to cost savings. The program improved test ordering appropriateness, though the emergency department showed less improvement.

Keywords:
TSHcostdiagnostic stewardshipfree T4quality improvementthyroid function laboratory tests

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Area of Science:

  • Clinical Laboratory Science
  • Healthcare Quality Improvement
  • Endocrinology

Background:

  • Thyroid function tests are frequently ordered inappropriately in acute care, increasing costs and risks.
  • Pilot data indicated over two-thirds of thyroid-stimulating hormone (TSH) tests were unnecessary, suggesting significant cost-saving potential.
  • Inappropriate laboratory test ordering contributes to diagnostic uncertainty and potential therapeutic errors.

Purpose of the Study:

  • To decrease the rate of inappropriate thyroid function test ordering among inpatients and emergency department patients.
  • To evaluate the impact of a multipronged initiative on TSH and free T4 test ordering practices.
  • To quantify cost savings associated with improved thyroid function test ordering.

Main Methods:

  • A controlled, single-center, before-and-after study was conducted at Wake Forest Baptist Medical Center.
  • Interventions included electronic ordering changes, provider education, and informational cards, excluding emergency department resident education.
  • Primary outcome measured was the change in inappropriate TSH test orders; secondary outcomes included cost savings and inappropriate free T4 orders.

Main Results:

  • Inappropriate TSH orders decreased by 13% (P = .062), with reductions across most services except the ED.
  • Inappropriate Free T4 orders saw a statistically significant reduction of 30% (P = .01).
  • Annual cost savings were estimated at approximately $6,000, with no therapy changes based on inappropriate tests.

Conclusions:

  • A multipronged quality improvement initiative led to a significant reduction in inappropriate free T4 orders and cost savings.
  • The initiative demonstrated a trend towards reduced inappropriate TSH orders, though not statistically significant.
  • The exclusion of the emergency department from direct education may explain the lack of improvement in that setting.