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Promoting Choosing Wisely Thyroid Function Test Guidelines in a Large Pediatric Hospital System.

Ilka Warshawsky1, Hanna Lemerman2, Samantha Gunkelman2,3,4

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Summary

Implementing a reflex free thyroxine (fT4) test significantly reduced unnecessary fT4 orders and saved costs in a pediatric hospital system. This quality improvement initiative optimized thyroid testing protocols for better patient care and resource management.

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Area of Science:

  • Clinical Chemistry
  • Quality Improvement
  • Health Services Research

Background:

  • Inappropriate free thyroxine (fT4) testing is a common issue in clinical practice.
  • A need exists to optimize diagnostic testing strategies in pediatric healthcare settings.

Purpose of the Study:

  • To implement and evaluate a quality improvement initiative aimed at reducing non-indicated free thyroxine (fT4) testing in a pediatric hospital system.
  • To identify and establish an optimal approach for appropriate fT4 test ordering.

Main Methods:

  • Evidence-based guidelines and best practices informed the development of a reflex testing strategy (thyroid-stimulating hormone with reflex to fT4).
  • Clinical decision support tools were integrated into electronic health records for outpatient thyroid panels.
  • Provider education, feedback, and revisions to order sets were conducted over a 44-month period.

Main Results:

  • A significant reduction in co-ordering of fT4 with thyroid-stimulating hormone was observed, decreasing from 67% to 15% among non-endocrinology providers.
  • The utilization of reflex fT4 testing increased from 0% to 77%.
  • Over three years, 5179 fewer fT4 tests were performed, resulting in direct cost savings of $45,800.

Conclusions:

  • The implementation of a reflex fT4 testing strategy, coupled with clinical decision support and provider education, effectively reduced inappropriate fT4 orders.
  • The study demonstrated a sustainable reduction in fT4 testing and achieved significant cost savings.
  • This quality improvement model offers a scalable approach for optimizing thyroid function test ordering in pediatric populations.