Routine T4 No More? Reducing Excess Thyroid Hormone Testing at a Pediatric Tertiary Care Hospital.

OBJECTIVES: To promote resource stewardship in thyroid hormone testing at a pediatric tertiary care hospital. STUDY DESIGN: Quality improvement approaches generated 3 change ideas that were implemented simultaneously in the hospital electronic medical record: (1) a reflex free thyroxine (fT4), whereby fT4 is automatically reported if the thyroid-stimulating hormone is outside the normal range; (2) a forced-function for thyroid hormone ordering, whereby a provider must select an appropriate indication for ordering fT4 or triiodothyronine (T3); and (3) a clinical decision support message displayed at the time of ordering thyroid function tests. Laboratory data were audited to determine the mean number of fT4 and T3 tests performed per week as well as indications for testing. RESULTS: The mean number of fT4 and T3 tests processed per week decreased from 154 ± 21 and 11 ± 7, respectively, in the preintervention period, to 107 ± 12 (30% reduction) and 4 ± 3 (66% reduction) postintervention. These reductions were sustained for the full 20-week assessment period. Process and balancing measures revealed no unintended adverse consequences. Approximate cost savings were $43 000 per year. CONCLUSIONS: We describe the successful implementation of electronic medical record-based interventions (reflex fT4, forced-function selection of indication, decision support text) leading to sustained improvements in healthcare use, with significant associated cost-savings.

Frequency of thyroid function tests and examinations in participants of a population-based study.

BACKGROUND: Thyroid disorders are common in the adult German population. Little is known about guideline implementation in clinical practice and the prevalence of diagnostic procedures in ambulatory care. The study aims to investigate the use of thyroid hormone measurements, thyroid ultrasound, thyroid scintiscan and associated costs in ambulatory care at population level. METHODS: Data were derived from two independent population-based cohorts of the Study of Health In Pomerania (SHIP). Ambulatory billing data from the Association of Statutory Health Insurance Physicians Mecklenburg-Vorpommern were individually linked for the period 2002-2016 with SHIP data. The main outcomes were the frequency of outpatient ultrasound, scintiscan, serum TSH level measurement, free triiodothyronine (fT3) and free thyroxine (fT4) measurement, TSH-receptor-antibodies and microsomal antibodies measurement within 1 year and 3 years prior to the study entrance of the participants. Multinomial logistic regression models were used to assess the association of age, sex, thyroid medication intake and Charlson-Comorbidity-Index with frequency of TSH measurements and ultrasound examinations. RESULTS: A total of 5552 participants (47% male, median age 55) were included in the analysis. 25% (1409/5552) had a diagnosed thyroid disorder or treatment, 40% (2191/5552) had clinical findings based on ultrasound or laboratory testing in SHIP only and 35% (1952/5552) neither a coded thyroid disorder or clinical finding nor thyroid medication. In the total study population 30% (1626/5552) received at least one TSH measurement, 6.8% (378/5552) at least one thyroid ultrasound and 2.6% (146/5552) at least one scintiscan within the past year before the study examination. Tests were performed more frequently in patients with thyroid medication and coded thyroid disorders. Hence, this group caused the highest expenditures. CONCLUSIONS: Given the high prevalence of thyroid disorders, diagnostic and monitoring tests should be used rationally with regard to costs. TSH levels should be monitored regularly in patients on thyroid medication. A consensus on monitoring frequency and iteration of monitoring of morphological thyroid disorders with TSH and ultrasound and specific guideline recommendations are needed. TRIAL REGISTRATION: Versorgungsforschung Deutschland (VfD_17_003880).

Adoption of TSH Reflex algorithm in an Italian clinical laboratory.

BACKGROUND: TSH Reflex is an automated diagnostic algorithm which follows the rule "If ... then", in which the initial determination of TSH is followed by the determination of fT4, and possibly of fT3, if TSH is not within the reference limits. The aim of our study was to evaluate the results of the introduction and implementation of the test "TSH Reflex", which started in late 2013 in the hospital of Grosseto, comparing the requests of thyroid hormones for external patients, in 2012, 2014 and 2015. METHODS: In our study we analyzed the number of thyroid tests prescribed in 2012, 2014 and 2015 and we calculated the increase in prescription of "TSH Reflex" from 2014 to 2015; the prescriptive appropriateness, after the introduction of the "TSH Reflex", through the ratios TSH/FT4, TSH/FT3 and the ratio "TSH Reflex"/TSH. Finally we calculated the total spending for the reagents in 2012, 2014 and 2015 and the consequent savings in euros (the costs of the reagents did not change during that time). RESULTS: Requests for TSH decreased by 4.6% in 2014, compared to 2012 and by 5.4% in 2015 compared to 2014, with a 9.8% reduction in 2015 compared to 2012. The requests for FT4 decreased by 11.5%, comparing 2014 with 2012, by 5.3% comparing 2015 with 2014, with a 16.2% reduction in 2015 compared to 2012. The requests for FT3 decreased by 13.3% in 2014 compared to 2012 and by 8.4% in 2015 compared to 2014, with a 20.6% reduction in 2015 compared to 2012. The appropriateness, evaluated the indicator TSH/FT4, increased by 7.6%, comparing 2014 with 2012, and remained unchanged in 2015. In 2012 71,134 euros were spent, 63,998 euros in 2014, 60,055 euros in 2015, resulting in a saving of € 11,079 in 2015 compared to 2012. The spending for "TSH Reflex" should be subtracted (1,964 Euros in 2015) from the previous savings. CONCLUSIONS: The improvement of the efficiency and the prescriptive appropriateness was better in 2014, the first year of implementation of the "TSH Reflex". The overall assessment suggests that the 2014 results are attributable to the letters that general practitioners received in December 2013, with a temporary increase of the use of the test. We need further analyses with the same indicators in order to assess the possibility of additional improvements in the future.

Thyroid function testing in an inpatient mental health unit.

OBJECTIVE: Thyroid function tests are a common screening investigation for patients admitted to a psychiatric inpatient unit. METHOD: This study aimed to retrospectively assess the clinical utility of routine thyroid function testing performed on newly admitted psychiatric patients over a 4-year period in Victoria, Australia via chart review of all abnormal results identified. RESULTS: Our retrospective audit revealed only two cases where identification of thyroid dysfunction informed patient management. In each case, the patient had a known history of thyroid disease. In this audit period, 893 patients required screening to yield one clinically relevant abnormal result, costing AU$24,975.57. CONCLUSION: Such low clinical utility does not support routine admission thyroid function tests for psychiatric inpatients. We conclude that thyroid function tests should only be performed where the history and clinical signs suggest a likely contribution of thyroid dysfunction to the psychiatric presentation.

Hypothyroidism is a rare cause of isolated constipation.

The prevalence of constipation in children is high and accounts for a large percentage of pediatric and pediatric gastroenterology visits. Thyroid testing is frequently ordered to evaluate constipation and other gastrointestinal complaints in children. We reviewed all of the patients with thyroid testing ordered by our pediatric gastroenterology division during a 5-year period. We found 873 patients on whom thyroid testing was performed, and 56 patients had evidence of hypothyroidism. Nine patients had constipation and clinically significant hypothyroidism in this group; however, only 1 child had constipation as their sole presenting symptom. The contribution of occult hypothyroidism to isolated constipation in children may have been previously overestimated.

Thyroid Hormone Tests Ordering Practice and Cost-Effectiveness in Samples Referred to International Clinical Laboratories from Addis Ababa Health Facilities.

BACKGROUND: Thyroid dysfunction accounts for majority of endocrine disorders. In sub-Saharan Africa Graves' disease and hypothyroidism have accounted for 13.1% and 8.8% while the burden of thyroid disorder has ranged from 6.18 to47.34% among countries in the Arab world. The cost for a primary thyroid test done to evaluate the gland function constituted a large proportion of the public health budget. For instance, 10 million thyroid functions have been done each year by laboratories which cost 30 million UK pounds, and they represent 8% of laboratory charge in the US. When a TSH-only protocol (guideline) was used, 95% of the requests were sufficient for diagnosis without requiring further tests, thereby resulting in 50% savings on FT4 reagent and reducing the annual TFT reagent cost by 25%. This is an original study, and its objective was to assess the ordering pattern of TSH tests and their cost-effectiveness in patients' samples referred to ICL from Addis Ababa health facilities between July2015 to June 2016. METHOD: An institution-based cross-sectional study design was utilized to study the ordering pattern of thyroid function tests using one-year retrospective data from ICL. RESULTS: Thyroid profiles were ordered more frequently (49.5%) compared to TSH only (24.3%). An additional 2625.70 USD was paid by patients for individual components in the profile tests that turned out normal. CONCLUSION: Guidelines advocate TSH as the initial test for thyroid dysfunction, but the use of a combination of tests is more common.

Universal screening for thyroid disease SHOULD NOT be recommended before and during pregnancy.

Thyroid dysfunction in pregnancy is strongly associated with adverse maternal and foetal outcomes. The effects of treatment are less clear. There is ongoing discussion on whom to treat, when to treat and whether treatment is beneficial. Although universal screening for thyroid disease during pregnancy increases diagnosis and treatment of thyroid dysfunction, there is currently insufficient evidence demonstrating a positive effect of screening on maternal and foetal outcomes. We therefore, at present, recommend against universal screening for thyroid disease before and during pregnancy.

Universal screening for thyroid disease during pregnancy should be performed.

Thyroid disease can significantly impact the pregnant woman and her child. Human and animal studies have firmly linked overt hypothyroidism and overt hyperthyroidism to miscarriage, preterm delivery and other adverse pregnancy outcomes. Overt hypothyroidism and overt hyperthyroidism affect 1% of all pregnancies. Treatment is widely available, and if detected early, results in decreased rates of adverse outcomes. Universal screening for thyroid disease in pregnancy can identify patients with thyroid disease requiring treatment, and ultimately decrease rates of complications. Universal screening is cost-effective compared to the currently accepted practice of targeted screening and may even be cost-saving in some healthcare systems. Targeted screening, which is recommended by most professional associations, fails to detect a large proportion of pregnant women with thyroid disease. In fact, an increasing number of providers are performing universal screening for thyroid disease in pregnancy, contrary to society guidelines. Limited evidence concerning the impact of untreated and treated subclinical disease and thyroid autoimmunity has distracted from the core rationale for universal screening - the beneficial impact of detecting and treating overt thyroid disease. Evidence supporting universal screening for overt disease stands independently from that of subclinical and autoimmune disease. The time to initiate universal screening is now.

In primary care, is measuring free-thyroxine plus thyroid-stimulating hormone to detect hypopituitarism cost-effective? A cost utility analysis using Markov chain models.

OBJECTIVE: We examined whether it is cost-effective to measure free thyroxine (FT4) in addition to thyrotropin (thyroid-stimulating hormone (TSH)) on all requests for thyroid function tests from primary care on adult patients. BACKGROUND: Hypopituitarism occurs in about 4 people per 100 000 per year. Loss of thyrotropin (TSH) secretion may lead to secondary hypothyroidism with a low TSH and low FT4, and this pattern may help to diagnose hypopituitarism that might otherwise be missed. DESIGN: Markov model simulation. PRIMARY OUTCOME MEASURE: Incremental cost-effectiveness ratio (ICER), the ratio of cost in pounds to benefit in quality-adjusted life years of this strategy. RESULTS: The ICER for this strategy was £71 437. Factors with a large influence on the ICER were the utilities of the treated hypopituitary state, the likelihood of going to the general practitioner (GP) and of the GP recognising a hypopituitary patient. The ICER would be below £20 000 at a cost to the user of an FT4 measurement of £0.61. CONCLUSION: With FT4 measurements at their present cost to the user, routine inclusion of FT4 in a thyroid hormone profile is not cost-effective.

Reducing waste: a guidelines-based approach to reducing inappropriate vitamin D and TSH testing in the inpatient rehabilitation setting.

Background: Laboratory overutilisation increases healthcare costs, and can lead to overdiagnosis, overtreatment and negative health outcomes. Discipline-specific guidelines do not support routine testing for Vitamin D and thyroid-stimulating hormone (TSH) in the inpatient rehabilitation setting, yet 94% of patients had Vitamin D and TSH tests on admission to inpatient rehabilitation at our institution. Our objective was to reduce Vitamin D and TSH testing by 25% on admission to inpatient Stroke, Spinal Cord Injury, Acquired Brain Injury and Amputee Rehabilitation units. Methods: A fishbone framework for root cause analysis revealed potential causes underlying overutilisation of Vitamin D and TSH testing. A series of Plan-Do-Study-Act (PDSA) cycles were introduced to target remediable factors, starting with an academic detailing intervention with key stakeholders that reviewed applicable clinical guidelines for each patient care discipline and the rationale for reducing admission testing. Simultaneously, computerised clinical decision support (CCDS) limited Vitamin D testing to specific criteria. Audit and feedback were used in a subsequent PDSA cycle. Frequency of Vitamin D and TSH testing on admission was the primary outcome measure. The number of electronic admission order caresets containing automatic Vitamin D and/or TSH orders before and after the interventions was the process measure. Rate of Vitamin D supplementation and changes in thyroid-related medication were the balancing measures. Results: After implementation, 2.9% of patients had admission Vitamin D testing (97% relative reduction) and 53% of patients had admission TSH testing (43% relative reduction). Admission order caresets with prepopulated Vitamin D and TSH orders decreased from 100% (n=6) to 0%. The interventions were successful; similar to previous literature, CCDS was more effective than education and audit and feedback interventions alone. The interventions represent >$9000 annualised savings.

Cost for treatment and follow-up of thyroid cancer increases according to the severity of disease.

BACKGROUND: The aim of this study was to provide an analysis of thyroid cancer-related health care costs over a 5-year period, according to the extent of thyroid surgery. METHODS: The study included 33 patients from our institutional database who underwent thyroid cancer surgery in 2010. Patients were divided into four groups based on surgical extent: (1) hemithyroidectomy, (2) total thyroidectomy, (3) total thyroidectomy with ipsilateral radical neck dissection, and (4) total thyroidectomy with bilateral radical neck dissection and mediastinal dissection. Costs for admission and outpatient follow-up for 5 years were analyzed. RESULTS: Costs for outpatient follow-up and admission, and overall cost increased with increasing stage of disease and increasing extent of thyroid surgery. Patients who underwent only hemithyroidectomy had the lowest costs for outpatient follow-up and admission, as well as the lowest overall cost. CONCLUSION: Over the 5-year follow-up period, surgery performed at an early disease stage was the most cost-effective.

Stability of thyroid function in older adults: the Birmingham Elderly Thyroid Study.

BACKGROUND: Thyroid function tests (TFTs) are among the most requested tests internationally. However, testing practice is inconsistent, and potentially suboptimal and overly costly. The natural history of thyroid function remains poorly understood. AIM: To establish the stability of thyroid function over time, and identify predictors of development of overt thyroid dysfunction. DESIGN AND SETTING: Longitudinal follow-up in 19 general practices in the UK. METHOD: A total of 2936 participants from the Birmingham Elderly Thyroid Study (BETS 1) with a baseline TFT result indicating euthyroid or subclinical state were re-tested after approximately 5 years. Change in thyroid-stimulating hormone (TSH), free thyroxine (FT4), and thyroid status between baseline and follow-up was determined. Predictors of progression to overt dysfunction were modelled. RESULTS: Participants contributed 12 919 person-years; 17 cases of overt thyroid dysfunction were identified, 13 having been classified at baseline as euthyroid and four as having subclinical thyroid dysfunction. Individuals with subclinical results at baseline were 10- and 16-fold more likely to develop overt hypothyroidism and hyperthyroidism, respectively, compared with euthyroid individuals. TSH and FT4 demonstrated significant stability over time, with 61% of participants having a repeat TSH concentration within 0.5 mIU/L of their original result. Predictors of overt hypothyroidism included new treatment with amiodarone (odds ratio [OR] 92.1), a new diagnosis of atrial fibrillation (OR 7.4), or renal disease (OR 4.8). CONCLUSION: High stability of thyroid function demonstrated over the 5-year interval period should discourage repeat testing, especially when a euthyroid result is in the recent clinical record. Reduced repeat TFTs in older individuals is possible without conferring risk, and could result in significant cost savings.

Analysis of current thyroid function test ordering practices.

RATIONALE: Current guidelines recommend thyroid stimulating hormone (TSH) alone as the best test to detect and monitor thyroid dysfunction, yet free thyroxine (FT4) and free triiodothyronine (FT3) are commonly ordered when not clinically indicated. Excessive testing can lead to added economic burden in an era of rising healthcare costs, while rarely contributing to the evaluation or management of thyroid disease. OBJECTIVE: To evaluate our institution's practice in ordering thyroid function tests (TFTs) and to identify strategies to reduce inappropriate FT4 and FT3 testing. METHODS: A record of all TFTs obtained in the San Antonio Military Health System during a 3-month period was extracted from the electronic medical record. The TFTs of interest were TSH, FT4, thyroid panel (TSH + FT4), FT3, total thyroxine (T4), and total triiodothyronine (T3). These were categorized based on the presence or absence of hypothyroidism. RESULTS: Between August 1 and October 31, 2016, there were 38 214 individual TFTs ordered via 28 597 total laboratory requests; 11 486 of these requests were in patients with a history of hypothyroidism. The number (percent) of laboratory requests fell into these patterns: TSH alone 14 919 (52.14%), TSH + FT4 7641 (26.72%), FT3 alone 3039 (10.63%), FT4 alone 1219 (4.26%), TSH + FT4 + FT3 783 (2.74%), and others 996 (3.48%); 36.0% of TFTs ordered were free thyroid hormones. Projected out to a year, using Department of Defense laboratory costs, $317 429 worth of TFTs would be ordered, with free thyroid hormone testing accounting for $107 720. CONCLUSION: Inappropriate ordering of free thyroid hormone tests is common. In an era of rising healthcare costs, inappropriate thyroid function testing is an ideal target for efforts to reduce laboratory overutilization, which in our system, could save up to $120 000 per year. Further evaluation is needed to determine strategies that can reduce excessive thyroid hormone testing.

Alternative sequences of thyrotropin and free thyroxine assays for routine thyroid function testing. Quality and cost.

BACKGROUND: Current guidelines and practices for thyroid function testing are strongly affected by the usually higher patient billing charges and Medicare reimbursement for thyrotropin (TSH) vs free thyroxine (FT4) tests, despite their comparable direct costs. OBJECTIVE: Due to recently reduced laboratory costs, to reexamine the effectiveness and cost of alternative test sequences. METHODS: Alternative test sequences involve using the TSH test first, followed, if the TSH test result is abnormal, by the FT4 test; the FT4 test first, followed by the TSH test; and doing both tests together. We applied these strategies to consecutive patients referred for any thyroid function test to a health maintenance organization, a multispecialty fee-for-service group, a military hospital, and a commercial laboratory. Effectiveness was determined from a literature review. The cost was determined from direct costs and the distribution of diagnostic categories. RESULTS: The TSH and FT4 tests have similar sensitivities for detecting clinical hyperthyroidism and hypothyroidism. The TSH test detects subclinical function, and it monitors thyroxine treatment better; the FT4 test detects central hypothyroidism, and it monitors rapidly changing function better. Direct costs for both were equal, but charges for the TSH test were higher. The average direct cost per patient, starting with the FT4 test, was $4.61; starting with the TSH test, $5.90; and starting with both tests together, $6.50. Medicare reimbursements correlated poorly with costs. CONCLUSIONS: Starting with the TSH test and reflexing to the FT4 test provides a better first-line all-purpose sequence than the reverse. In managed care settings, the slightly higher direct cost of this approach is offset by greater clinical effectiveness. In fee-for-service settings, cost differences can be nearly eliminated by equalizing TSH and FT4 charges to reflect current direct-cost realities. Obtaining both tests together overcomes the disadvantages of each at a slightly higher direct cost.

Detecting unsuspected thyroid dysfunction by the free thyroxine index.

The free thyroxine index (FTI) was used in 2,704 adults to detect unsuspected thyroid dysfunction. Among 2,581 adults found to be clinically euthyroid without thyroid medication, 2,571 had a truly normal FTI (121 to 360) and ten had a falsely abnormal FTI (seven less than 121, three greater than 360). Among 25 subjects with newly diagnosed thyroid dysfunction, there were eight hyperthyroid (prevalence, 0.31%) and 14 hypothyroid (prevalence, 0.50%) subjects. The sensitivity of the FTI was 1.0, and the specificity was 0.996. The predictive value of an abnormal FTI with a prevalence of 0.81% was 67%. The cost to find a new case averaged $127. The annual incidence of symptomatic hyperthyroidism was 0.05%; of hypothyroidism, about 0.08%. We conclude that the FTI is cost-effective for case finding in thyroid dysfunction.

[Medico-economic assessment of two methods for implementing thyroid testing guidelines]. / Evaluation médico-économique de la mise en oeuvre de recommandations de prescription des examens biologiques explorant la fonction thyroïdienne.

BACKGROUND: To compare independent and combined effectiveness and cost-effectiveness of two implementation interventions of guidelines for ordering thyroid function tests. The two implementation interventions were a Memorandum Pocket Card (MPC) and a Test Request Form (TRF). Intervention groups were wards. METHODS: The study used an experimental 2*2 factorial design with matching hospitals according to size and activity and wards according to pre-intervention appropriateness for test ordering. Four ward groups were established: the dual intervention group, the order form group, the pocket card group and the control group. Physicians in all groups received guidelines and were invited to a local information meeting. The main outcome measure of effectiveness was the Guideline Conformity Rate (GCR). The cost-effectiveness ratio was the cost difference between the tested intervention and the control intervention upon effectiveness difference between the tested intervention and the control intervention. RESULTS: Six hospitals participated in the study (two middle-sized hospitals, two small-sized hospitals and two psychiatric hospitals). A total of 1412 orders for thyroid function tests were collected. GCR was 78% in the dual intervention group, 83% in the order form group, 73% in the pocket card group and 62% in the control group. The interaction between TRF and MPC was not significant (B=-0.70, p=0.21). Compared to simple information, TRF was effective in increasing GCR (OR=2.65, 95% Confidence Interval [CI]: 1.52-4.62), unlike MPC (OR=1.28, CI: 0.75-2.19). TRF was the less expensive and the most effective intervention. CONCLUSION: Using a robust design, our study shows a greater effectiveness of TRF than MPC and their association in implementing thyroid function test guidelines. The development of clinical practice improvement projects through the second procedure of accreditation in France is a good opportunity to develop a guidelines implementation research project.

[Overutilization of clinical biochemical analyses?]. / Overrekvirering av laboratorieanalyser i medisinsk biokjemi.

BACKGROUND: A pilot study was conducted in order to highlight the possibly unnecessary requisitioning of biochemical analyses in a Norwegian hospital. MATERIAL AND METHODS: The following parameters from consecutive patients and focusing repeated testing were included in the study: i) serum protein electrophoresis (30 patients), ii) thyroid function tests in serum (43 patients), iii) prothrombin time test (PT-INR) (30 patients), iv) haemoglobin (30 patients) and v) an analysis package of 13 single tests designed for the primary investigation of "acute abdomen" (30 patients). Criteria for correct and incorrect requisitioning were defined. RESULTS: 69% of the acute abdomen test package requisitions were incorrect, although single tests within the package may have been justified. 17% of PT-INR and 15% of haemoglobin tests were superfluous, while nearly all serum protein electrophoresis and thyroid analyses were not unnecessarily repeated. INTERPRETATION: The study demonstrated a clear possibility for reducing financial as well as labour costs by correct requisitioning of biochemical analyses, without loss to the quality of diagnostic service and treatment.

[Cost-effectiveness analysis of universal screening for thyroid disease in pregnant women in Spain]. / Análisis coste-efectividad del cribado universal de la enfermedad tiroidea en mujeres embarazadas en España

OBJECTIVE: To assess the cost-effectiveness of universal screening for thyroid disease in pregnant women in Spain as compared to high risk screening and no screening. METHODOLOGY: A decision-analytic model comparing the incremental cost per quality-adjusted life year (QALY) of universal screening versus high risk screening and versus no screening. was used for the pregnancy and postpartum period. Probabilities from randomized controlled trials were considered for adverse obstetrical outcomes. A Markov model was used to assess the lifetime period after the first postpartum year and account for development of overt hypothyroidism. The main assumptions in the model and use of resources were assessed by local clinical experts. The analysis considered direct healthcare costs only. RESULTS: Universal screening gained .011 QALYs over high risk screening and .014 QALYS over no screening. Total direct costs per patient were €5,786 for universal screening, €5,791 for high risk screening, and €5,781 for no screening. Universal screening was dominant compared to risk-based screening and a very cost-effective alternative as compared to no screening. Use of universal screening instead of high risk screening would result in €2,653,854 annual savings for the Spanish National Health System. CONCLUSIONS: Universal screening for thyroid disease in pregnant women in the first trimester is dominant in Spain as compared to risk-based screening, and is cost-effective as compared to no screening (incremental cost-effectiveness ratio of €374 per QALY). Moreover, it allows diagnosing and treating cases of clinical and subclinical hypothyroidism that may not be detected when only high-risk women are screened.

Therapeutic drug monitoring of mood stabilizers in Medicaid patients with bipolar disorder.

OBJECTIVE: The authors' goal was to determine the extent and pattern of blood serum monitoring of mood stabilizers in Medicaid patients with bipolar disorder. METHOD: Data were drawn from a Medicaid medical claims data set from Pittsburgh and the surrounding region. The authors identified bipolar patients using lithium, valproate, and carbamazepine (N = 718) and then examined the patient demographic, diagnostic, and service use variables associated with therapeutic drug monitoring. RESULTS: A substantial proportion of lithium users (36.5%), valproate users (42.4%), and carbamazepine users (42.2%) with bipolar disorder diagnoses did not receive therapeutic drug level testing during the 12-month study period. Carbamazepine users who were male or in the 30-49-year age range were significantly less likely to be tested for serum drug level. Lithium users who did not receive partial-hospitalization psychiatric services and valproate users who received mental health case management were also less likely to be tested for serum drug level. Over one-half of the lithium users (54.1%) did not receive thyroid function tests, and few (4.2%) received renal function tests. Patients who did receive tests for serum drug level were likely to receive the other recommended tests. CONCLUSIONS: Many Medicaid patients with bipolar disorder received no therapeutic drug monitoring. Patient sociodemographic characteristics contributed little to explaining this omission, although some types of service utilization were related to rates of serum drug level testing.