Real world evidence: patients with alopecia areata in Italy.

BACKGROUND: This real-world analysis aimed at characterizing patients hospitalized for alopecia areata (AA) in Italy, focusing on comorbidities, treatment patterns and the economic burden for disease management. METHODS: Administrative databases of healthcare entities covering 8.9 million residents were retrospectively browsed to include patients of all ages with hospitalization discharge diagnosis for AA from 2010 to 2020. The population was characterized during the year before the first AA-related hospitalization (index-date) and followed-up for all the available successive period. AA drug prescriptions and treatment discontinuation were analyzed during follow-up. Healthcare costs were also examined. RESULTS: Among 252 patients with AA (mean age 32.1 years, 40.9% males), the most common comorbidities were thyroid disease (22.2%) and hypertension (21.8%), consistent with literature; only 44.4% (112/252) received therapy for AA, more frequently with prednisone, triamcinolone and clobetasol. Treatment discontinuation (no prescriptions during the last trimester) was observed in 86% and 88% of patients, respectively at 12 and 24-month after therapy initiation. Overall healthcare costs were 1715€ per patient (rising to 2143€ in the presence of comorbidities), mostly driven by hospitalization and drugs expenses. CONCLUSIONS: This first real-world description of hospitalized AA patients in Italy confirmed the youth and female predominance of this population, in line with international data. The large use of corticosteroids over other systemic therapies followed the Italian guidelines, but the high discontinuation rates suggest an unmet need for further treatment options. Lastly, the analysis of healthcare expenses indicated that hospitalizations and drugs were the most impactive cost items.

Introducing day case thyroid lobectomy at a tertiary head and neck centre.

BACKGROUND: Thyroid lobectomy is considered to be a safe day case procedure by the British Association of Day Surgery. However, currently only 5.5% of thyroid surgeries in the UK are undertaken as day cases. We determine if and how thyroid lobectomy with same-day discharge could safely be introduced in our centre. METHODS: We analysed all thyroid lobectomy surgeries performed between April 2015 and May 2019. Exclusion criteria included completion surgery, revision surgery, additional procedures and disseminated disease. Outcomes were benchmarked against surgeon-reported complications from the British Association of Endocrine and Thyroid Surgery's 5th National Audit. Additionally, we reviewed the number of patients who met day case criteria currently in use at our hospital to determine accessibility to the service. RESULTS: In total, 259 thyroid lobectomy surgeries were undertaken and of these 173 met the inclusion criteria. There was no mortality, return to theatre for evacuation of postoperative haematoma or readmission. There was one postoperative haematoma which was drained at the bedside. Some 47 of the 173 (27.2%) patients met day case criteria currently in use at our centre. CONCLUSIONS: Day case surgery provides a cost-effective solution to rising bed pressures and a coherent protocol can optimise patient safety and experience.

Rising Cost of Thyroid Surgery in Adult Patients.

BACKGROUND: The aim of this study is to describe the economic trends in adults who underwent elective thyroidectomy. METHODS: We performed a population-based study utilizing the Premier Healthcare Database to examine adult patients who underwent elective thyroidectomy between January 2006 and December 2014. Time was divided into three equal time periods (2006-2008, 2009-2011, and 2012-2014). To examine trend in patient charges, we modeled patient charges using generalized linear regressions adjusting for key covariates with standard errors clustered at the hospital level. RESULTS: Our study cohort consisted of 52,012 adult patients who underwent a thyroid operation. During the study period, the most common procedure changed from a thyroid lobectomy to bilateral thyroidectomy. Over the study period, there was an increase in the proportion of completion thyroidectomies from 1.1% to 1.6% (P < 0.001), malignant diagnoses from 21.7% to 26.8% (P < 0.001), procedures performed at teaching hospitals from 27.7% to 32.9% (P < 0.001), and procedures performed on an outpatient basis from 93.85% to 97.55% (P < 0.001). The annual increase in median patient charge adjusted for inflation was $895 or 4.3% resulting in an increase of 38.8% over 9 y. Higher thyroidectomy charges were associated with male patients, malignant surgical pathology, patients undergoing limited or radical neck dissection, experiencing complications, those with managed health care insurance, and a prolonged length of stay. CONCLUSIONS: Despite recent changes in thyroid surgery practices to decrease the economic burden of hospitals, costs continue to rise 4.3% annually. Additional prospective studies are needed to identify factors associated with this increasing cost.

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.

Effect of Travel Time for Thyroid Surgery on Treatment Cost and Morbidity.

Regionalizing surgical care to high-volume centers has improved outcomes for endocrine surgery. This shift is associated with increased travel time, costs, and morbidity within certain patient populations. We examined travel time-related differences in demographics, health-care utilization, thyroid-specific disease, and cost for patients undergoing thyroid surgery at a single high-volume center. Data were extracted from the 2005 to 2014 ACS-NSQIP and clinical data repository for patients undergoing thyroid surgery. Travel times between patients' home address and the hospital were calculated using Google Earth under assumptions of standard road conditions and speed restrictions. Travel time was divided into <2 hours versus ≥2 hours. Primary outcomes were hospital cost and 30-day morbidity. Factors associated with travel time and primary outcomes were analyzed using appropriate bivariate tests and multivariable regression modeling. A total of 1046 thyroid procedures were included, with median (IQR) travel time of 68.8 (40.1-107.2) minutes. Eight hundred forty-seven (80.9%) patients traveled <2 hours compared with 199 (19.1%) traveled ≥2 hours. Patients traveling ≥2 hours were more likely to have complex thyroid disease (37.7% vs 27.6%, P = 0.005), uninsured status (31.1% vs 11.8%, P < 0.001), lower preoperative morbidity risk (2.3% vs 2.7%, P = 0.02), and longer length of stay (1.21 vs 1.07 days, P = 0.04), but similar median operative times (163 vs 165 minutes, P = 0.89). Average cost was higher for patients traveling ≥2 hours ($7300 vs $6846 [2014 USD], P = 0.05). Despite observed patient differences, hospital costs and postoperative morbidity did not differ after adjustment. Existing management practices and the nature of the disease process may be protective against the potential negative effects of regionalization.

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.

An Evaluation of Postoperative Complications and Cost After Short-Stay Thyroid Operations.

BACKGROUND: Concern for postoperative complications causing airway compromise has limited widespread acceptance of ambulatory thyroid surgery. We evaluated differences in outcomes and hospital costs in those monitored for a short stay of 6 h (SS), inpatient observation of 6-23 h (IO), or inpatient admission of >23 h (IA). METHODS: We retrospectively reviewed all patients undergoing thyroidectomy from 2006 to 2012. The incidence of postoperative hemorrhage, nerve dysfunction, and hypocalcemia were evaluated, as well as cost data comparing the SS and IO groups. RESULTS: Of 1447 thyroidectomies, 880 (60.8 %) were performed as SS, 401 (27.7 %) as IO, and 166 (11.5 %) as IA. Fewer patients in the SS group (59 %) underwent total thyroidectomy than IO (73 %) and IA (71 %; p < 0.01), and SS patients had smaller thyroid weights (27.9 g) compared with IO and IA (47.2 and 98.9 g, respectively; p < 0.01). Ten (0.69 %) patients developed hematomas requiring reoperation, five of the ten patients received antiplatelet or anticoagulant therapy perioperatively. Only one patient in the IA group bled within the 6- to 23-h period, and no patients with bleeding who were discharged at 6 h would have benefitted from 23-h observation. Twenty-four (1.66 %) recurrent laryngeal nerve injuries were identified, 16 with temporary neuropraxias. In addition, 24 (1.66 %) patients had symptomatic hypocalcemia, which was transient in 17 individuals. Financial data showed higher payments and lower costs associated with SS compared with IO. CONCLUSIONS: Selective SS thyroidectomy can be safe and cost effective, with few overall complications in patients undergoing more complex operations involving larger thyroids who were admitted to hospital.

Increased efficiency of endocrine procedures performed in an ambulatory operating room.

BACKGROUND: Thyroid and parathyroid procedures historically have been viewed as inpatient procedures. Because of the advancements in surgical techniques, these procedures were transferred from the inpatient operating room (OR) to the outpatient OR at a single academic institution approximately 7 y ago. The goal of this study was to determine whether this change has decreased turnover times and maximized OR utilization. METHODS: We performed a retrospective review of 707 patients undergoing thyroid (34%) and parathyroid (66%) procedures by a single surgeon at our academic institution between 2005 and 2008. Inpatient and outpatient groups were compared using Student t-test, chi-square test, or the Kruskal-Wallis test where appropriate. Multiple regression analysis was used to determine how patient and hospital factors influenced turnover times. RESULTS: Turnover times were significantly lower in the outpatient OR (mean 18 ± 0.7 min) when compared with the inpatient OR (mean 36 ± 1.4 min) (P < 0.001). When compared by type of procedure, all turnover times remained significantly lower in the outpatient OR. Patients in both ORs were similar in age, gender, and comorbidities. However, inpatients had a higher mean American Society of Anesthesiologists score (2.30 versus 2.13, P < 0.001) and were more likely to have an operative indication of cancer (23.1% versus 9.2%, P < 0.001). Using multiple regression, the inpatient OR remained highly significantly associated with higher turnover times when controlling for these small differences (P < 0.001). CONCLUSIONS: Endocrine procedures performed in the outpatient OR have significantly faster turnover times leading to cost savings and greater OR utilization for hospitals.

A short-stay unit for thyroidectomy patients increases discharge efficiency.

BACKGROUND: Patients traditionally recover overnight on a general surgery ward after a thyroidectomy; however, these units often lack the efficiency and focus for rapid discharge, which is the goal of a short-stay (SS) unit. Using an SS unit for thyroidectomy patients, who are often discharged in <24 h, may reduce the duration of hospital stay and subsequently decrease associated costs and increase hospital bed and resource availability. METHODS: A retrospective review of 400 patients undergoing thyroidectomy at a single academic hospital. We analyzed postoperative discharge information and hospital cost data. Adult patients who stayed a single night in the hospital were included. We compared patients staying on a designated SS unit versus a general surgery (GS) ward. RESULTS: A total of 223 patients were admitted to SS, and 177 to GS. Trends of admission location were blocked based on time period, with most patients per time period going to the same location. Discharge times were significantly quicker for patients admitted to SS (P < 0.001). A total of 70% of SS patients were discharged before noon, versus 40% of GS patients (P < 0.001). Many variances were identified to account for these differences. Direct costs were significantly lower with SS, owing to savings in pharmacy, recovery room, and nursing expenses (all P < 0.01). CONCLUSIONS: A designated short-stay hospital unit is an effective model for increasing the efficiency of discharge for thyroidectomy patients compared with those admitted to a general surgery ward. It also serves to increase bed availability, which decreases hospital cost and may improve patient flow.

The clinical use of thyroid function tests.

Laboratory tests are essential for accurate diagnosis and cost-effective management of thyroid disorders. When the clinical suspicion is strong, hormonal levels just confirms the diagnosis. However, in most patients, symptoms are subtle and unspecific, so that only biochemical tests can detect the disorder. The objective of this article is to do a critical analysis of the appropriate use of the most important thyroid function tests, including serum concentrations of thyrotropin (TSH), thyroid hormones and antithyroid antibodies. Through a survey in the MedLine database, we discuss the major pitfalls and interferences related to daily use of these tests and recommendations are presented to optimize the use of these diagnostic tools in clinical practice.

Increased costs of perioperative risk assessment for thyroid surgery in elderly people (over 80 years) presenting with benign disease.

BACKGROUND/OBJECTIVES: Evaluate how surgical treatment of benign thyroid disease in elderly people is prone to induce an increase of costs in the next future due to the aging process of the population. METHODS: A retrospective analysis has been performed on a total of 116 patients operated between January 2007 and September 2011, divided in a group of 58 patients aged over 80 years (Group A) and 58 patients younger than 80 years (Group B). The analyzed data included age, preoperative diagnosis, severe co-morbidities, procedures other than standard needed to evaluate anaesthesiological risk, postoperative hospital stay, complications, duration of postoperative intensive care monitoring, pathologic characteristics, and costs of anaesthesiological risk assessment. RESULTS: Statistical analysis of collected data showed that the costs related to perioperative risk assessment (p value < 0.001) and the duration of hospital stay (p value < 0.001) were higher in Group A than in Group B. Instead, surgery-related complications were not statistically different. CONCLUSIONS: Despite feasibility and safety of modern surgical techniques, indications for surgery in elderly patients affected by benign thyroid disease should be reserved mainly for those patients with severe medical necessity.

Utilização dos testes de função tireoidiana na prática clínica / The clinical use of thyroid function tests

Exames laboratoriais são fundamentais para o diagnóstico acurado e o monitoramento custo-efetivo das disfunções tireoidianas. Quando há alta suspeita clínica, as dosagens hormonais apenas confirmam o diagnóstico. No entanto, na maioria dos pacientes, a sintomatologia é sutil e inespecífica, de forma que apenas testes bioquímicos podem detectar o transtorno. O objetivo deste artigo é fazer uma análise crítica do uso apropriado dos principais testes de função tireoidiana, entre eles a dosagem sérica do hormônio estimulante da tireoide (TSH), dos hormônios tireoidianos e dos anticorpos antitireoidianos. Mediante um levantamento na base de dados do MedLine, são discutidas as principais armadilhas e interferências relacionadas ao uso cotidiano desses testes e apresentadas recomendações para otimizar a utilização dessas ferramentas diagnósticas na prática clínica.

Laboratory tests are essential for accurate diagnosis and cost-effective management of thyroid disorders. When the clinical suspicion is strong, hormonal levels just confirms the diagnosis. However, in most patients, symptoms are subtle and unspecific, so that only biochemical tests can detect the disorder. The objective of this article is to do a critical analysis of the appropriate use of the most important thyroid function tests, including serum concentrations of thyrotropin (TSH), thyroid hormones and antithyroid antibodies. Through a survey in the MedLine database, we discuss the major pitfalls and interferences related to daily use of these tests and recommendations are presented to optimize the use of these diagnostic tools in clinical practice.

Epidemiological and economic trends in inpatient and outpatient thyroidectomy in the United States, 1996-2006.

BACKGROUND: Traditionally, thyroid surgery has been an inpatient procedure due to the risk of several well-documented complications. Recent research suggests that for selected patients, outpatient thyroid surgery is safe and feasible, with the additional potential benefit of cost savings. In recognition of these observations, we hypothesized that there would be an increase in U.S. outpatient thyroidectomies with a concurrent decline in inpatient thyroidectomies over time. METHODS: Comparative cross-sectional analyses of the National Survey of Ambulatory Surgery (NSAS) and Nationwide Inpatient Sample (NIS) databases from 1996 and 2006 were performed. All cases of thyroid surgery were extracted, as well as data on age, sex, and insurance status. Diagnoses and surgical cases were identified using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic and treatment codes. Hospital charges were acquired from the NIS 1996 and 2006 and NSAS 2006 releases, using imputed data where necessary. After survey weights were applied, patient characteristics, diagnoses, and procedures were compared for inpatient versus outpatient procedures. RESULTS: The total number of thyroidectomies increased 39%, from 66,864 to 92,931 cases per year during the study timeframe. Outpatient procedures increased by 61%, while inpatient procedures increased by 30%. The proportion of privately insured inpatients declined slightly from 63.8% to 60.1%, while those covered by Medicare increased from 22.8% to 25.8%. In contrast, the proportion of privately insured outpatients declined sharply from 76.8% to 39.9%, while those covered by Medicare rose from 17.2% to 45.7%. These trends coincided with a small increase in the mean inpatient age from 50.2 to 52.3 years and a larger increase in the mean outpatient age from 50.7 to 58.1 years. Inflation-adjusted per-capita charges for inpatient thyroidectomies more than doubled from $9,934 in 1996 to $22,537 in 2006, while aggregate national inpatient charges tripled from $464 million to $1.37 billion. By comparison, per-capita charges for outpatient thyroidectomy totaled $7,222 in 2006. CONCLUSIONS: From 1996 to 2006, there has been a concurrent modest increase in inpatient and pronounced increase in outpatient thyroidectomies in the United States, with a consequential demographic shift and economic impact.

Cost-effectiveness analysis of repeat fine-needle aspiration for thyroid biopsies read as atypia of undetermined significance.

BACKGROUND: The 2007 National Cancer Institute (NCI) conference on Thyroid Fine-Needle Aspiration (FNA) introduced the category atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS). Repeat FNA in 3 to 6 months was recommended for low-risk patients. Compliance with these recommendations has been suboptimal. We hypothesized that repeat FNA would be more effective than diagnostic lobectomy, with decreased costs and improved rates of cancer detection. METHODS: Cost-effectiveness analysis was performed in which we compared diagnostic lobectomy with repeat FNA. A Markov model was developed. Outcomes and probabilities were identified from literature review. Third-party payer costs were estimated in 2010 US dollars. Outcomes were weighted by use of the quality-of-life utility factors, yielding quality-adjusted life years (QALYs). Monte Carlo simulation and sensitivity analysis were used to examine the uncertainty of probability, cost, and utility estimates. RESULTS: The diagnostic lobectomy strategy cost $8,057 and produced 23.99 QALYs. Repeat FNA cost $2,462 and produced 24.05 QALYs. Repeat FNA was dominant until the cost of FNA increased to $6,091. Dominance of the repeat FNA strategy was not sensitive to the cost of operation or the complication rate. CONCLUSION: The NCI recommendations for repeat FNA regarding follow-up of AUS/FLUS results are cost-effective. Improving compliance with these guidelines should lead to less overall costs, greater quality of life, and fewer unnecessary operations.

Characteristics of inpatient thyroid surgery at US academic and affiliated medical centers.

OBJECTIVE: Describe data from patients undergoing thyroid surgeries for benign and malignant disease at US academic medical centers. STUDY DESIGN: Retrospective, database search. SETTING: The University Health System (UHC) Consortium (Oak Brook, Illinois) data compiled from discharge summaries. SUBJECTS AND METHODS: Discharge data were collected from the first quarter of 2002 through the fourth quarter of 2009. Searching strategy was based on diagnosis of thyroid disease and patients undergoing thyroid surgery across all UHC facilities. Demographic information was collected as well as length of stay (LOS) and costs. Complications were evaluated in this analysis. RESULTS: During the study period, 68,014 thyroidectomies were performed, with 27,200 for thyroid cancer. During the same period 6365 neck dissections were performed, with 1539 as stand-alone procedures. Total thyroidectomy was the procedure of choice for malignant disease. More total thyroidectomies and fewer hemithyroidectomies were being performed for benign thyroid disease in the inpatient setting. Almost all postoperative complications were more frequent after surgery for cancer except myocardial infarction and aspiration pneumonia. On average, LOS was longer for benign disease, but costs were higher for malignant disease. CONCLUSION: This is the largest series reporting inpatient LOS and mortality for thyroid surgery. The limitation of this study is that it reports patients whose stays were more than 23 hours, leaving out a significant number of thyroid surgeries that are performed as outpatients. Although the results contribute greatly to characterizing inpatient surgery, the results may not reflect current US trends for thyroid surgery.

When do new biomarkers make economic sense?

Cost-effectiveness and cost-utility studies are commonly used to make payment decisions for new drugs and expensive interventions. Such studies are relatively rare for evaluating the cost-utility of clinical laboratory tests. As medical costs continue to increase in the setting of decreased resources it is likely that new biomarkers may increasingly be examined with respect to their economic benefits in addition to clinical utility. This will represent an additional hurdle for routine use of new biomarkers. Before reaching the final economic hurdle new biomarkers will still need to demonstrate clinical usefulness. Thus a new biomarker will never make economic sense if it is not clinically useful. Once diagnostic accuracy and potential clinical usefulness is established there are several types of economic studies that new biomarkers may undergo. The most common of these are cost-utility studies which estimate the ratio between the cost of an intervention or test and the benefit it produces in the number of years gained in full health. The quantity used most often to describe this is amount of money per quality adjusted life year (QALY) gained. The threshold for being considered cost-effective is generally USD 50,000 per QALY gained. Examples of biomarkers that have been subjected to economic analyses will be provided.

A population-based study of outcomes from thyroidectomy in aging Americans: at what cost?

BACKGROUND: We wanted to evaluate clinical and economic outcomes after thyroidectomy in patients 65 years of age and older, with special analyses of those aged 80 years and older, in the US. STUDY DESIGN: This was a population-based study using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, 2003-2004, a national administrative database of all patients undergoing thyroidectomy and their surgeon providers. Independent variables included patient demographic and clinical characteristics and surgeon descriptors, including case volume. Clinical and economic outcomes included mean total costs and length of stay (LOS), in-hospital mortality, discharge status, and complications. RESULTS: There were 22,848 patients who underwent thyroidectomies, including 4,092 (18%) aged 65 to 79 years and 744 (3%) 80 years of age or older. On a population level, patient age is an independent predictor of clinical and economic outcomes. Average LOS for patients 80 years and older is 60% longer than for similar patients 65 to 79 years of age (2.9 versus 2.2 days; p < 0.001), complication rates are 34% higher (5.6% versus 2.1%; p < 0.001), and total costs are 28% greater ($7,084 versus $5,917; p < 0.001). High-volume surgeons have shorter LOS and fewer complications but perform fewer thyroidectomies for aging Americans; although they do nearly 29% of these procedures in patients younger than 65 years, they do just 15% of thyroidectomies in patients 80 years and older and 23% in patients 65 to 79 years. CONCLUSIONS: On a population level, clinical and economic outcomes for patients 65 years and older undergoing thyroidectomies are considerably worse than for similar, younger patients. The majority of thyroidectomies in aging Americans is performed by low-volume surgeons. More data are needed about longterm outcomes, but increased referrals to high-volume surgeons for aging Americans are necessary.

Day-case and short-stay surgery: the future for thyroidectomy?

Day-case and short-stay thyroid surgery is carried out routinely around the world. In the UK longer postoperative stay is usually advocated to circumvent/identify potentially catastrophic complications following thyroidectomy. In the current climate of the National Health Service with focus on patient-centred service, reduced hospital stay and cost cutting, we conducted a review to provide a comprehensive assessment of day-case and short-stay thyroidectomy. A systematic electronic literature search using MEDLINE, Ovid, Embase, PubMed and Cochrane databases revealed 22 original studies that met our inclusion criteria. Generally studies demonstrated encouraging results regarding the feasibility of these approaches. Complication rates appeared equivocal to traditional longer stay thyroidectomy and only one patient died. The majority of life-threatening complications occurred in the immediate postoperative period. Of concern, some late haemorrhage has been documented at 5 days postsurgery. Complication rates following day-case/short-stay thyroid surgery appears comparable with inpatient thyroidectomy. Further study is required to determine whether this approach is truly safe.

Cirugía endocrina en régimen ambulatorio / Ambulatory endocrine surgery

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Mortality in a complete 4-year follow up of 85-year-old residents of Leiden, classified by serum level of thyrotropin and thyroxine.

BACKGROUND: The authors of the source article emphasize the clinical tendency to screen for, detect and treat for thyroid dysfunction in very elderly patients, in which it is a fairly common disorder, often with occult or no symptoms. Published evidence is conflicting on the benefit, if any, of such a program. Accordingly, they devised a prospective, population-based study to determine outcomes, including survival outcome, based on serum levels of thyroid-stimulating hormone (TSH) and thyroxine. METHODS: A cohort of 558 subjects who had their 85th birthday between September 1997 and September 1999 was enrolled after consent of the subject and screening examination that included serum TSH and thyroxine levels. This represented a 79% sample of all 85-year-old residents of Leiden, the Netherlands. Follow up was complete for survival 4 years to the subject's 89th birthday or prior death, although 70 subjects refused the annual re-examination. Thyroid function, disability, cognitive function and number of chronic diseases were analyzed, in addition to mortality, through Cox regression and other statistical methods. RESULTS: In 67 subjects with abnormally high TSH (>4.8 mIU/ L), the mean annual mortality rate was derived as 64 deaths per 1000 per year. In the 491 subjects with normal TSH or low TSH (<0.3 mIU/L), the mean annual mortality rate was derived at 114 per 1000 per year. Laboratory evidence of hypothyroidism (initially low serum thyroxine) was found in only 37 of the 67 subjects. CONCLUSION: In the 13% of elderly subjects in Leiden with abnormally high serum TSH levels, the mean annual mortality rate was significantly lower than the mortality rate in the 87% of the elderly patients with normal or low serum TSH. The significance is based on 95% confidence levels of the Poisson distribution. The rate in the group with high TSH levels had 16 deaths in 264 person-years of follow up (FU). The majority with normal or low TSH levels had 193 deaths in 1698 person-years of FU.