1. Thyroid Function Testing in the VA Ambulatory Clinic
David Sanders
Cost Conscious Medicine
May 2017

2. Thyroid Function Screening?
Controversial to screen asymptomatic non-pregnant adults
No clinical trials have examined the benefits of screening
USPSTF: Insufficient evidence to recommend screening general population

3. Whom to Test All patients with symptoms of hyper or hypothyroid
Substantial hyperlipidemia
Hyponatremia
High serum CK
Macrocytic Anemia
Pericardial or pleural effusions
Previous thyroid injury
Hyponatremia
Pituitary or hypothalamic disease
History of autoimmune disease

4. Objective
To evaluate whether TSH testing is over-utilized in the VA ambulatory setting

5. Methods
Chart review of 49 patients seen consecutively by Resident D in the Bravo clinic at the LBVA from July – December 31st 2016
Laboratory tests are generally ordered prior to the patient coming to clinic
Each patient was assessed if TSH was ordered for that visit
Each clinic patient was assessed for one of the previously mentioned indications for testing

6. Results TSH ordered for 26/49 patients
Of patients with TSH, testing was reasonably indicated in 9/26 patients
Some indications that were found acceptable for those 9 patients
Stiffness
Unintended weight loss
Weight gain
High degree AV block
Depression

7. Results Continued
Thyroid testing was most often ordered for patients visiting clinic for routine health maintenance and without any specific symptoms or other indications for testing.
Of the 17 patients who were unnecessarily tested 1 had an abnormal TSH

8. Cost of Testing According to Health Care Blue Book TSH costs $44.
$44 x 26 patients underwent testing = $1,144 over 6 months total
$44 x 17 patients unnecessarily tested = $748 over 6 months
$748 x 2 = $1,496 per year, for unnecessary testing in one resident’s patient panel
0/17 times TSH result changed management

9. Conclusions
TSH was often ordered as a part of routine screening for many patients visiting LBVA Bravo clinic
This overutilization of the TSH test was costly and did not alter management