GP Alerts Could Improve Hypothyroidism Management

Liam Davenport

November 12, 2019

BRIGHTON — Electronic prompts bolted onto existing patient management systems could significantly improve the management of patients with hypothyroidism in primary care, with the potential to tailor management to individual circumstances, UK study findings suggest.

Dr Anh Tran, a general practitioner at Shadbolt Park House Surgery, Worcester Park, Surrey, developed a series of alerts that would prompt GPs when they needed to perform annual thyroid stimulating hormone (TSH) tests or when values fell out of range.

The results, presented at Society for Endocrinology BES 2019, showed that the number of appropriately managed patients on thyroid hormone replacement therapy rose significantly over 1 year.

Dr Tran told the audience that, "the electronic alert system appeared to help improve thyroid function optimisation, and the effect appears to be maintained after 2 years".

'Alert Fatigue'

While the improvements were indeed maintained, there were few further gains, leading to questions as to how to combat "alert fatigue" in general practitioners.

Dr Jacqueline Gilbert, a consultant endocrinologist at King's College Hospital, London, who co-chaired the session, told Medscape News UK that the study was "interesting" and shows that there is "a lot of scope" for developing alert systems tailored to individual patient management.

Dr Gilbert pointed out that the improvements "were sustained but, as described, they were static between 12 months and 24 months and hence the question around potential fatigue with the alert receipt".

She believes that this is an "important point" and "one needs to think how one refreshes an alert in such a way that it becomes a positive prompt and not another thing that appears in the inbox and then might not be actioned as we might wish".

Presenting the study, Dr Tran said that it is "not uncommon" for patients with hypothyroidism to have suboptimal thyroid function, and so they developed a protocol based on electronic alerts "to see if we could improve outcomes".

She pointed out that, under the Quality and Outcome Framework (QOF), general practitioners were required to check thyroid function annually, "but this stopped in 2014".

The current approach adds an electronic alert system via on-screen prompts within EMIS Web, a commonly used clinical management tool.

This, Dr Tran said, "attempted to replicate" the QOF requirement, "but in addition to also tell GPs when the patient’s latest TSH is out of range".

GP Practice Data

To examine the impact of the protocol on the monitoring and management of levothyroxine replacement in primary care patients with primary hypothyroidism, they recruited five general practices in the local area.

The practices, which covered a total population of 74,511 patients, had the electronic prompt system installed.

General practitioners were then alerted to perform annual thyroid function tests on all patients with diagnosed hypothyroidism, those receiving levothyroxine, and those with subclinical hypothyroidism.

They were alsoalerted for patients treated with levothyroxine had TSH levels outside the reference range, pregnant women receiving levothyroxine or coded with hypothyroidism, and when patients had not received a follow-up levothyroxine prescription within 6 months.

The team then ran searches on the system at baseline and 12 and 24 months on common parameters of hypothyroidism management.

Study Findings

They found that the prevalence of treated primary hypothyroidism remained steady over the course of the study, at 3.3%.

The proportion of patients with their TSH levels checked in the previous 12 months increased from 76% at baseline to 82% at 12 months following the introduction of the electronic prompt and 83% at 24 months.

In addition, the proportion of patients with the latest TSH level within the reference range increased from 68% at baseline to 72% at 12 and 24 months.

When the team looked at the proportion of patients who both had their TSH checked within the last 12 months and had their last test result within the reference range, the proportion rose from 53% at baseline to 59% at 12 months and 24 months (p<0.0001 for both).

The results compared favourably with those from previous studies, although Dr Tran noted that 28% of patients not having their latest TSH result within the reference range "is still quite a big percentage, and other measures are likely to achieve further improvement".

Alert Overload

During the post-presentation discussion, Dr Shazia Hussain, Department of Endocrinology, Barts Health NHS Trust, London, asked whether they had a category for patients who were "on thyroxine but their TSH would be normal".

Dr Tran replied that they did, and explained that they excluded patients with hyperpituitarism, secondary hypothyroidism, thyroid cancer, and pregnant women from the low TSH but not the high TSH analysis, "because we would still want to know if they’ve got high TSH".

She added that, for patients with secondary hypothyroidism, only an annual TSH alert was sent "because the majority of them were under secondary care, and there is a risk of inappropriate adjustment of thyroxine".

Session co-chair Dr Carla Moran, a consultant endocrinologist at Beacon Hospital, Dublin, pointed out that doctors can become overwhelmed with pop-ups and alerts and wondered whether there was a way of overcoming alert "fatigue" or incentivising doctors to respond to them?

Dr Tran acknowledged that is "difficult", especially with there being "so many QOF areas that we have to address, and thyroid is not one of them".

She said: "If someone, let’s say, has diabetes and is on the QOF register, these alerts would appear on the screen, and the thing people may not be aware of is that the screen is only capable of displaying eight alerts at the same time, so anything else will fall off the bottom."

However, Dr Tran said that it is possible to develop alerts that stay on screen until an action is taken, adding: "Anything is possible, it depends on your priorities and funding."

The study was supported by the British Thyroid Association.

No conflicts of interest declared.

Society for Endocrinology BES 2019: Abstract OP2.3. Presented 11th November.


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