Thyroid function testing in eastern Nepal and the impact of CME on subsequent requests

Investigating Investigation (Ab)Use: Thyroid Function Test Audit in a Tertiary Care Teaching Institute in Eastern India

An essential component of contemporary health care is laboratory testing. As the utilization of diagnostic tests grow, there is also an increase in the scrutiny of such tests for its effectiveness, balance of cost and over- utilization. Thyroid dysfunction is common across all age groups and is associated with a number of comorbid states. The thyroid function tests (TFTs) are very important for the diagnosis and monitoring of such patients. The guidelines recommend serum thyroid stimulating hormone (TSH) as the single most reliable test to diagnose all common forms of hypothyroidism and hyperthyroidism, except in few cases. This study was conducted to study the investigation requesting pattern of TFTs. Our results showed that TFT panel was ordered in almost equal numbers (35.58%) as single test of TSH (41.27%). Subclinical thyroid disease was diagnosed in 22.1% of cases and the rest were excluded as having any thyroid dysfunction. Over 2/3rd of all requests were for women. An important conclusion from our study was that, the essentiality of lab tests is a decision entirely in the hands of the treating physician keeping in mind the cost and best outcome for patients. Hospitals can develop strategic protocols for ordering laboratory tests keeping resources, need and patient satisfaction and outcomes optimal.

Effectiveness of Practices to Support Appropriate Laboratory Test Utilization: A Laboratory Medicine Best Practices Systematic Review and Meta-Analysis

Objectives

To evaluate the effectiveness of practices used to support appropriate clinical laboratory test utilization.

Methods

This review followed the Centers for Disease Control and Prevention (CDC) Laboratory Medicine Best Practices A6 cycle method. Eligible studies assessed one of the following practices for effect on outcomes relating to over- or underutilization: computerized provider order entry (CPOE), clinical decision support systems/tools (CDSS/CDST), education, feedback, test review, reflex testing, laboratory test utilization (LTU) teams, and any combination of these practices. Eligible outcomes included intermediate, systems outcomes (eg, number of tests ordered/performed and cost of tests), as well as patient-related outcomes (eg, length of hospital stay, readmission rates, morbidity, and mortality).

Results

Eighty-three studies met inclusion criteria. Fifty-one of these studies could be meta-analyzed. Strength of evidence ratings for each practice ranged from high to insufficient.

Conclusion

Practice recommendations are made for CPOE (specifically, modifications to existing CPOE), reflex testing, and combined practices. No recommendation for or against could be made for CDSS/CDST, education, feedback, test review, and LTU. Findings from this review serve to inform guidance for future studies.

Need for an Individualized and Aggressive Management of Multinodular Goiters of Endemic Zones by Specially Trained Surgeons: Experience in Western Nepal

BACKGROUND

The goals of the present study were to explore the presentation of multinodular goiter (MNG) and solitary thyroid nodules (STN) in the sub-Himalayan belt, including the risk of malignancy, and to evaluate whether specialized surgeon training in endocrine surgery has an effect on reducing complications.

METHODS

This retrospective study (1998-2003) analyzed 624 patients with thyroid disorders seen in the thyroid clinic of a tertiary care hospital in western Nepal. The findings included 67.7% (n = 423: euthyroid, 297, toxic, 126) multinodular goiters (MNG) and 18.5% (n = 116) STN. Rest of patients of other thyroid disorders were excluded from the study. Ultrasonography and fine-needle aspiration cytology (FNAC) were the available diagnostic adjuncts. To evaluate the role of surgeon training, outcomes were compared between patients cared for by surgeons specially trained in endocrine surgery and those who were not. Prognostic markers indicated aggressiveness of cancers.

RESULTS

Of the 539 MNG and STN patients in this series, 236 underwent operation. Of these, 25.7% (139/539) were toxic, and 11.31% had associated carcinoma. Aggressive cancers, like poorly differentiated (4.9%) and anaplastic types (18%), were more common than in series of patients from iodine-sufficient regions. Patients 40-55 years of age were more likely to have toxicity, and those > 60 years of age were more likely to have aggressive cancers. Postoperative complication rates were lower in the group treated by surgeons who had special training in endocrine surgery.

CONCLUSIONS

There is a higher incidence of toxicity and malignancy in MNG in an endemic goiter zone. The limited diagnostic and therapeutic facilities in the region under study warrant a high degree of clinical suspicion and judgment, sound knowledge of thyroid physiology, thorough interpretation of hormone test results, and meticulous surgical techniques. The treatment must be individualized with consideration of humanitarian and socioeconomic factors, without compromising the quality of care and its long-term consequences. Aggressive management of malignancy and toxicity with total thyroidectomy is needed as primary therapy in many instances. However, subtotal excision is more useful in carefully selected cases with a small remnant. Specialized training in thyroid surgery appears to be valuable in reducing complications.

Getting evidence into practice: what works in developing countries?

PURPOSE

We summarize and comment on the available literature on the effectiveness of interventions designed to change professional behaviour in order to bring evidence into practice in developing countries.

DATA SOURCES

We used a strategy adapted from the Effective Practice & Organization Care (EPOC) Cochrane group.

STUDY SELECTION

Forty-four studies met pre-defined selection criteria. Controlled and uncontrolled trials of interventions were included. Studies measured either professional compliance with agreed standards or patients' clinical outcomes. Data extraction. Data were extracted using a pre-defined extraction tool and studies were appraised accordingly.

RESULTS OF DATA SYNTHESIS

Data were synthesized and categorized according to different types of intervention. Audit and feedback was found to be effective, at least in the short term, when combined with other approaches. Similarly, educational interventions were more effective when designed to address local educational needs and organizational barriers. We found insufficient evidence to assess the effectiveness of educational outreach, local opinion leaders, use of mass media, and reminders. Educational materials alone are unlikely to influence change. However, the majority of studies had weak designs and failed to exclude possible biases.

CONCLUSION

Current evidence for the effectiveness of interventions to change health professionals' behaviour in developing countries is either scanty or flawed due to poorly designed research. Given the recent drive to improve quality of care, this should be a priority area for researchers and international agencies supporting health systems development in developing countries. This review provides an insight into some of the methodological issues that interested researchers may face.

Pathology tests: is the time for demand management ripe at last?

With the ever increasing demands for pathology testing within the National Health Service there is a need to manage the demand for these tests. This review discusses strategies for the demand management of requests made by clinicians in the disciplines of biochemistry, haematology, and microbiology. The various approaches that have been used to manage demand will be described, along with specific clinical strategies for demand management.