Forgotten drugs: long-term prescriptions of thyroid hormones - a cross-sectional study

[Clinical quality governance-a practical approach in general practice with the example of influenza vaccination]

We understand clinical quality governance (CQG) as quality management in the clinical domain. In 2020, presumably due to the coronavirus pandemic, more patients requested to be vaccinated against influenza as compared to previous years so that it became apparent that there would be a shortage for high-risk patients. To meet the problem, we started a CQG process. This article is explicitly not a research article but an exemplary description of a CQG process intended as a stimulus and for discussion. We initiated the following process: (1) evaluation of the present state, (2) patients who already had requested a vaccination were prioritized and vaccinated first, and (3) contacting via telephone and vaccination of high-risk patients not on the list. We chose patients with chronic obstructive pulmonary disease (COPD) older than 60 years as an indicator for the group of highest priority. In the beginning only 3 (8%) of our 38 patients with COPD were vaccinated against influenza. After prioritization and vaccination of the high-risk collective in the list of those who had requested to be vaccinated, 25 (66%) of our 38 patients with COPD were vaccinated. After a phone call of high-risk patients not on the list, 28 (74%) patients were vaccinated. This represents an increase of vaccination coverage from 8% to 74% which is close to the rate recommended by the World Health Organization (WHO). In times of a pandemic, family physicians occasionally have to deal with a scarcity of resources and have to develop strategies for fair resource allocation. Not only in this context is CQG worth the effort. The generation of list queries could be improved by the providers of electronic patient records.

Typology of drug discontinuation trials - Methodological recommendations

OBJECTIVE

Due to the increasing concerns about polypharmacy, there is a growing need for clinical recommendations for drug discontinuation. This requires studies investigating the process on several levels. This paper addresses the methodological problems of drug discontinuation trials (DDTs). To that end, we offer a new typology of research aims and corresponding methodological recommendations for trials evaluating drug discontinuation.

STUDY DESIGN AND SETTING

Multi-stage development process, including literature search and expert panels.

RESULTS

Clinical trials are only required in cases of scientific uncertainty. We identified three situations of uncertainty associated with drug discontinuation from which we derived three study types: 1) Uncertainty regarding the effectiveness and/or safety of a drug; 2) Uncertainty regarding the procedure of discontinuing a previously taken drug; 3) Uncertainty regarding the effectiveness of complex strategies used to discontinue one or more drugs. We developed specific methodological recommendations for each study type.

CONCLUSION

We offer a comprehensive definition of research aims, study designs, and methodological recommendations regarding DDTs. The typology we propose can help investigators clarify their research aims and study design. The type-specific methodological recommendation should improve the quality of future drug discontinuation trials.

International variation in GP treatment strategies for subclinical hypothyroidism in older adults: a case-based survey

BACKGROUND

There is limited evidence about the impact of treatment for subclinical hypothyroidism, especially among older people.

AIM

To investigate the variation in GP treatment strategies for older patients with subclinical hypothyroidism depending on country and patient characteristics.

DESIGN AND SETTING

Case-based survey of GPs in the Netherlands, Germany, England, Ireland, Switzerland, and New Zealand.

METHOD

The treatment strategy of GPs (treatment yes/no, starting-dose thyroxine) was assessed for eight cases presenting a woman with subclinical hypothyroidism. The cases differed in the patient characteristics of age (70 versus 85 years), vitality status (vital versus vulnerable), and thyroid-stimulating hormone (TSH) concentration (6 versus 15 mU/L).

RESULTS

A total of 526 GPs participated (the Netherlands n = 129, Germany n = 61, England n = 22, Ireland n = 21, Switzerland n = 262, New Zealand n = 31; overall response 19%). Across countries, differences in treatment strategy were observed. GPs from the Netherlands (mean treatment percentage 34%), England (40%), and New Zealand (39%) were less inclined to start treatment than GPs in Germany (73%), Ireland (62%), and Switzerland (52%) (P = 0.05). Overall, GPs were less inclined to start treatment in 85-year-old than in 70-year-old females (pooled odds ratio [OR] 0.74 [95% confidence interval [CI] = 0.63 to 0.87]). Females with a TSH of 15 mU/L were more likely to get treated than those with a TSH of 6 mU/L (pooled OR 9.49 [95% CI = 5.81 to 15.5]).

CONCLUSION

GP treatment strategies of older people with subclinical hypothyroidism vary largely by country and patient characteristics. This variation underlines the need for a new generation of international guidelines based on the outcomes of randomised clinical trials set within primary care.

Reducing Polypharmacy from the Perspectives of General Practitioners and Older Patients: A Synthesis of Qualitative Studies

BACKGROUND

Polypharmacy, common in elderly multimorbid adults, leads to increased iatrogenic health risks. Yet, no consistent approach to stopping medicines exists in primary healthcare.

OBJECTIVES

Our objective was to synthesize qualitative studies exploring the perspectives and experiences of general practitioners (GPs) and older patients in reducing polypharmacy and to discover approaches already being practiced.

METHODS

We conducted a search in the PubMed, Cochrane Library, Web of Science Core Collection, and Scopus databases to identify qualitative studies in the primary care setting addressing multimorbid older patients and polypharmacy reduction. The seven-step model of meta-ethnography allowed for cross-interpretation between studies considering their original context and developing theories.

RESULTS

A total of 14 studies from the perspectives of patients (n = 6) and providers (n = 8) were included, although discontinuing medicines only occurred as a sub-theme in patient studies. Emerging key concepts for patients were experimenting with medicines, attitudes and experiences towards medicines, necessity of prioritizing treatments, relationship to GP, and system-related contributors. For GPs, they covered assumptions about elderly patients, interface prescribing problems, evidence-based guidelines, failure to meet the challenge of complex decision-making, and solutions.

DISCUSSION

Complex medication regimens and uncertainties in decision making are challenges for both GPs and patients. For patients, symptom experiences with medicines, relationship with their prescriber, and fragmented care are at the forefront; for GPs, it is the decision-making responsibility in the context of unsuitable guidelines, time constraints, and deficient multidisciplinary co-operation. Heuristics such as prioritizing and individualizing treatments and relaxation of guidelines emerged. These strategies require professional awareness of the problem and establishing a trusting, patient-centered consultation style and supportive work conditions.

[Quality of documented diagnosis in primary care - An analysis using the example of thyroid disorders]

BACKGROUND

Routine data of statutory health insurance (SHI) provide a great potential for evaluating the healthcare situation in Germany by providing, e. g., morbidity estimates. In the context of secondary data, analyses based on insurance data were conducted using the outpatient medical billing diagnosis. If, however, medical billing data, which are collected for this primary purpose, are the only source of these morbidity estimates, a limited validity of outpatient medical diagnostic data will have to be assumed or validity will have to be assured. This investigation aimed to analyse the quality of family practitioners' documentation regarding diagnostic data in patients with thyroid disease based on medical records for billing purposes.

METHODS

As part of the pilot study General practitioners' Views on Polypharmacy and its Consequences for Patient Health Care, the medical records of 548 multi-morbid patients with thyroid disease from six general practices in Dresden, Saxony, were analysed with respect to the congruence of prescriptions of thyroid medication and associated thyroid diagnosis. Logistic regression was used to investigate predictors of limited diagnostic data of thyroid disease.

RESULTS

There was insufficient documentation of thyroid diagnoses in 26.8% (n=147) of the included patients diagnosed with or treated for thyroid disease. The proportion of undocumented (1.1 to 35.8%), imprecise (4.6 to 22.3%) and non-specific documented (14.9 to 73.8%) thyroid diagnoses varied in all general practices. Due to undocumented thyroid disease, the corrected prevalence of thyroid diseases summarised for all practices was 5.5 percentage points higher than the originally documented prevalence (29.7 instead of 24.2%). An increasing number of prescribed drugs was a significant predictor for inadequate documentation of thyroid disease (for 5 to 8 routinely taken medications: OR=2.4/p<0.001; for 9 to 12: OR=4.0/p<0.001; for 13 to 20: OR=7.4/p<0.001).

CONCLUSIONS

Due to the limited data quality of outpatient medical billing diagnoses as a basis for morbidity estimates, GPs' diagnostic data should be subjected to regular internal and external diagnostic validation in SHI routine data. Additional case-related interviews with documenting GPs would significantly increase data validity. Also, intelligent e-tools supporting electronic patient documentation could be helpful to improve the quality of primary care documentation.

Influence of thyroid hormone therapy on the fracture rate - A claims data cohort study

INTRODUCTION

It has been debated for years whether long-term thyroid hormone intake causes fractures. Not only have previous studies suffered from design limitations, they also reached contradictory conclusions. We investigated thyroid hormones (thyroxine) as a possible risk factor for fractures in a cohort of 6.7 million persons based on administrative data.

METHODS

The database consists of anonymized settlement data of approximately 70 German statutory health insurances covering a time period of six years. All subjects aged 60 and above were included in the study; subjects with repeated thyroxine prescriptions were assigned to the exposure group; members without thyroxine prescriptions to the control group. Outcome was any incident fracture during a declared time period. In order to calculate fracture risk, we performed multivariate cox regression analyses to adjust for confounders.

RESULTS

Of 798 770 subjects fulfilling the inclusion criteria, 11.7% took thyroxine regularly and belong to the exposure group. The final cox regression showed that subjects taking thyroxine have a 6.3% higher risk (HR 1.063; CI 1.046-1.080, p=<.0001) than members of the control group.

DISCUSSION

The study supports the assumption that long term thyroxine intake leads to an increase in fracture risk among patients older than 60years. The findings have implications for long term thyroxine treatment.

Appropriateness of prescribing thyroxine in primary care

Introduction

A practice hypothyroid register is part of the quality and outcomes framework. In literature, the prevalence of hypothyroidism is stated to be 2% but the prevalence, defined from quality and outcomes framework data, is 3.2% in the UK and 3.6% in Plymouth. We sought to investigate the diagnosis of hypothyroidism and reasons for prescription of thyroxine to patients on the hypothyroid register in Plymouth.

Methods

A letter was sent to the 10 practices with the highest prevalence of hypothyroidism requesting a list of patients on their registers. The hospital pathology system was used to identify those with biochemically documented hypothyroidism (defined as thyroid stimulating hormone >10mU/L) For two large practices the clinical records of the remaining patients were reviewed to ascertain the reasons for prescription of thyroxine and whether it led to symptomatic improvement.

Results

Seven practices responded with 1246 patients on their registers, of whom 43.6% had documented hypothyroidism. A review of notes of patients on the register, but without documented hypothyroidism, showed <25% to have an improvement in symptoms after prescription of thyroxine. Tiredness was the most common symptom prompting prescription of thyroxine.

Conclusion

Of the patients on the register, only 43.6% had documented biochemical evidence of hypothyroidism and, from notes review of those without documented hypothyroidism, at least two-thirds may have been prescribed thyroxine outwith current national guidance. If this is correct, it has significant resource implications, impacts upon the workload of primary care, pharmacy and the laboratory service and may have clinical implications for patients.