Variation in treatment strategies of Swiss general practitioners for subclinical hypothyroidism in older adults

Christine Baumgartner; Wendy  P. J. den Elzen; Manuel  R. Blum; Michael Coslovsky; Sven Streit; Peter Frey; Lilli Herzig; Dagmar  M. Haller; Simon  P. Mooijaart; Thomas Bischoff; Thomas Rosemann; Jacobijn Gussekloo; Nicolas Rodondi

doi:10.4414/smw.2015.14156

Original article

Vol. 145 No. 3132 (2015)

Variation in treatment strategies of Swiss general practitioners for subclinical hypothyroidism in older adults

Christine Baumgartner
Wendy P. J. den Elzen
Manuel R. Blum
Michael Coslovsky
Sven Streit
Peter Frey
Lilli Herzig
Dagmar M. Haller
Simon P. Mooijaart
Thomas Bischoff
Thomas Rosemann
Jacobijn Gussekloo
Nicolas Rodondi

DOI: https://doi.org/10.4414/smw.2015.14156
Cite this as:: Swiss Med Wkly. 2015;145:w14156
Published: 26.07.2015

Summary

QUESTIONS UNDER STUDY: As the best management of subclinical hypothyroidism is controversial, we aimed to assess variations in treatment strategies depending on different Swiss regions, physician and patient characteristics.

METHODS: We performed a case-based survey among general practitioners (GPs) in different Swiss regions, which consisted of eight hypothetical cases presenting a female patient with subclinical hypothyroidism and nonspecific complaints differing by age, vitality status and thyroid-stimulating hormone (TSH) concentration.

RESULTS: A total of 262 GPs participated in the survey. There was considerable variation in the levothyroxine starting dose chosen by GPs, ranging from 25 µg to 100 µg. Across the Swiss regions, GPs in the Bern region were significantly more inclined to treat, with a higher probability of initiating treatment (60%, p = 0.01) and higher mean starting doses (45 µg, p <0.01) compared with the French-speaking region (44%, 36 µg); the Zurich region had intermediate values (52%, 39 µg). We found no association between treatment rate and other physician characteristics. GPs were more reluctant to initiate treatment in 85-year-old than in 70-year-old women (odds ratio [OR] 0.77, 95% confidence interval [CI] 0.63–0.94), and more likely to treat women with a TSH of 15 mU/l than those with a TSH of 6mU/l (OR 8.71, 95% CI 6.21–12.20).

CONCLUSIONS: There are strong variations in treatment strategies for elderly patients with subclinical hypothyroidism across different Swiss regions, including use of higher starting doses than the recommended 25 µg in the Swiss guidelines, which recommend a starting dose of 25 µg. These variations likely reflect the current uncertainty about the benefits of treatment, which arise from the current lack of evidence from adequately powered clinical trials.

References

Helfand M. Screening for subclinical thyroid dysfunction in nonpregnant adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Internal Med. 2004;140(2):128–41.
Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The Colorado thyroid disease prevalence study. Arch Intern Med. 2000;160(4):526–34.
Hollowell JG, Staehling NW, Flanders WD, Hannon WH, Gunter EW, Spencer CA, et al. Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab. 2002;87(2):489–99.
Rodondi N, den Elzen WP, Bauer DC, Cappola AR, Razvi S, Walsh JP, et al. Subclinical hypothyroidism and the risk of coronary heart disease and mortality. JAMA. 2010;304(12):1365-74. Epub 2010/09/23. doi: 10.1001/jama.2010.1361.
Gencer B, Collet TH, Virgini V, Bauer DC, Gussekloo J, Cappola AR, et al. Subclinical thyroid dysfunction and the risk of heart failure events: an individual participant data analysis from 6 prospective cohorts. Circulation. 2012;126(9):1040–9.
Surks MI, Ortiz E, Daniels GH, Sawin CT, Col NF, Cobin RH, et al. Subclinical thyroid disease: scientific review and guidelines for diagnosis and management. JAMA.2004;291(2):228–38.
Villar HC, Saconato H, Valente O, Atallah AN. Thyroid hormone replacement for subclinical hypothyroidism. The Cochrane database of systematic reviews. 2007(3):CD003419.
Collet TH, Gussekloo J, Bauer DC, den Elzen WP, Cappola AR, Balmer P, et al. Subclinical hyperthyroidism and the risk of coronary heart disease and mortality. Arch Intern Med. 2012;172(10):799–809.
Wirth CD, Blum MR, da Costa BR, Baumgartner C, Collet TH, Medici M, et al. Subclinical thyroid dysfunction and the risk for fractures: a systematic review and meta-analysis. Ann Intern Med. 2014;161(3):189–99.
den Elzen WP, Lefebre-van de Fliert AA, Virgini V, Mooijaart SP, Frey P, Kearney PM, et al. International variation in GP treatment strategies for subclinical hypothyroidism in older adults: a case-based survey. Br J Gen Pract. 2015;65(631):e121–32.
Gharib H, Tuttle RM, Baskin HJ, Fish LH, Singer PA, McDermott MT. Subclinical thyroid dysfunction: a joint statement on management from the American Association of Clinical Endocrinologists, the American Thyroid Association, and the Endocrine Society. J Clin Endocrinol Metab. 2005;90(1):581–5; discussion 6–7.
Vanderpump MP, Ahlquist JA, Franklyn JA, Clayton RN. Consensus statement for good practice and audit measures in the management of hypothyroidism and hyperthyroidism. The Research Unit of the Royal College of Physicians of London, the Endocrinology and Diabetes Committee of the Royal College of Physicians of London, and the Society for Endocrinology. BMJ. 1996;313(7056):539–44.
Müller B. «Subklinische» Hypo- und Hyperthyreose. Schweizerische Gesellschaft für Endokrinologie und Diabetologie. http://www.sgedssed.ch/fileadmin/files/dokumente/EDM_Key_Slides_2010-2011/SGED_Subklinische_Hypo_Hyperthyresose.pdf2010-2011. German.
American Academy of Family Physicians. Periodic health examination: Summary of AAFP policy recommendations and age charts, revision 4.0. American Academy of Family Physicians, 2000.
NETQ. http://wwwnetq-enquetenl/nl.
DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–88.
McDermott MT, Haugen BR, Lezotte DC, Seggelke S, Ridgway EC. Management practices among primary care physicians and thyroid specialists in the care of hypothyroid patients. Thyroid. 2001;11(8):757–64.
Burch HB, Burman KD, Cooper DS, Hennessey JV. A 2013 survey of clinical practice patterns in the management of primary hypothyroidism. J Clin Endocrinol Metab. 2014;99(6):2077–85.
Pearce SH, Brabant G, Duntas LH, Monzani F, Peeters RP, Razvi S, et al. 2013 ETA Guideline: Management of Subclinical Hypothyroidism. Eur Thyroid J. 2013;2(4):215–28.
Garber JR, Cobin RH, Gharib H, Hennessey JV, Klein I, Mechanick JI, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Thyroid. 2012;22(12):1200–35.
McAvoy BR, Kaner EF. General practice postal surveys: a questionnaire too far? BMJ. 1996;313(7059):732–3; discussion 3–4.
Kellerman SE, Herold J. Physician Response to Surveys. A Review of the Literature. Am J Prev Med. 2001;20(1):61–7.
Baumgartner C, Blum MR, Rodondi N. Subclinical hypothyroidism: summary of evidence in 2014. Swiss Med Wkly. 2014;144:w14058.
mediX. Guideline Schilddrüsenerkrankungen. http://www.medix.ch/wissen/guidelines/stoffwechselkrankheiten/schilddruesenerkrankungen.html. 2011. German.
Wensing M, Broge B, Riens B, Kaufmann-Kolle P, Akkermans R, Grol R, et al. Quality circles to improve prescribing of primary care physicians. Three comparative studies. Pharmacoepidemiol Drug Saf. 2009;18(9):763–9.
Frei A, Senn O, Huber F, Vecellio M, Steurer J, Woitzek K, et al. Congruency of diabetes care with the Chronic Care Model in different Swiss health care organisations from the patients’ perspective: a cross sectional study. Swiss Med Wkly. 2014;10(144).
Cranney M, Warren E, Barton S, Gardner K, Walley T. Why do GPs not implement evidence-based guidelines? A descriptive study. Fam Pract. 2001;18(4):359–63.
Rodondi N, Bauer DC. Subclinical hypothyroidism and cardiovascular risk: how to end the controversy. J Clin Endocrinol Metab. 2013;98(6):2267–9.
Mooijaart SP. Letter regarding the Paper by Pearce et al. Entitled “2013 ETA Guideline: Management of Subclinical Hypothyroidism”. Eur Thyroid J. 2014;3(2):141–2.

How to Cite

1.

Baumgartner C, den Elzen WPJ, Blum MR, Coslovsky M, Streit S, Frey P, Herzig L, Haller DM, Mooijaart SP, Bischoff T, Rosemann T, Gussekloo J, Rodondi N. Variation in treatment strategies of Swiss general practitioners for subclinical hypothyroidism in older adults. Swiss Med Wkly [Internet]. 2015 Jul. 26 [cited 2024 Nov. 18];145(3132):w14156. Available from: https://smw.ch/index.php/smw/article/view/2052

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Most read articles by the same author(s)

Annina Stauber, Andreas Müller, Nikki Rommers, Stefanie Aeschbacher, Nicolas Rodondi, Leo H. Bonati, Juerg H. Beer, Raban V. Jeger, David J. Kurz, Claudia Liedtke, Peter Ammann, Marcello Di Valentino, Patricia Chocano, Richard Kobza, Michael Kühne, David Conen, Stefan Osswald, Alain M. Bernheim, Association of chocolate consumption with neurological and cardiovascular outcomes in atrial fibrillation: data from two Swiss atrial fibrillation cohort studies (Swiss-AF and BEAT-AF) , Swiss Medical Weekly: Vol. 153 No. 8 (2023)
Lacher Simone, Albert Wettstein, Oliver Senn, Thomas Rosemann, Susann Hasler, Types of abuse and risk factors associated with elder abuse , Swiss Medical Weekly: Vol. 146 No. 0304 (2016)
Stefan Neuner-Jehle, Thomas Grischott, Stefan Markun, Marc Maeder, Thomas Rosemann, Oliver Senn, What interventions do general practitioners recommend avoiding? A nationwide survey from Switzerland , Swiss Medical Weekly: Vol. 150 No. 2526 (2020)
Malte Kohns Vasconcelos, Patrick M. Meyer Sauteur, Kristina Keitel, Regina Santoro, Adrian Egli, Michael Coslovsky, Michelle Seiler, Marco Lurà, Henrik Köhler, Natasha Loevy, Christian R. Kahlert, Ulrich Heininger, Johannes van den Anker, Julia A. Bielicki, Detection of mostly viral pathogens and high proportion of antibiotic treatment initiation in hospitalised children with community-acquired pneumonia in Switzerland – baseline findings from the first two years of the KIDS-STEP trial , Swiss Medical Weekly: Vol. 153 No. 2 (2023)
Christian Mueller, Klaus Bally, Marc Buser, Andreas J. Flammer, Jean-Michel Gaspoz, François Mach, Giorgio Moschovitis, Matthias Paul, Andreas Zeller, Ellen Heitlinger, Bianca Fay, Thomas Rosemann, Roadmap for the treatment of heart failure patients after hospital discharge: an interdisciplinary consensus paper , Swiss Medical Weekly: Vol. 150 No. 0506 (2020)
David Conen, Nicolas Rodondi, Andreas Müller, Juerg H. Beer, Angelo Auricchio, Peter Ammann, Daniel Hayoz, Richard Kobza, Giorgio Moschovitis, Dipen Shah, Jürg Schläpfer, Jan Novak, Marcello Di Valentino, Paul Erne, Christian Sticherling, Leo H. Bonati, Georg Ehret, Laurent Roten, Urs Fischer, Andreas Monsch, Christoph Stippich, Jens Wuerfel, Matthias Schwenkglenks, Michael Kühne, Stefan Osswald, for the Swiss-AF study investigators, Design of the Swiss Atrial Fibrillation Cohort Study (Swiss-AF): structural brain damage and cognitive decline among patients with atrial fibrillation , Swiss Medical Weekly: Vol. 147 No. 2728 (2017)
Arnaud Chiolero, Fred Paccaud, Drahomir Aujesky, Valérie Santschi, Nicolas Rodondi, How to prevent overdiagnosis , Swiss Medical Weekly: Vol. 145 No. 0304 (2015)
Christine Baumgartner, Manuel Raphael Blum, Nicolas Rodondi, Subclinical hypothyroidism: summary of evidence in 2014 , Swiss Medical Weekly: Vol. 144 No. 5152 (2014)
Renata Vidonscky Lüthold, Nicole Christin Henz, Connor Fuhrer, Andrea Häner, Michael Schenk, Katharina Tabea Jungo, Sven Streit, Inappropriate proton-pump inhibitor prescribing in primary care – an observational study with quality circles , Swiss Medical Weekly: Vol. 153 No. 9 (2023)
Rahel Meier, Thomas Grischott, Yael Rachamin, Levy Jäger, Oliver Senn, Thomas Rosemann, Jakob M. Burgstaller, Stefan Markun, Importance of different electronic medical record components for chronic disease identification in a Swiss primary care database: a cross-sectional study , Swiss Medical Weekly: Vol. 153 No. 10 (2023)

1 2 3 4 5 > >>

[1] Helfand M. Screening for subclinical thyroid dysfunction in nonpregnant adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Internal Med. 2004;140(2):128–41.

[2] Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The Colorado thyroid disease prevalence study. Arch Intern Med. 2000;160(4):526–34.

[3] Hollowell JG, Staehling NW, Flanders WD, Hannon WH, Gunter EW, Spencer CA, et al. Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab. 2002;87(2):489–99.

[4] Rodondi N, den Elzen WP, Bauer DC, Cappola AR, Razvi S, Walsh JP, et al. Subclinical hypothyroidism and the risk of coronary heart disease and mortality. JAMA. 2010;304(12):1365-74. Epub 2010/09/23. doi: 10.1001/jama.2010.1361.

[5] Gencer B, Collet TH, Virgini V, Bauer DC, Gussekloo J, Cappola AR, et al. Subclinical thyroid dysfunction and the risk of heart failure events: an individual participant data analysis from 6 prospective cohorts. Circulation. 2012;126(9):1040–9.

[6] Surks MI, Ortiz E, Daniels GH, Sawin CT, Col NF, Cobin RH, et al. Subclinical thyroid disease: scientific review and guidelines for diagnosis and management. JAMA.2004;291(2):228–38.

[7] Villar HC, Saconato H, Valente O, Atallah AN. Thyroid hormone replacement for subclinical hypothyroidism. The Cochrane database of systematic reviews. 2007(3):CD003419.

[8] Collet TH, Gussekloo J, Bauer DC, den Elzen WP, Cappola AR, Balmer P, et al. Subclinical hyperthyroidism and the risk of coronary heart disease and mortality. Arch Intern Med. 2012;172(10):799–809.

[9] Wirth CD, Blum MR, da Costa BR, Baumgartner C, Collet TH, Medici M, et al. Subclinical thyroid dysfunction and the risk for fractures: a systematic review and meta-analysis. Ann Intern Med. 2014;161(3):189–99.

[10] den Elzen WP, Lefebre-van de Fliert AA, Virgini V, Mooijaart SP, Frey P, Kearney PM, et al. International variation in GP treatment strategies for subclinical hypothyroidism in older adults: a case-based survey. Br J Gen Pract. 2015;65(631):e121–32.

[11] Gharib H, Tuttle RM, Baskin HJ, Fish LH, Singer PA, McDermott MT. Subclinical thyroid dysfunction: a joint statement on management from the American Association of Clinical Endocrinologists, the American Thyroid Association, and the Endocrine Society. J Clin Endocrinol Metab. 2005;90(1):581–5; discussion 6–7.

[12] Vanderpump MP, Ahlquist JA, Franklyn JA, Clayton RN. Consensus statement for good practice and audit measures in the management of hypothyroidism and hyperthyroidism. The Research Unit of the Royal College of Physicians of London, the Endocrinology and Diabetes Committee of the Royal College of Physicians of London, and the Society for Endocrinology. BMJ. 1996;313(7056):539–44.

[13] Müller B. «Subklinische» Hypo- und Hyperthyreose. Schweizerische Gesellschaft für Endokrinologie und Diabetologie. http://www.sgedssed.ch/fileadmin/files/dokumente/EDM_Key_Slides_2010-2011/SGED_Subklinische_Hypo_Hyperthyresose.pdf2010-2011. German.

[14] American Academy of Family Physicians. Periodic health examination: Summary of AAFP policy recommendations and age charts, revision 4.0. American Academy of Family Physicians, 2000.

[15] NETQ. http://wwwnetq-enquetenl/nl.

[16] DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–88.

[17] McDermott MT, Haugen BR, Lezotte DC, Seggelke S, Ridgway EC. Management practices among primary care physicians and thyroid specialists in the care of hypothyroid patients. Thyroid. 2001;11(8):757–64.

[18] Burch HB, Burman KD, Cooper DS, Hennessey JV. A 2013 survey of clinical practice patterns in the management of primary hypothyroidism. J Clin Endocrinol Metab. 2014;99(6):2077–85.

[19] Pearce SH, Brabant G, Duntas LH, Monzani F, Peeters RP, Razvi S, et al. 2013 ETA Guideline: Management of Subclinical Hypothyroidism. Eur Thyroid J. 2013;2(4):215–28.

[20] Garber JR, Cobin RH, Gharib H, Hennessey JV, Klein I, Mechanick JI, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Thyroid. 2012;22(12):1200–35.

[21] McAvoy BR, Kaner EF. General practice postal surveys: a questionnaire too far? BMJ. 1996;313(7059):732–3; discussion 3–4.

[22] Kellerman SE, Herold J. Physician Response to Surveys. A Review of the Literature. Am J Prev Med. 2001;20(1):61–7.

[23] Baumgartner C, Blum MR, Rodondi N. Subclinical hypothyroidism: summary of evidence in 2014. Swiss Med Wkly. 2014;144:w14058.

[24] mediX. Guideline Schilddrüsenerkrankungen. http://www.medix.ch/wissen/guidelines/stoffwechselkrankheiten/schilddruesenerkrankungen.html. 2011. German.

[25] Wensing M, Broge B, Riens B, Kaufmann-Kolle P, Akkermans R, Grol R, et al. Quality circles to improve prescribing of primary care physicians. Three comparative studies. Pharmacoepidemiol Drug Saf. 2009;18(9):763–9.

[26] Frei A, Senn O, Huber F, Vecellio M, Steurer J, Woitzek K, et al. Congruency of diabetes care with the Chronic Care Model in different Swiss health care organisations from the patients’ perspective: a cross sectional study. Swiss Med Wkly. 2014;10(144).

[27] Cranney M, Warren E, Barton S, Gardner K, Walley T. Why do GPs not implement evidence-based guidelines? A descriptive study. Fam Pract. 2001;18(4):359–63.

[28] Rodondi N, Bauer DC. Subclinical hypothyroidism and cardiovascular risk: how to end the controversy. J Clin Endocrinol Metab. 2013;98(6):2267–9.

[29] Mooijaart SP. Letter regarding the Paper by Pearce et al. Entitled “2013 ETA Guideline: Management of Subclinical Hypothyroidism”. Eur Thyroid J. 2014;3(2):141–2.