Routine T4 No More? Reducing Excess Thyroid Hormone Testing at a Pediatric Tertiary Care Hospital.

OBJECTIVES To promote resource stewardship in thyroid hormone testing at a pediatric tertiary care hospital. STUDY DESIGN Quality improvement approaches generated three change ideas that were implemented simultaneously in the hospital electronic medical record (EMR): (1) a reflex free thyroxine (fT4), whereby fT4 is automatically reported if the thyroid stimulating hormone (TSH) is outside the normal range; (2) a forced-function for thyroid hormone ordering, whereby a provider must select an appropriate indication for ordering fT4 or triiodothyronine (T3); and (3) a clinical decision support message displayed at the time of ordering thyroid function tests. Laboratory data were audited to determine the mean number of fT4 and T3 tests performed per week as well as indications for testing. RESULTS The mean number of fT4 and T3 tests processed per week decreased from 154 ± 21 and 11 ± 7, respectively, in the pre-intervention period, to 107 ± 12 (30% reduction) and 4 ± 3 (66% reduction) post-intervention. These reductions were sustained for the full 20-week assessment period. Process and balancing measures revealed no unintended adverse consequences. Approximate cost savings were $43,000 per year. CONCLUSIONS We describe the successful implementation of EMR-based interventions (reflex fT4, forced-function selection of indication, decision support text) leading to sustained improvements in health-care utilization, with significant associated cost-savings.