Background:
Hypothyroidism is the most common pregnancy-related thyroid condition, associated with increased risks including: miscarriage, preterm delivery, reduced birthweight, and offspring intellectual impairment. Such risks may be reduced through timely diagnosis and thyroxine initiation to achieve maternal euthyroid state. To streamline access to Endocrinology services for women with thyroid dysfunction in pregnancy, Sutherland Hospital implemented a simplified referral management algorithm in February 2021.
Aims:
The primary outcome was to compare the proportion of referred patients who achieved target TSH during pregnancy, before and after algorithm implementation. Secondary outcomes included change in (a)referral numbers, (b)rate of guideline-appropriate investigations, and (c)mean time to Endocrinology consultation.
Methods:
A retrospective database search was performed for the first one-hundred consecutive patients referred to the Sutherland Hospital Gestational Thyroid Clinic with hypothyroidism (thyroid stimulating hormone (TSH)>2.5mIU/L) between April-September 2020 (pre-intervention) and April-September 2021 (post-intervention) for the two sample populations. Detailed clinical data were compared.
Results:
All women pre- and post-intervention achieved target TSH during pregnancy (median final TSH 1.6mIU/L, IQR:1.2-2.3mIU/L). The Endocrinology Clinic received 94 referrals pre-intervention and 109 post-intervention (total 203). While there was no significant difference in guideline-discordant referrals (ie referred with normal TSH) (28% ‘before’ vs 18% ‘after’, p=0.24), significantly more women with an elevated TSH had undergone thyroid autoantibody testing post-intervention (55.5% vs 78%, p=0.035). Women post-intervention attended Endocrinology consultation earlier in pregnancy (median 19 vs 22-weeks, p=0.032) and had their TSH measured earlier in pregnancy (median 5.5 vs 6.5-weeks, p=0.011). The number of women with a raised TSH who were prescribed thyroxine prior to first appointment was unchanged (68% ‘before’ vs 70% ‘after’, p=0.83).
Conclusions:
Although service effectiveness in achieving target TSH remained unchanged post-algorithm implementation, the use of a dedicated referral algorithm can improve referral efficiency measures including earlier initial TSH measurement, increased autoantibody testing, and reduced consultation waiting time.