Towards De-Implementation of low-value thyroid care in older adults

Abstract

Purpose of reviewThis review discusses the current literature regarding low-value thyroid care in older adults, summarizing recent findings pertaining to screening for thyroid dysfunction and management of hypothyroidism, thyroid nodules and low-risk differentiated thyroid cancer. Recent findingsDespite a shift to a ''less is more'' paradigm for clinical thyroid care in older adults in recent years, current studies demonstrate that low-value care practices are still prevalent. Ineffective and potentially harmful services, such as routine treatment of subclinical hypothyroidism which can lead to overtreatment with thyroid hormone, inappropriate use of thyroid ultrasound, blanket fine needle aspiration biopsies of thyroid nodules, and more aggressive approaches to low-risk differentiated thyroid cancers, have been shown to contribute to adverse effects, particularly in comorbid older adults.

Putting GLP-1 RAs and Thyroid Cancer in Context: Additional Evidence and Remaining Doubts

“…Overdiagnosis of well-differentiated papillary-cell malignancies, which are often subclinical when diagnosed via imaging as well as slow growing and/or indolent, may be of increased concern in patients with diabetes due to overuse of low-value thyroid care in older and multimorbid adult patients (15)(16)(17). Indeed, in 2017, the United States Preventative Services Task Force issued a recommendation against screening for thyroid cancer in asymptomatic adults, giving the practice their lowest evidence rating of a D (indicating that the harms may outweigh the benefits), and more conservative staging and treatment guidelines have been recently established (18,19).…”

Optimizing TSH testing: minimizing overdiagnosis and unnecessary interventions

“…Adhering to the guidelines from the National Health and Nutrition Examination Survey (NHANES III), which recommend a TSH upper threshold of 7.5 mIU/L for individuals older than 80, is crucial. Ignoring the necessity for age-based threshold adjustments could inadvertently increase the likelihood of overdiagnosis and consequent unnecessary treatments, along with their potential adverse effects [3,16]. Moreover, TSH diagnostic accuracy is influenced by pretest probability.…”

“…This slow process reveals a significant healthcare paradox: the hesitancy to adopt proven interventions while outdated or less effective practices continue, particularly in thyroid health management [1,2]. This situation points to a significant gap between knowledge generation and its application, underscoring a critical area for improvement across all medical areas, including endocrinology [3]. The frequent use of Thyroid Stimulating Hormone (TSH) tests has come under scrutiny for contributing to the overdiagnosis and unnecessary treatment of conditions like subclinical hypothyroidism, which remains a contentious area in medical practice [4][5][6].…”

Biological variation in thyroid function tests in older adults and clinical implications

“…Moreover, an increased CV I for TSH would cause a more frequent detection of TSH above the upper reference limit in older adults, raising the risk of overdiagnosis and treatment. 19,20 We generated data on biological variation in thyroid function tests in older adults. These data were used to evaluate the significance of changes in serial testing, the utility of reference ranges and the number of samples needed to settle the individual set-point in older adults.…”

“…Thus, it may be hypothesised that variation changes with advancing age. Moreover, an increased CV I for TSH would cause a more frequent detection of TSH above the upper reference limit in older adults, raising the risk of overdiagnosis and treatment 19,20 …”