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

den Elzen, W. P.; Lefebre-van de Fliert, A. A.; Virgini, Vanessa; Mooijaart, S. P.; Frey, Peter; Kearney, P. M.; Kerse, N.; Mallen, C. D.; McCarthy, V. J.; Muth, C.; Rosemann, T.; Russell, A.; Schers, H.; Stott, D. J.; de Waal, M. W.; Warner, A.; Westendorp, R. G.; Rodondi, Nicolas; Gussekloo, J. (2015). International variation in GP treatment strategies for subclinical hypothyroidism in older adults: a case-based survey. British journal of general practice, 65(631), e121-e132. Royal College of General Practitioners 10.3399/bjgp15X683569

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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

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