The hypothyroidism indicators offer few points but practices should look beyond the contract to bring real clinical benefit to patients, says Dr Matthew Lockyer
Of the 550 points on offer for meeting the clinical indicators of the new contract, the largest share goes to the major disease areas such as heart disease, hypertension and diabetes.
In other areas, creating a disease register is the main requirement, possibly to form the basis of more challenging targets for management in the future. Hypothyroidism is one of these areas.
Clinical indicators for hypothyroidism
Thyroid indicator 1
Thyroid indicator 1 requires the practice to produce a register of patients with hypothyroidism. Preferred Read codes are CO4% (acquired hypothyroidism) and CO3% (congenital hypothyroidism).
Computerised practices should find it easy to achieve this indicator, by searching for thyroxine. Unlike searches for diabetes or asthma treatments, thyroxine is always administered for hypothyroidism and never for any other indication.
Hypothyroidism is common, and the register will reflect a female:male ratio of approximately 10:1. Mean incidence is 3.5 per 1000 for women and 0.6 per 1000 for men.1 The highest incidence is in women aged 75-80 years, when the probability of developing hypothyroidism is 1.4 in 100.
In our practice of approximately 9000 patients we have between 500 and 600 patients taking thyroxine, giving a prevalence of approximately 6%.
The PCO may wish to verify the completeness of the practice register by comparing the prevalence shown with the expected prevalence.
Hypothyroidism is screened for at birth as part of the Guthrie test. It is not formally screened for at other times of life as the identification rate is too low to justify a programme.
The classic symptoms of hypothyroidism are malaise, tiredness, weight gain, constipation and intolerance to cold. Physical signs include coarsening of hair and facial features, bradycardia and slow relaxation of ankle jerks. The condition is sometimes associated with carpal tunnel syndrome.
Many cases do not show any of the classic features and GPs detect many by opportunistic screening or when thyroid function testing is part of a battery of tests for ill-defined symptoms. Hypothyroidism runs in families and patients sometimes ask to be tested for this reason.
|Table 1: Clinical indicators for monitoring hypothyroidism|
|Clinical indicator||Points||Qualifier||Preferred Read code||Exception reporting & Read codes||Payment stages|
|Thyroid 1||Register of patients with hypothyroidism||2||Acquired hypothyroidism CO4% Congenital hypothyroidism CO3%||Unsuitable/dissent N/A|
|Thyroid 2||Percentage of patients with thyroid function tests||6||Recorded in the past 15 months||Thyroid function tests 442%||Patient unsuitable 9h71.
Informed dissent 9h72.
The contract does not require practices to detect patients at high risk for developing hypothyroidism; however, it may be worth considering testing the following at-risk groups annually for thyroid stimulating hormone:
- Patients with a previous history of hyperthyroidism
- Patients who have been treated with partial thyroidectomy or radioactive iodine
- Patients taking amiodarone
- Patients taking lithium
- Patients with a history of pituitary disease.
Diabetes patients are at risk of developing hypothyroidism, and a TSH test is recommended as part of the annual diabetes review.
Adding to the register in this way would be in line with the consensus statement for management of thyroid disorders from which the indicators are taken.2 There is also some published evidence of the effectiveness of extending the register in general practice.3
Thyroid indicator 2
Thyroid indicator 2 relates to the percentage of patients with hypothyroidism for whom there is a record of a thyroid function test in the previous 15 months. Payment begins when 25% of patients comply and maximum points are earned for 90% or more.
The values of the tests should be recorded as well as the preferred coding, 442%, which may be searched by MIQUEST. Alternatively, the PCO may choose to sample a selection of patients to check that their records confirm the claim of tests completed.
The consensus statement for thyroid disease management states that once the appropriate replacement dose of thyroxine has been established it remains constant in most patients. The dose is usually between 100 and 200 micrograms of thyroxine daily.
The correct dose should restore the clinical state to normal and relieve symptoms. Usually this corresponds to a normal or very slightly raised serum thyroxine concentration, a normal tri-iodothyronine concentration and a normal or below normal TSH concentration.
There is still controversy concerning the possibility that TSH-suppressive doses of thyroid hormone may increase the risk of osteoporosis.
The consensus statement recommends that serum thyroxine and TSH are checked annually. This is to aid compliance and to check to see if dose adjustments are needed because of concomitant drug treatment – with anticonvulsants, for example, which interact with thyroid hormones. The contract requires that the test is performed and does not specify outcome measures with regard to values.
Monitoring hypothyroidism is a minor area of the new contract, but the points it offers should be easy to achieve. When the systems required to meet these clinical indicators are established, the effort required in subsequent years will be much less. Although it will not be rewarded with points, extending the register will greatly increase its clinical value.
- Vanderpump MP,Tunbridge WM,French JM et al. The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham Survey. Clin Endocrinol 1995; 43: 55- 68.
- Vanderpump MP,Ahlquist JA,Franklyn JA, Clayton RN. Consensus statement for good practice and audit measures in the management of hypothyroidism and hyperthyroidism. Br Med J 1996; 313: 539-44.
- Hill JP, Pitts-Tucker T. Consensus statement on management of hypothyroidism and hyperthyroidism. Registers based in general practice are essential in long term surveillance. Br Med J 1996; 313: 1488 (letter).