Spyridoula Maraka1,2, Raphael Mwangi3, Xiaoxi Yao3,4, Lindsey R Sangaralingham3,5, Naykky M Singh Ospina2,6, Derek T O'Keeffe7, Rene Rodriguez-Gutierrez2,8,9, Marius N Stan10, Juan P Brito2,10, Victor M Montori2,10, Rozalina G McCoy3,4,11. 1. Division of Endocrinology and Metabolism, Center for Osteoporosis and Metabolic Bone Diseases, University of Arkansas for Medical Sciences and the Central Arkansas Veterans Health Care System, Little Rock, AR. 2. Knowledge and Evaluation Research Unit in Endocrinology (KER_Endo), Mayo Clinic, Rochester, MN. 3. Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN. 4. Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN. 5. OptumLabs, Cambridge, MA. 6. Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL. 7. Division of Endocrinology, Department of Medicine, National University of Ireland, Galway, Ireland. 8. Division of Endocrinology, Department of Internal Medicine, University Hospital "Dr. Jose E. Gonzalez", Autonomous University of Nuevo Leon, Monterrey, Mexico. 9. Plataforma INVEST Medicina UANL-KER Unit (KER Unit México), Universidad Autónoma de Nuevo León, Monterrey, México. 10. Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN. 11. Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.
Abstract
CONTEXT: Although thyroid hormone replacement may improve outcomes in pregnant women with subclinical hypothyroidism (SCH), the extent to which they receive treatment is unknown. OBJECTIVE: To describe levothyroxine (LT4) treatment practices for pregnant women with SCH. DESIGN: Retrospective cohort study. SETTING: Large U.S. administrative claims database. PARTICIPANTS: Pregnant women with SCH defined by untreated TSH 2.5-10 mIU/L. MAIN OUTCOME MEASURE: Initiation of LT4 as a function of treating clinician specialty (endocrinology, obstetrics/gynecology, primary care, or other), baseline TSH, patient clinical and demographic factors, and U.S. region. RESULTS: We identified 7,990 pregnant women with SCH; only 1,214 (15.2%) received LT4. Treatment was significantly more likely in patients with higher TSH, obesity, recurrent pregnancy loss, thyroid disease, and cared by endocrinologists. Proportion of treated women increased over time; LT4 treatment was twice as likely in 2014 as in 2010. Women in Northeast and West U.S. were significantly more likely to receive LT4 compared to other regions. Asian women were more likely, while Hispanic women were less likely, to receive LT4 compared to White women. Endocrinologists started LT4 at lower TSH thresholds than other specialties, and treated women who were more likely to have had recurrent pregnancy loss and thyroid disease than women treated by other clinicians. CONCLUSIONS: We found large variation in the prescription of LT4 to pregnant women with SCH, though most treatment-eligible women remained untreated. Therapy initiation is associated with geographic, clinician, and patient characteristics. This evidence can inform quality improvement efforts to optimize care for pregnant women with SCH.
CONTEXT: Although thyroid hormone replacement may improve outcomes in pregnant women with subclinical hypothyroidism (SCH), the extent to which they receive treatment is unknown. OBJECTIVE: To describe levothyroxine (LT4) treatment practices for pregnant women with SCH. DESIGN: Retrospective cohort study. SETTING: Large U.S. administrative claims database. PARTICIPANTS: Pregnant women with SCH defined by untreated TSH 2.5-10 mIU/L. MAIN OUTCOME MEASURE: Initiation of LT4 as a function of treating clinician specialty (endocrinology, obstetrics/gynecology, primary care, or other), baseline TSH, patient clinical and demographic factors, and U.S. region. RESULTS: We identified 7,990 pregnant women with SCH; only 1,214 (15.2%) received LT4. Treatment was significantly more likely in patients with higher TSH, obesity, recurrent pregnancy loss, thyroid disease, and cared by endocrinologists. Proportion of treated women increased over time; LT4 treatment was twice as likely in 2014 as in 2010. Women in Northeast and West U.S. were significantly more likely to receive LT4 compared to other regions. Asian women were more likely, while Hispanic women were less likely, to receive LT4 compared to White women. Endocrinologists started LT4 at lower TSH thresholds than other specialties, and treated women who were more likely to have had recurrent pregnancy loss and thyroid disease than women treated by other clinicians. CONCLUSIONS: We found large variation in the prescription of LT4 to pregnant women with SCH, though most treatment-eligible women remained untreated. Therapy initiation is associated with geographic, clinician, and patient characteristics. This evidence can inform quality improvement efforts to optimize care for pregnant women with SCH.
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