Abstract
Approximately 1.7 million people in the U.S. have type 1 diabetes mellitus. Autoimmune thyroid disease occurs in 17 to 30% of patients with type 1 diabetes. The American Diabetes Association recommends that thyroid function be assessed at diagnosis of type 1 diabetes and repeated every 1 to 2 years thereafter or sooner if clinically indicated. With Centricity, our former electronic medical records (EMR) system, an EMR aid automatically imported key diabetes metrics including the TSH test. Our new EMR system, MedConnect, does not have an EMR aid that imports these metrics. We hypothesized that the screening rate for thyroid dysfunction in type 1 diabetic patients would be higher with the previous EMR system than with the new EMR system. We also hypothesized that the screening rate in patients followed by an endocrinologist would be higher than in those followed by a primary care physician.
Methods: We compared practice patterns with Centricity (from June 1, 2013, to May 30, 2016) versus MedConnect (from January 1, 2017, to December 31, 2019) in both primary care and endocrinology clinics. A total of 502 patients (271 Centricity, 231 MedConnect) were identified by chart review with age ≥18 years and ICD 9/10 codes for type 1 diabetes mellitus in outpatient clinics in our multicenter system.
Results: Baseline TSH was done in 253 of 271 (93.4%) Centricity patients and in 181 of 231 (78.4%) MedConnect patients. The odds of baseline TSH with Centricity was 3.88 times higher compared to MedConnect (OR = 3.88, 95% CI=2.19,6.88). Of the 214 patients with normal baseline TSH, 135 (63.1%) had repeat TSH done in 1-2 years; and of the 136 MedConnect patients with normal baseline TSH, 86 (63.2%) had repeat TSH done in 1-2 years. Of 434 patients with baseline TSH, 81 (18.6%) had abnormal TSH. Of these patients, 67 (82.7%) had hypothyroidism, 1 (1.2%) had hyperthyroidism, 8 (9.8%) had subclinical hypothyroidism, and 5 (6.1%) had subclinical hyperthyroidism. Of the total 502 patients, 380 (75.7%) were followed by an endocrinologist and 122 (24.3%) were followed by a primary care provider. Among patients followed by an endocrinologist, 348 (91.6%) had a baseline TSH result. Only 86 of 122 (70.5 %) patients followed by a primary care physician had a baseline TSH. Endocrinologists had 4.6 times higher odds of TSH screening at baseline compared with primary care physicians (p <0.0001).
Conclusion: Thyroid function was not assessed at baseline in all patients with type 1 diabetes mellitus and was not followed at the recommended intervals per the guidelines. Higher screening rates were seen with an EMR aid. Endocrinologists screened significantly more patients than primary care physicians. Education of providers regarding the guidelines is needed, and addition of an EMR aid may help to improve detecting thyroid dysfunction in patients with type 1 diabetes mellitus.
Developing a case definition for type 1 diabetes mellitus in a primary care electronic medical record database: an exploratory study
