Optimizing Care for Older Adults through Thyroid Hormone Deprescribing

Abstract/Project Summary Older adults have a disproportionately higher prevalence of hypothyroidism compared to their younger counterparts, with levothyroxine (the most widely used synthetic thyroid hormone) consistently one of the top most frequently prescribed medications in the United States. Alarmingly, up to 48% of older adults aged 65 years receive a thyroid hormone dose that is too high, resulting in overtreatment. In addition, thyroid hormone therapy is often initiated for inappropriate indications (misuse) which can also lead to overtreatment. This is especially concerning for older adults, who comprise the fastest growing demographic group and the most vulnerable to polypharmacy. Studies conducted by our team and others have demonstrated that thyroid hormone overtreatment can lead to significant cardiovascular and skeletal risks, and increased mortality. Despite potential patient harm, ~90% of patients continue lifelong thyroid hormone treatment. Thus, in the context of thyroid hormone overtreatment, there is a critical need to deprescribe, which can be achieved either via thyroid hormone dose de-escalation (in patients overtreated) or thyroid hormone discontinuation (in patients without an appropriate indication). The proposed study is the first multi-site trial to evaluate a novel evidence-based adapted multilevel intervention, D-THIO (Deprescribing Thyroid Hormone In Older Adults), consisting of evidence-based pharmaceutical opinion letters to providers, education brochures to patients and facilitated by clinical champions, to support thyroid hormone deprescribing in older adults. We will conduct a type 1 hybrid effectiveness- implementation trial of D-THIO vs. enhanced usual care (American Thyroid Association [ATA] provider abbreviated guidelines, ATA patient brochure) at 3 sites (University of Michigan, Henry Ford, University of California San Francisco) in 150 providers (primary care, endocrinologists, geriatricians, advance practice providers) and 750 of their patients 65 years overtreated with thyroid hormone. We will randomize 1:1 at the provider level within each site. We propose three specific aims: 1) to assess the effectiveness of D-THIO on thyroid hormone deprescribing by providers and on reducing overtreatment and misuse with thyroid hormone via EMR, 2) to assess the effectiveness of D-THIO on provider and patient knowledge and attitudes regarding thyroid hormone deprescribing via surveys, and 3) to identify factors related to the implementation of D-THIO across diverse general care settings via post-trial interviews with key stakeholders. Ultimately, our findings will serve as a model for deprescribing inappropriate medications for other endocrine conditions and conditions with biochemical monitoring, and advance our understanding of de-implementation of low-value care in older adults across the nation.