Indications for ordering thyroid-stimulating hormone in noncritically ill adult inpatients-A Delphi consensus recommendation

Background Thyroid-stimulating hormone (TSH) is ordered commonly among inpatients, but the possibility of nonthyroidal illness syndrome challenges interpretation. Objective Our objective was to obtain Canadian consensus on appropriate indications for ordering TSH in the first 48 h following presentation of a noncritically ill internal medicine patient. Design, Setting and Participants Canadian endocrinologists with inpatient expertise were invited via snowball sampling to an online 3-round Delphi study. Main Outcome and Measures using a 6-point Likert scale, they rated 58 indications on appropriateness for measuring TSH in medical inpatients. These indications included clinical presentations, signs, and symptoms. Items that reached consensus and agreement (>= 80% of participants selecting a rating of 5 or 6 on the Likert scale) were tabulated and dropped after each round. Qualitative analysis of comments identified additional contextual considerations as themes. Results There were 45 participants (academic setting: 84%) representing 8 provinces (Ontario: 64%). Rounds 2 and 3 were completed by 42 and 33 participants, respectively. Nine indications reached consensus and agreement: presumed myxedema coma, presumed thyroid storm, atrial fibrillation/flutter, euvolemic hyponatremia, proptosis, adrenal insufficiency, hypothermia, thyroid medication noncompliance, and goiter. There was also agreement that two contextual considerations identified in thematic analysis, including a recent abnormal outpatient TSH, and the presence of other findings of thyroid dysfunction, would significantly change some mid-range responses. Conclusions Canadian experts agreed upon nine specific indications for ordering an inpatient TSH, with others requiring consideration of previous TSH measurement and clinical context.