FP28-6 The Effect of Geographical Location in the United States on the Management of Graves' Disease

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: FP28-Thyroid Autoimmunity
Sunday, June 16, 2013: 10:45 AM-11:15 AM
Presentation Start Time: 11:10 AM
Room 103 (Moscone Center)

Poster Board SUN-433
Andrew J Brackbill*1, Kenneth Burman2, David S Cooper3 and Henry B Burch4
1Walter Reed National Military, Bethesda, MD, 2MedStar Washington Hospital Center, Washington, DC, 3The Johns Hopkins University School of Medicine, Baltimore, MD, 4Uniformed Services University of the Health Sciences, Bethesda, MD
Introduction: In a 2011 survey, we showed continued international differences in management practices for Graves’ disease (GD)1. The current study focuses on differences in GD management among regions of the United States (U.S.).

Members of the American Thyroid Association, the Endocrine Society, and the American Association of Clinical Endocrinologists were asked to take a web-based survey consisting of 32 questions dealing with testing, treatment preference, and modulating factors in GD patients.  States were grouped according to Census Bureau regions, including the Midwest (MW), Northeast (NE), South (SO), and West (WE).  Statistical analysis assessed overall group differences using Fisher’s exact test, followed by pairwise testing when group differences were significant.

427 U.S. respondents completed the survey, with 20.8% from the MW, 27.9% from the NE, 30.4% from the SO, and 21.1% from the WE.  Demographics including year of medical school graduation and specialty were similar among regions.  Diagnostic testing was also similar across regions, including measurement of radioactive iodine (RAI) uptake by 61.1-66.9% (P=0.835), thyroid scanning by 43.2-49.4% (P=0.839), and ultrasound by 12.4-22.3% (P=0.156), with a trend towards group differences in TSH-receptor antibody testing (P=0.051).  Regional differences were noted in the choice of primary therapy for GD (P=0.002), with a higher use of RAI therapy in the MW (70.9%) and SO (65.9%), compared to the WE (51.7%) and NE (50.0%).  Routine pretreatment with ATDs before RAI therapy was selected similarly across regions (21.3-25.4%, P=0.954), as was post-treatment with ATDs after RAI therapy (10.6-23.5%, P=0.209).  Patients with ophthalmopathy were preferentially treated with ATDs in all regions (53.3-62.5%), rather than RAI plus corticosteroids (17.9-22.1%), surgery (13.6-23.8%), or RAI alone (1.8-4.5%).  Routine monitoring of liver function during ATD therapy differed among regions (P=0.001), with greater use in the SO (63.8%) and NE (55.9%) than in the NW (42.7%) and WE (41.1%); CBC monitoring was similar across regions (35.6-47.7%, P=0.318).  Respondents from the WE were more likely to switch to an alternate ATD than change to non-ATD therapy in the event of a rash on an ATD (P=0.034).  Women planning pregnancy were preferentially treated with ATDs with no differences among regions (40.5-46.6%, P=0.285). There was a trend towards differences in switching from methimazole (MMI) to propylthiouracil (PTU) in the first trimester (P=0.053), but the rate of switching from PTU to MMI in the 2ndtrimester was similar across regions (49.4-61.2%, P=0.379).

Conclusions: In the first study to examine regional differences in GD management in the U.S., we report significant regional variability in the choice of primary therapy for this disorder, with up to a 20% disparity in the use of RAI therapy across different regions of the U.S.

Burch HB, Burman KD, Cooper DS.  A 2011 survey of current clinical practice in the management of Graves’ disease. J Clin Endocrinol Metab. 2012 Dec;97(12):4549-58.  PMID:23043191

Disclosure: HBB: Consultant, Up To Date. Nothing to Disclose: AJB, KB, DSC

*Please take note of The Endocrine Society's News Embargo Policy at http://www.endo-society.org/endo2013/media.cfm

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