|LETTER TO THE EDITOR
|Year : 2013 | Volume
| Issue : 1 | Page : 35-36
Direct access testing in thyroidology: Perils aplenty
Sanjay Kalra1, Bharti Kalra2, Kanishka Sawhney3
1 Department of Endocrinology, Bharti Hospital, Karnal, India
2 Department of Obstetrics, Bharti Hospital, Karnal, India
3 Medical Student, Subharti Medical College, Meerut, India
|Date of Web Publication||10-Jan-2013|
Department of Endocrinology, Bharti Hospital, Karnal - 132 001
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kalra S, Kalra B, Sawhney K. Direct access testing in thyroidology: Perils aplenty. Thyroid Res Pract 2013;10:35-6
Along with the epidemic of thyroid diseases, obvious in our outdoor clinics and indoor wards, is a surge in the number of patients presenting with self-ordered thyroid function test reports.
Such direct access testing (DAT) for thyroid function is encouraged by both reference laboratories and smaller diagnostic centers, which advertise the (frequently non-specific) clinical features of thyroid disease, in order to convince people to get investigated. Individuals often order thyroid function tests without getting simpler investigations such as hemoglobin and serum calcium, in a misguided attempt to explain their symptoms.
DAT finds popularity in patients who wish to keep control over their health status, and are proactive about seeking health care. While in some ways, this is an encouraging trend, there are misgivings and concerns about the medical, psychological and economic consequences of DAT.
Interpreting thyroid function test is not as easy as the laboratory-printed normal range values would have us believe. Normal values may differ according to time of collection of sample, age of patient, and during pregnancy. Discrepancy between results of thyroid stimulating hormone (TSH) on one hand, and triiodothyronine (T3) and thyroxin (T4) values on the other, can be resolved only by a clinical thyroidologist. Similarly, differentiating non thyroidal illness (NTI) from central hypothyroidism needs clinical acumen, which cannot be replaced by algorithms. Often, abnormal thyroid function tests are due to obesity, rather than the other way around. At times, "wrong" T3 and T4 become "correct" when a free T3 and free T4 is ordered.
Wrong interpretation of thyroid functions done by DAT may lead to avoidable psychological stress, as well as improper recommendations and mistreatment. This in turn may have unwanted consequences on both short-term and long-term health of the individual.
Many laboratories use unproven or unvalidated methods of testing to assess thyroid function, and do not mention the reliability of their kits. It, therefore, becomes difficult to interpret these results, or base clinical judgments upon them. We have come across TSH reports given in negative value (eg., −2.4 mIU/ml), from a reputed government laboratory. When requested for an explanation, the senior biochemist replied: "The results are from a foreign kit: How can I argue with them?"
Unfortunately, DAT is encouraged for commercial interests, rather than for public good. Apart from the money (usually paid from pocket) spent in DAT, expenses related to unnecessary treatment, to management of self-created complications, and to appropriate investigations advised by a thyroidologist at a later stage, add to the financial burden on the patient.
No study has proven the utility of DAT or universal screening of either adults or children in case finding for thyroid disorders. The cost benefit of such an approach is doubtful.
One benefit of the easy availability of DAT in India is the enhanced community awareness of thyroid disease, and a perceptibly more positive health care seeking behavior of the public. There must be more economical and effective ways of achieving this, however.
The American Thyroid Association advises patients to seek advice from their healthcare provider when considering thyroid function testing via DAT. Furthermore, patients should always discuss any changes in their treatment with their providers before doing so based on DAT results. 
The Indian Thyroid Society, and Thyroid Research and Practice, should come out with similar guidelines, relevant to the Indian context, and try to regulate the misuse of DAT in thyroidology. This will help reduce the negative public health impact of this practice. 
| References|| |
|1.||American Thyroid Association (ATA). Position statement on Direct Access Testing (DAT) for thyroid function. Available from: http://www.thyroid.org/professionals /publications/statements/u8-11-28- dat.html. [Last accessed on 2012 Sep 16]. |
|2.||Kalra S, Unnikrishnan AG, Sahay R. Thyroidology and public health: The challenges ahead. Indian J Endocrinol Metab 2011;15:S73-5. |