047 Barriers and facilitators to appropriate thyroid function testing: a provincial mixed-methods study

Objectives Overdiagnosis of thyroid dysfunction is closely linked with thyroid function testing practices. Thyroid function testing in healthcare is common and unfortunately, often unnecessary. Guidelines outline that thyroid tests should not be carried out on asymptomatic patients and testing for thyroid stimulating hormone in these instances may lead to the detection of subclinical disease. To prevent overdiagnosis, de-implementation efforts must be made to reduce low-value use of thyroid function testing. To understand the underlying contributors to these testing practices, we performed a mixed-methods provincial study, to explore underlying clinical and social barriers and facilitators to appropriate testing. To guide future de-implementation, we mapped these factors onto the combined Theoretical Domains Framework (TDF) and Capability, Opportunity, Motivation – Behaviour (COM-B) model. Method Using a mixed-methods approach, we conducted a province-wide survey of healthcare practitioners (HCPs) on thyroid function testing in British Columbia, Canada. Interested survey respondents were invited to attend focus group sessions. A semi-structured focus group guide was developed based on survey responses. The surveys and focus groups were conducted between June to October 2023. The survey quantitative data was summarized using simple statistics and the open-ended survey questions were summarized using summative content analysis. The survey results informed the design of the focus group guide. All focus group sessions were recorded and transcribed verbatim. The transcripts were analyzed using thematic analysis. The results were then synthesised and mapped onto the TDF COM-B model. Results 230 respondents completed the survey and 50 practitioners attended 6 focus groups. Results showed that social influences, namely patient expectations, driven by internet searches, were key influences over HCPs ordering thyroid function tests, linking to the opportunity section of TDF COM-B. Requests for specific tests made by alternative medicine practitioners, that differ from standard practice, caused patient confusion regarding care responsibility, adding to the social influence of patients. Further, the opportunity to change was influenced by system level factors such as limited access to both previous test results and specialists in remote areas. The capability of HCPs centred around knowledge gaps, due to lack of clear guidance regarding testing for specific patient groups. HCPs were motivated to change their thyroid testing practices. HCPs identified leveraging information systems (Opportunity), providing personalized feedback (Opportunity), and creating more educational resources (Opportunity and Capability) as facilitators of behaviour change towards appropriate thyroid testing. Conclusions To reduce the risk of overdiagnosis of thyroid dysfunction, interventions must target specific barriers to appropriate thyroid function testing. Using the combined TDF and COM-B, we established specific barriers and facilitators within the clinical and social context of thyroid testing in British Columbia. Our findings showed that healthcare providers were motivated to make changes to their thyroid testing practices. We found that changes could be made to their capability to change via educational resources and opportunity to change could be improved by introducing patient information materials and improving information systems. Our study outlines a systematic way forward for the design of tailored, multi-level, de-implementation interventions towards reducing unnecessary thyroid testing. Future studies should focus on implementing and evaluating such intervention elements to investigate if improvements can be made to thyroid testing practices in the province.

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