Definition of urgency levels at the referral of a thyroid patient to a specialist
The aim of our article is to clarify dilemmas occurring at the referral of patients with the suspicion of thyroid disorder to a thyroid specialist. Due to the limitations of health care system, not every patient may get help from the specialist immediately. Levels of urgency that are listed in the »Rules on the referral of patients, the management of waiting lists, and the maximum permissible waiting times« should enable patients to get help when it is needed. Within the eReferral system with the eReferral document, patients are classified according to the level of urgency. In our opinion, this demanding professional task should be performed by a relevant specialist and not by other medical staff or administrative workers. Only a sufficient amount of information stated in the eReferral document makes proper classification of patients possible. Otherwise, the eReferral document should be supplemented accordingly. In a patient with the suspicion of thyroid dysfunction, the level of urgency is not determined on the basis of laboratory results alone, although they are very important and should be referenced in the referral document. Other valuable items of information are patient’s age, accompanying diseases, any already prescribed medication, possible pregnancy or assisted reproductive technology procedures. In a patient with the suspicion of goiter or thyroid nodule, valuable information is the clinical estimation of thyroid size, the presence of suspicious neck lymph nodes, and the results of performed imaging examinations. Thyroid diseases are very frequent, and therefore not every patient can get help from the specialist immediately. However, correctly filled as well as accurately classified eReferral documents may provide an adequate treatment appointment for the majority of patients.
Pravilnik o naročanju in upravljanju čakalnih seznamov ter najdaljših dopustnih čakalnih dobah. Uradni list RS 3/2018.522-25. [cited 2018 Nov 1] Available from: http://www.pisrs.si/Pis.web/pregledPredpisa?id=PRAV13238
Gaberšček S. Ščitnica. Košnik M, ur. Interna medicina, 5. izd. Medicinska fakulteta: Slovensko zdravniško društvo. Buča; 2018. pp. 741–5.
Zaletel K, Gaberšček S, Pirnat E, Krhin B, Hojker S. Ten-year follow-up of thyroid epidemiology in Slovenia after increase in salt iodization. Croat Med J. 2011 Oct;52(5):615–21. https://doi.org/10.3325/cmj.2011.52.615 PMID:21990079
Collet TH, Gussekloo J, Bauer DC, den Elzen WP, Cappola AR, Balmer P, et al.; Thyroid Studies Collaboration. Subclinical hyperthyroidism and the risk of coronary heart disease and mortality. Arch Intern Med. 2012 May;172(10):799–809. https://doi.org/10.1001/archinternmed.2012.402 PMID:22529182
Hollowell JG, Staehling NW, Flanders WD, Hannon WH, Gunter EW, Spencer CA, et al. Serum TSH, T4 and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab. 2002 Feb;87(2):489–99. https://doi.org/10.1210/jcem.87.2.8182 PMID:11836274
Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The Colorado thyroid disease prevalence study. Arch Intern Med. 2000 Feb;160(4):526–34. https://doi.org/10.1001/archinte.160.4.526 PMID:10695693
Almandoz JP, Gharib H. Hypothyroidism: etiology, diagnosis, and management. Med Clin North Am. 2012 Mar;96(2):203–21. https://doi.org/10.1016/j.mcna.2012.01.005 PMID:22443971
Krhin B. Kakovostna laboratorijska diagnostika ščitničnih bolezni. In: Gaberšček S, Zaletel K, ur. Zbornik prispevkov: Bolezni ščitnice. Podiplomska šola za zdravnike; 2017 Maj 12-13; Logarska dolina, Slovenija. Slovensko združenje za nuklearno medicino; 2017. p. 15-19.
Molnar Novak H. Katica Bajuk Studen. Boleča ščitnica. In: Gaberšček S, Zaletel K, ur. Zbornik prispevkov: Bolezni ščitnice. Podiplomska šola za zdravnike; 2018 Maj 11-12; Logarska dolina, Slovenija. V Ljubljani: Slovensko združenje za nuklearno medicino; 2018. p. 57−61.
Hennessey JV. Subacute thyroiditis. In: De Groot LJ, Chrousos G, Dungan K, Feingold KR, Grossman A, Hershman JM, et al. eds. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-2015. [cited 2018 Nov 1] Available from: https://www.ncbi.nlm.nih.gov/books/NBK279084/
Slatosky J, Shipton B, Wahba H. Thyroiditis: differential diagnosis and management. Am Fam Physician. 2000 Feb;61(4):1047–52. PMID:10706157
Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, et al. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016 Jan;26(1):1–133. https://doi.org/10.1089/thy.2015.0020 PMID:26462967
Dean DS, Gharib H. Epidemiology of thyroid nodules. Best Pract Res Clin Endocrinol Metab. 2008 Dec;22(6):901–11. https://doi.org/10.1016/j.beem.2008.09.019 PMID:19041821
Gharib H, Papini E, Paschke R, Duick DS, Valcavi R, Hegedüs L, et al. AACE(AME(ETA Task Force on Thyroid Nodules. American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. Endocr Pract. 2010;16 Suppl 1:1–43. https://doi.org/10.4158/10024.GL PMID:20497938
Cancer in Slovenia. 2014. Ljubljana: Institute of Oncology Ljubljana, Epidemiology and Cancer Registry. Cancer Registry of Republic of Slovenia 2015. [cited 2018 Nov 1] Available from: https://www.onko-i.si/fileadmin/onko/datoteke/dokumenti/RRS/LP_2015.pdf
Gaberšček S, Zaletel K. Thyroid physiology and autoimmunity in pregnancy and after delivery. Expert Rev Clin Immunol. 2011 Sep;7(5):697–706. https://doi.org/10.1586/eci.11.42 PMID:21895480
Alexander EK, Pearce EN, Brent GA, Brown RS, Chen H, Dosiou C, et al. 2017 guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum. Thyroid. 2017 Mar;27(3):315–89. https://doi.org/10.1089/thy.2016.0457 PMID:28056690
Lazarus J, Brown RS, Daumerie C, Hubalewska-Dydejczyk A, Negro R, Vaidya B. 2014 European thyroid association guidelines for the management of subclinical hypothyroidism in pregnancy and in children. Eur Thyroid J. 2014 Jun;3(2):76–94. https://doi.org/10.1159/000362597 PMID:25114871
Wiersinga WM, Duntas L, Fadeyev V, Nygaard B, Vanderpump MP. 2012 ETA guidelines: the use of L-T4 + L-T3 in the treatment of hypothyroidism. Eur Thyroid J. 2012 Jul;1(2):55–71. https://doi.org/10.1159/000339444 PMID:24782999
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