Patients’ attitudes and perceptions towards treatment of hypothyroidism in general practice: an in-depth qualitative interview study

Background: Suboptimal thyroid hormone replacement is common in patients with hypothyroidism and the behavioural factors underlying this are poorly understood. Aim: To explore the attitudes and perceptions of patients to thyroid hormone replacement therapy. Design & setting: An in-depth qualitative interview study with patients with hypothyroidism residing in Northumberland, and Tyne and Wear, UK. Method: Twenty-seven patients participated, of which 15 patients had thyroid stimulating hormone (TSH) levels within the reference range (0.4–4.0 mU/L) and 12 patients had TSH levels outside the reference range. A grounded theory approach was used to explore and develop emerging themes, which were mapped to the health belief model (HBM). Results: Patients generally had a low understanding of their condition or of the consequences of suboptimal thyroid hormone replacement. Patients that had experienced hypothyroid symptoms at initial diagnosis had a better perception of disease susceptibility, and this was reflected in excellent adherence to levothyroxine in this group of patients. The main benefits of optimal thyroid Dew R et al. BJGP Open 2017; DOI: 10.3399/bjgpopen17X100977 1 of 13 RESEARCH replacement were improved wellbeing and performance. However, patients who remained unwell despite a normal serum TSH level felt that their normal result presented a barrier to further evaluation of their symptoms by their GP. Conclusion: Educating patients with hypothyroidism regarding the consequences of inadequate thyroid hormone replacement may reduce barriers and improve treatment outcomes. An overreliance on TSH as a sole marker of wellbeing reduced opportunities for clinicians to address patient symptoms. Evaluating symptoms in combination with biochemical indices, may lead to better patient outcomes than relying on laboratory tests alone. How this fits in There is limited information on the behavioural factors that influence disease outcomes in patients with hypothyroidism. This qualitative study of patients’ attitudes and perceptions shows that patients generally adhered well to treatment but were often unable to obtain clear, reliable information about their disease or its treatment. A TSH concentration within the reference range was perceived by most patients to be an unsatisfactory measure of wellbeing that often precluded meaningful interaction with their practitioners. Outcomes may be improved by the provision of better quality information, together with a clinical approach that addresses patients’ symptoms and concerns, alongside their biochemical indices of thyroid function. Introduction Hypothyroidism is a chronic condition affecting 2–5% of the population. About 3% of the UK population receive levothyroxine therapy with the aim of treatment being to achieve patient wellbeing and restore serum thyroid stimulating hormone (TSH) levels to within the reference range. Levothyroxine is the third most dispensed drug in England with 29.7 million items dispensed in 2015 alone. After individual dose adjustment levothyroxine is generally well-tolerated and most patients continue lifelong therapy without complications. Suboptimal replacement as shown by abnormal TSH levels, however, has remained problematic for over 20 years, despite increasing regularity in the biochemical monitoring of patients. Patients with suboptimal replacement may have an increased risk of cardiovascular events and fractures. Furthermore, women of childbearing age established on levothyroxine often have out-ofrange TSH levels at the time of conception, increasing the risk of adverse pregnancy outcomes. Reduced quality of life is common among patients with hypothyroidism, particularly relating to energy, motivation, physical capabilities, physical appearance, and weight gain. In addition, there are substantial healthcare resource implications of having abnormal TSH levels including repeat laboratory testing, levothyroxine dose adjustments, and medicines wastage. Potential causes of inadequate thyroid hormone replacement include medication adherence as well as biochemical, pharmacogenomic, and medication formulation factors. To date, most guidance on managing thyroid hormone replacement has focused on physiological and pharmacological factors. However, there is little information on behavioural factors even though patient perception and attitudes towards their illness play a pivotal role in improving chronic disease outcomes. To begin to address this problem this study explored the behavioural factors that may contribute to suboptimal treatment in patients with hypothyroidism.