# Improvement of Free T4 in Newly Diagnosed Graves Disease Patients Through a Multifaceted Quality Improvement Approach

## TL;DR

A quality improvement approach helped more children with newly diagnosed Graves disease achieve normal thyroid hormone levels within 3 months and maintain them for 6 months.

## Contribution

A multifaceted quality improvement strategy improved treatment outcomes in newly diagnosed pediatric Graves disease patients.

## Key findings

- 78% of patients achieved normal free T4 levels by 3 months, up from 47% previously.
- Improvements were sustained for 6 months but declined by 12 months.
- Barriers included missed appointments, language, medication adherence, and lack of insurance.

## Abstract

Graves disease (GD) is the most common cause of pediatric hyperthyroidism, and if untreated, may result in multisystem complications and decreased quality of life. Through a multifaceted quality improvement (QI) approach, we aimed to address treatment barriers after a new diagnosis of GD and increase the percentage of patients attaining an euthyroid state within 3 months from diagnosis and sustain for 12 months.

Using standard QI methodologies from January to November 2023, our plan, do, study, act cycles focused on an educational handout and checklist at diagnosis, a standardized methimazole dose based on initial free thyroxine (T4) and age, and frequent provider check-ins with phone call at 2 weeks, telehealth visit at 4 weeks with laboratories, and continued QI follow-up for 3 months as process measures. Outcome measure was the percentage of patients achieving normalization of free T4 level by 3 months. We used an electronic dashboard to track patients.

Of the 46 patients, 76% (34) received written education; 67% (30) were initiated on standardized methimazole dosing; 80% (37) and 70% (32), respectively, attended the 2-week telephone and 1-month telehealth visits, and 83% (38) obtained 1-month laboratories. By 3 months, the outcome measure increased to 78% (36/46) from 47% (15/32) (P < 0.01), sustained at 6 months (58% versus 22%) but decreased by 12 months (45% versus 40%). Barriers included missed appointments/laboratories, language, medication adherence, and/or lack of insurance.

Through a multifaceted QI approach, we increased the percentage of newly diagnosed GD patients with normal free T4 levels and sustained for 6 months. Extension of follow-up is planned.