Using age, sex, and race-specific standards could reclassify many thyroid disease diagnoses

Embargoed for release until 5:00 p.m. ET on Monday 5 May 2025   

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Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.   
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1. Using age, sex, and race-specific standards could reclassify many thyroid disease diagnoses

Nearly half of subclinical hypothyroid cases may be over-diagnosed

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-01559

Editorial: https://www.acpjournals.org/doi/10.7326/ANNALS-25-01333

URL goes live when the embargo lifts           

A cross-sectional analysis of adults examined how newly identified age-, sex-, and race-specific reference intervals for thyroid function diagnostic tests reclassify people into different disease categories compared with current reference intervals. The study found that using age-, sex-, and race-specific reference intervals reclassify many patients who are thought to have thyroid disease, especially those with subclinical thyroid diseases, as having normal thyroid function. The findings should help establish more accurate reference intervals for thyroid disease. The study is published in Annals of Internal Medicine.

In the first study of its kind, researchers from Shandong First Medical University in Shandong, China and colleagues studied data from the U.S. NHANES (National Health and Nutrition Examination Survey) of a nationally representative sample of adults aged 20 and older. They supplemented this sample with data from a Chinese database of routine health checkups from 49 hospitals of adults aged 18 and older. The researchers used this data to examine the differences in thyroid function tests across age, sex and race and identified new diagnostic intervals. They then used these newly defined intervals to classify people into disease categories and measure the difference in disease prevalence between current intervals and the new intervals. The researchers found that there was an increase in the 97.5^th percentile levels of thyroid-stimulating hormone (TSH) as age increased, the most pronounced change in thyroid function indicators. However, total triiodothyronine (TT3) levels declined with age and there was no change in total thyroxine (TT4) levels. Women had higher TT4 levels, and White participants had higher TSH levels. Using age-, sex-, and race-specific reference intervals instead of current intervals reclassified 48.5% of people with subclinical hypothyroidism as normal, especially women and White participants, and reclassified 31.2% of people with subclinical hyperthyroidism as normal, especially women, Black participants and Hispanic participants. These findings were similar in the supplemental sample from the Chinese database as well. The researchers hope these findings will inform the development of a consensus about how to define and manage thyroid diseases.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To contact corresponding author Yongfeng Song, MD, PhD, please email syf198506@163.com.

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2. Study suggests confirmatory testing for primary aldosteronism, a common cause of hypertension, often misinforms care and should be removed from the diagnostic care pathway

Study conclusions represent a significant paradigm shift in the field of hypertension

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-03153

URL goes live when the embargo lifts             

A clinical trial of diagnostic test accuracy found that the seated saline suppression test (SSST), a confirmatory test for primary aldosteronism (PA), commonly misinforms downstream treatment decisions, resulting in missed opportunities or intervention, even among patients who would clearly benefit from treatment. This is important because PA is one of the most common causes of high blood pressure, affecting 10% to 30% of all people with hypertension. According to the study authors, their findings suggest that SSST is an unnecessary barrier to care. Removal of confirmatory testing from the diagnostic care pathway for PA may help to improve diagnostic accuracy and reduce time to treatment. This represents a large paradigm shift in the field of hypertension. The study is published in Annals of Internal Medicine.  

People with PA have overactive adrenal glands that produce too much aldosterone, a salt-retaining hormone. It is important to recognize because excellent treatments are available and it is potentially curable, but under 1% of patients are diagnosed and treated due to challenges associated with the lengthy and complicated diagnostic process. In the first study of its kind, researchers from the University of Calgary conducted a clinical trial between January 2017 to August 2024 of 156 adults with a positive screening test result for PA to determine whether a subsequent confirmatory test (the SSST) accurately diagnosed PA. Every patient in the trial was treated for PA; this included either surgery (to remove an overactive adrenal gland that was producing too much aldosterone) or the use of specialized medications (to block the effects of aldosterone). Treatment response was then used as the gold standard to determine disease status. Successful response (consistent with PA) was based on a large reduction in blood pressure, reduction in the number of blood pressure medications, and normalization of biochemistry following treatment. The researchers discovered that the SSST could not discriminate between treatment responders and non-responders any differently than chance. A large number of patients who responded to treatment for PA were incorrectly misclassified as being “normal” by the SSST.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To contact corresponding author Alexander A. Leung, MD, MPH, please email Kelly Johnston at kelly.johnston2@ucalgary.ca.  

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3. 1 in 10 internal medicine physicians experience severe burnout

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-02896

URL goes live when the embargo lifts             

A cross-sectional study described the prevalence of burnout among U.S. internal medicine physicians in different geographic regions, facility types and clinical settings. The national study found that approximately 10% of internal medicine physicians report a high level of burnout, with burnout prevalence highest among physicians in the West. The findings are published in Annals of Internal Medicine.  

Researchers from the University of Michigan analyzed survey results from a randomly selected cohort of 629 internal medicine physicians (response rate 44.3%). They assessed burnout using the validated Maslach Burnout Inventory - Human Services Survey and examined burnout levels across three domains: exhaustion, depersonalization and low personal accomplishment. Burnout was present if a physician’s scores met thresholds for all three domains. 44.8% worked at a community medical center, 30.1% worked at a Veterans Affairs medical center and 13.9% worked at an academic medical center. About half of participants provided primary care, and the other half were hospitalists. 9.8% of respondents met thresholds for all three burnout domains. There were no significant differences in burnout levels between hospitalists and non-hospitalists and among physicians working in different clinical settings and facility types. Burnout prevalence ranged between 6.6% and 9.4% for physicians in all regions of the US except for the West, where 15.4% of physicians experienced burnout. The findings reinforce prior research and adds to it by describing the prevalence of burnout among the specific population of internal medicine physicians. 

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To contact corresponding author Nathan Houchens, MD, please email nathanho@med.umich.edu.

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4. West Texas measles outbreak prompts call for adjustments to MMR vaccination practices

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-25-01730

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A new commentary published in Annals of Internal Medicine describes the current spread of measles in the U.S. and recommends that pediatricians and internists may need to revise aspects of their measles-mumps-rubella (MMR) immunization practices. The changes include children ages 6 to 11 months receiving an early MMR dose in areas of ongoing measles transmission; healthcare workers serving in a measles outbreak area receive two MMR doses regardless of birth year; and adults born after 1957 who live in a measles outbreak area receive a second dose of the MMR vaccine. The author warns against the current outbreak in West Texas spreading into other states and the possibility of the U.S. losing its measles elimination status.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To contact corresponding author Peter J Hotez, MD, PhD, please email Homa Warren at homa.warren@bcm.edu.

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5. Nut, seed and corn consumption not associated with increased risk of diverticulitis in women

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-03353

URL goes live when the embargo lifts            

A prospective cohort study examined whether dietary intake of nuts, seeds and corn increases the risk for diverticulitis in women. The study found no correlation between consumption of nuts, seeds and corn and diverticulitis risk. Additionally, healthy diet patterns were shown to reduce the risk of incident diverticulitis. According to the authors, this is the first study to examine whether select diets and food intake affect diverticulitis in women. The results are published in Annals of Internal Medicine. 

Researchers from the University of North Carolina, Chapel Hill studied data from women aged 35 to 75 years who responded to food frequency diverticulitis questionnaires and had no history of inflammatory bowel disease, cancer or diverticulitis. The women were first enrolled between 2003 and 2009 with follow up every two to three years. The cohort in this study included women who completed a fifth follow up questionnaire administered between 2020 and 2022. The researchers also used the data to calculate the correlation between diverticulitis risk and four dietary indexes: the Dietary Approaches to Stop Hypertension (DASH) diet, the Healthy Eating Index (HEI) 2015, the Alternative Healthy Eating Index (aHEI) 2010, and the Alternative Mediterranean (aMed) diet. The researchers found no association between dietary intake of nuts, seeds and corn or intake of fresh fruits with seeds and incident diverticulitis. Additionally, the four healthy diet patterns studied were associated with a reduced risk for incident diverticulitis. Women with diverticulitis were more likely to be older, current or former smokers, heavy alcohol users and overweight. These results are significant because dietary intake of particulate matter like nuts, seeds and corn has been presumed to be a trigger for diverticulitis.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To contact corresponding author Anne F. Peery, MD, MSCR, please email Kendall Daniels at Kendall.daniels@unchealth.unc.edu.

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6. New ACP paper addresses ethical implications of long-term care, prioritizing quality and safety  

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-03641

URL goes live when the embargo lifts            

The American College of Physicians (ACP) has published a new paper addressing the challenges and ethical implications of current long-term care services and business models, calling for more research into meeting vulnerable patient interests and scrutiny into the business practices. “Optimizing Ethical Care, Quality, and Safety in Long-Term Services and Supports: A Position Paper from the American College of Physicians” is published in Annals of Internal Medicine.   

Quality of care is inconsistent across long-term care business models, and can fluctuate among for-profit, nonprofit, government-owned, and private equity-owned. The latter business model is linked to higher rates of hospitalization, practices that can endanger residents, and reduced staffing levels of registered nurses. Such models can put profits before patient wellbeing, leaving a vulnerable population at risk.

The paper, developed by ACP’s Ethics, Professionalism and Human Rights Committee, outlines four positions from an ethical, patient-centered perspective.

• Long-term care professionals and facilities, its associated legislative policy, and business practices should incentivize and promote ethical evidence-based use of resources. This approach should optimize care quality and plans, patient preferences, and decision-making while prioritizing the safety of persons across lifespans residing in various settings in the community. 
• Long-term care professionals and facilities must respect the dignity, autonomy, and uniqueness of each individual and they have an ethical duty to do so. Individuals receiving long-term care can be vulnerable because of cognitive impairments, physical disabilities, and a limited social support network, and may lack advocates to speak on their behalf. Care should be patient-centered, not institution-centered, and tailored to individual needs rather than organizational efficiency or profit.
• Long-term care professionals and facilities must prioritize health equity in long-term care and undergo efforts to improve access to care and overcome stereotypes and prejudice based on race, ethnicity, age, and income. Ageism has a significant influence on long-term care. ACP recommends improved education of health care professionals and the public about the value of older adults in our society and the harms of prejudice against them. 
• Patients and families have the right to hold responsible parties accountable for the quality of long-term care, and this requires increased transparency and accountability. Information about those with a stake in management, operations or facility of long-term care should be readily accessible and easily interpretable so patients and families can evaluate quality, standards of care, and potential competing interests.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with someone at ACP please contact Andrew Hachadorian at ahachadorian@acponline.org.   

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7. New ACP review of performance measures for diabetes finds many measures inadequate 

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-03770

URL goes live when the embargo lifts            

A review by the American College of Physicians (ACP) of performance measures for diabetes found that of the 14 performance measures relevant to internal medicine, only four meet ACP’s rigorous standards for appropriate use, high-quality evidence, and scientific acceptability. Quality Indicators for Diabetes in Adults: A Review of Performance Measures by the American College of Physicians is published in Annals of Internal Medicine.    

The ACP Performance Measurement Committee (PMC) reviews performance measures using a rigorous process to recognize high-quality measures and address gaps and areas for improvement. ACP embraces performance measurement as a means to improve quality of care but believes that a performance measure must be methodologically sound and evidence based in order to be considered for inclusion in payment, accountability, or reporting programs. The PMC reviewed measures for diabetes screening; glycemic control; and monitoring comorbidities. In the paper, ACP supports kidney health evaluation, HbA1c control, eye examination, and ACE inhibitor or ARB therapy.

ACP also developed a new performance measure concept with a goal of increasing prescription rates for patients eligible for newer pharmacologic agents. Together, these recommendations aim to encourage implementers and developers to establish and test performance measures that will lead to improvement in health outcomes for patients with diabetes.  

In 2024, ACP published a clinical guideline, Newer Pharmacologic Treatments in Adults With Type 2 Diabetes: A Clinical Guideline From the American College of Physicians to provide clinical recommendations on the topic.  

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with someone at ACP please contact Andrew Hachadorian at ahachadorian@acponline.org. 

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