Trends in Thyroid Surgery and Guideline-Concordant Care in the United States, 2007–2018
Abstract
Background: The American Thyroid Association (ATA) published the 2015 Management Guidelines for patients with thyroid nodules and differentiated thyroid cancer, recommending a shift to less aggressive diagnostic, surgical, and postoperative treatment strategies. At the same time and perhaps related to the new guidelines, there has been a shift to outpatient thyroid surgery. The aim of the current study was to assess physician adherence to these recommendations by identifying and quantifying temporal trends in the rates and indications for thyroid procedures in the inpatient and outpatient settings.
Methods: Using the IBM® MarketScan® Commercial database, we identified employer-insured patients in the United States who underwent outpatient and inpatient thyroid surgery from 2007 to 2018. Thyroid surgery was classified as total thyroidectomy (TT), thyroid lobectomy (TL), or a completion thyroidectomy. The surgical indication diagnosis was also determined and classified as either benign or malignant thyroid disease. We compared outpatient and inpatient trends in surgery between benign and malignant thyroid disease both before and after the release of the 2015 ATA guidelines.
Results: A total of 220,088 patients who underwent thyroid surgery were included in the analysis. Approximately 80% of TLs were performed in the outpatient setting versus 70% of TTs. Longitudinal analysis showed a statistically significant changepoint for TT proportion occurring in November 2015. The proportion of TT as compared with TL decreased from 80% in September 2015 to 39% by December 2018. For thyroid cancer, there is an increasing trend in performing TL over TT, increasing from 17% in 2015 to 28% by the end of 2018.
Conclusions: There was a significant changepoint occurring in November 2015 in the operative and management trends for benign and malignant thyroid disease.
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References
1. Surveillance Epidemiology and End Results 2020. Available at http://seer.cancer.gov/ (accessed November 26, 2020).
2. Ahn HS, Kim HJ, Welch HG 2014 Korea's thyroid-cancer “epidemic”—screening and overdiagnosis. N Engl J Med 371:1765–1767.
3. Welch HG, Black WC 2010 Overdiagnosis in cancer. J Natl Cancer Inst 102:605–613.
4. Adam MA, Pura J, Gu L, Dinan MA, Tyler DS, Reed SD, Scheri R, Roman SA, Sosa JA 2014 Extent of surgery for papillary thyroid cancer is not associated with survival: an analysis of 61,775 patients. Ann Surg 260:601–605; discussion 605–607.
5. Wang TS, Goffredo P, Sosa JA, Roman SA 2014 Papillary thyroid microcarcinoma: an over-treated malignancy? World J Surg 38:2297–2303.
6. Kandil E, Krishnan B, Noureldine SI, Yao L, Tufano RP 2013 Hemithyroidectomy: a meta-analysis of postoperative need for hormone replacement and complications. ORL J Otorhinolaryngol Relat Spec 75:6–17.
7. Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, Pacini F, Randolph GW, Sawka AM, Schlumberger M, Schuff KG, Sherman SI, Sosa JA, Steward DL, Tuttle RM, Wartofsky L 2016 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 26:1–133.
8. Reinhart HA, Snyder SK, Stafford SV, Wagner VE, Graham CW, Bortz MD, Wang × 2018 Same day discharge after thyroidectomy is safe and effective. Surgery 164:887–894.
9. Terris DJ, Snyder S, Carneiro-Pla D, Inabnet WB, 3rd, Kandil E, Orloff L, Shindo M, Tufano RP, Tuttle RM, Urken M, Yeh MW 2013 American Thyroid Association statement on outpatient thyroidectomy. Thyroid 23:1193–1202.
10. Adam MA, Goffredo P, Youngwirth L, Scheri RP, Roman SA, Sosa JA 2016 Same thyroid cancer, different national practice guidelines: when discordant American Thyroid Association and National Comprehensive Cancer Network surgery recommendations are associated with compromised patient outcome. Surgery 159:41–50.
11. Haymart MR, Banerjee M, Stewart AK, Koenig RJ, Birkmeyer JD, Griggs JJ 2011 Use of radioactive iodine for thyroid cancer. JAMA 306:721–728.
12. Collier K, Sataloff J, Wirtalla C, Kuo L, Karakousis GC, Kelz RR 2017 Understanding readmissions following operations of the thyroid and parathyroid glands. Am J Surg 214:501–508.
13. Ullmann TM, Gray KD, Stefanova D, Limberg J, Buicko JL, Finnerty B, Zarnegar R, Fahey TJ, 3rd, Beninato T 2019 The 2015 American Thyroid Association guidelines are associated with an increasing rate of hemithyroidectomy for thyroid cancer. Surgery 166:349–355.
14. Butler D, Oltmann S 2017 Is outpatient thyroid surgery for everyone? Clin Med Insights Ear Nose Throat 10:1179550617724428.
15. Clark N, Schneider DF, Vrabec S, Bauer PS, Chen H, Sippel RS 2013 Increased efficiency of endocrine procedures performed in an ambulatory operating room. J Surg Res 184:200–203.
16. Marino M, Spencer H, Hohmann S, Bodenner D, Stack BC Jr. 2014 Costs of outpatient thyroid surgery from the University HealthSystem Consortium (UHC) database. Otolaryngol Head Neck Surg 150:762–769.
17. Snyder SK, Hamid KS, Roberson CR, Rai SS, Bossen AC, Luh JH, Scherer EP, Song J 2010 Outpatient thyroidectomy is safe and reasonable: experience with more than 1,000 planned outpatient procedures. J Am Coll Surg 210:575–582, 582–584.
18. Moore BJ, White S, Washington R, Coenen N, Elixhauser A 2017 Identifying Increased Risk of Readmission and In-hospital Mortality Using Hospital Administrative Data: the AHRQ Elixhauser Comorbidity Index. Med Care 55:698–705.
19. Pettitt AN 1979 A non-parametric approach to the change-point problem. J R Stat Soc Ser C (Appl Stat) 28:126–135.
20. Hirshoren N, Kaganov K, Weinberger JM, Glaser B, Uziely B, Mizrahi I, Eliashar R, Mazeh H 2018 Thyroidectomy Practice After Implementation of the 2015 American Thyroid Association Guidelines on surgical options for patients with well-differentiated thyroid carcinoma. JAMA Otolaryngol Head Neck Surg 144:427–432.
21. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman SI, Steward DL, Tuttle RM 2009 Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 19:1167–1214.
22. Mazzaferri EL, Young RL 1981 Papillary thyroid carcinoma: a 10 year follow-up report of the impact of therapy in 576 patients. Am J Med 70:511–518.
23. DeGroot LJ, Kaplan EL, McCormick M, Straus FH 1990 Natural history, treatment, and course of papillary thyroid carcinoma. J Clin Endocrinol Metab 71:414–424.
24. Samaan NA, Schultz PN, Hickey RC, Goepfert H, Haynie TP, Johnston DA, Ordonez NG 1992 The results of various modalities of treatment of well differentiated thyroid carcinomas: a retrospective review of 1599 patients. J Clin Endocrinol Metab 75:714–720.
25. Bilimoria KY, Bentrem DJ, Ko CY, Stewart AK, Winchester DP, Talamonti MS, Sturgeon C 2007 Extent of surgery affects survival for papillary thyroid cancer. Ann Surg 246:375–381; discussion 381–384.
26. Mitchell I, Livingston EH, Chang AY, Holt S, Snyder WH, 3rd, Lingvay I, Nwariaku FE 2007 Trends in thyroid cancer demographics and surgical therapy in the United States. Surgery 142:823–828; discussion 828.e821.
27. Sosa JA, Hanna JW, Robinson KA, Lanman RB 2013 Increases in thyroid nodule fine-needle aspirations, operations, and diagnoses of thyroid cancer in the United States. Surgery 154:1420–1426; discussion 1426–1427.
28. Ali SZ, Fish SA, Lanman R, Randolph GW, Sosa JA 2013 Use of the afirma® gene expression classifier for preoperative identification of benign thyroid nodules with indeterminate fine needle aspiration cytopathology. PLoS Curr 5:ecurrents.eogt.e557cbb5c7e4f66568ce582a373057e7.
29. Li J, Zhang B, Bai Y, Liu Y, Zhang B, Jin J 2020 Health-related quality of life analysis in differentiated thyroid carcinoma patients after thyroidectomy. Sci Rep 10:5765.
30. Hollingsworth JM, Funk RJ, Garrison SA, Owen-Smith J, Kaufman SR, Landon BE, Birkmeyer JD 2015 Differences between physician social networks for cardiac surgery serving communities with high versus low proportions of black residents. Med Care 53:160–167.
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Copyright 2021, Mary Ann Liebert, Inc., publishers.
History
Published online: 8 June 2021
Published in print: June 2021
Published ahead of print: 18 January 2021
Published ahead of production: 5 December 2020
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Authors' Contributions
Concept and design: A.T., C.C.L.; acquisition of data: A.T.; analysis and interpretations of data: A.T., C.C.L., C.D., V.V., M.S.J., J.C., G.S.G., and R.R.K.; drafting of the article: A.T., C.C.L.; critical revision of the article for important intellectual content: A.T., C.C.L., C.D., V.V., M.S.J., J.C., G.S.G., and R.R.K.; supervision: C.C.L.
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No competing financial interests exist.
Funding Information
This work was supported by NIH/NCI R37 CA231957 (C.C.L.). The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the article; and decision to submit the article for publication.
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