Effect of Implementing Community of Practice Modified Thyroid Imaging Reporting and Data System on Reporting Adherence and Number of Thyroid Biopsies

Quality Improvement Methodology to Improve Standardized Reporting of Pediatric Thyroid Ultrasounds Using TI-RADS

BACKGROUND/PURPOSE

The process of evaluating pediatric thyroid nodules at our institution was inconsistent with a high rate of negative biopsies raising concern of appropriate patient selection for biopsy. Our aim was to institute a standardized risk stratification reporting system for thyroid nodules to increase utilization and agreement of TI-RADS reporting at our institution.

METHODS

Radiology report data were collected and analyzed as part of a quality improvement project. A standardized TI-RADS dictation template was created, ultrasound technicians were trained, a multi-disciplinary conference initiated, and education provided for radiologists and clinicians. Control charts were used to track utilization and agreement of scoring of TI-RADS reporting based upon review by a radiologist trained in TI-RADS scoring.

RESULTS

From January 2019 to January 2021, 218 patients with a thyroid nodule had a thyroid ultrasound performed at our institution. TI-RADS was utilized in 0 % (0 of 57) of children in the four months prior to project initiation. Following creation of the template, utilization increased to 65 % (39 of 60) over 5 months. Utilization further increased after the first training conference and was maintained above 90 % for 13 months. Ultrasound reports were in agreement in 46.7 % (28 of 60) of children initially. Agreement in reporting improved to 71.4 % (10 of 14) in the 3 months following the first training and to 78.4 % (58 of 74) over 12 months. Agreement in reporting was maintained at 80 % in the following 6 months.

CONCLUSIONS

A quality improvement initiative can improve utilization and agreement of scoring using the TI-RADS system in pediatrics. This may ultimately reduce unnecessary biopsies and sedation in children.

LEVEL OF EVIDENCE

Level III.

TYPE OF STUDY

Quality Improvement.

Implementation strategies to support ultrasound thyroid nodule risk stratification: A systematic review

BACKGROUND

Ultrasound risk stratification can improve the care of patients with thyroid nodules by providing a structured and systematic approach for the evaluation of thyroid nodule features and thyroid cancer risk. The optimal strategies to support implementation of high quality thyroid nodule risk stratification are unknown. This study seeks to summarise strategies used to support implementation of thyroid nodule ultrasound risk stratification in practice and their effects on implementation and service outcomes.

METHODS

This is a systematic review of studies evaluating implementation strategies published between January 2000 and June 2022 that were identified on Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane, Scopus, or Web of Science. Screening of eligible studies, data collection and assessment for risk of bias was completed independently and in duplicate. Implementation strategies and their effects on implementation and service outcomes were evaluated and summarised.

RESULTS

We identified 2666 potentially eligible studies of which 8 were included. Most implementation strategies were directed towards radiologists. Common strategies to support the implementation of thyroid nodule risk stratification included: tools to standardise thyroid ultrasound reports, education on thyroid nodule risk stratification and use of templates/forms for reporting, and reminders at the point of care. System based strategies, local consensus or audit were less commonly described. Overall, the use of these strategies supported the implementation process of thyroid nodule risk stratification with variable effects on service outcomes.

CONCLUSIONS

Implementation of thyroid nodule risk stratification can be supported by development of standardised reporting templates, education of users on risk stratification and reminders of use at the point of care. Additional studies evaluating the value of implementation strategies in different contexts are urgently needed.

Improvement in thyroid ultrasound report quality with radiologists' adherence to 2015 ATA or 2017 TIRADS: a population study

Objectives

There has been slow adoption of thyroid ultrasound guidelines with adherence rates as low as 30% and no population-based studies investigating adherence to guideline-based malignancy risk assessment. We therefore evaluated the impact of adherence to the 2015 ATA guidelines or 2017 ACR-TIRADS guidelines on the quality of thyroid ultrasound reports in our healthcare region.

Methods

We reviewed 899 thyroid ultrasound reports of patients who received fine-needle aspiration biopsy and were diagnosed with Bethesda III or IV nodules or thyroid cancer. Ultrasounds were reported by radiology group 1, group 2, or other groups, and were divided into pre-2018 (before guideline adherence) or 2018 onwards. Reports were given a utility score (0-6) based on how many relevant nodule characteristics were included.

Results

Group 1 had a pre-2018 utility score of 3.62 and 39.4% classification reporting rate, improving to 5.77 and 97.0% among 2018-onwards reports. Group 2 had a pre-2018 score of 2.8 and reporting rate of 11.5%, improving to 5.58 and 93.3%. Other radiology groups had a pre-2018 score of 2.49 and reporting rate of 32.2%, improving to 3.28 and 61.8%. Groups 1 and 2 had significantly higher utility scores and reporting rates in their 2018-onward reports when compared to other groups' 2018-onward reports, pre-2018 group 1 reports, and pre-2018 group 2 reports.

Conclusions

Dedicated adherence to published thyroid ultrasound reporting guidelines can lead to improvements in report quality. This will reduce diagnostic ambiguity and improve clinician's decision-making, leading to overall reductions in unnecessary FNA biopsy and diagnostic surgery.

Standardization of thyroid ultrasound reporting in the community setting decreases biopsy rates

OBJECTIVE

With the rising incidence of thyroid cancer, a standardized approach to the evaluation of thyroid nodules is essential. Despite the presence of multiple national guidelines detailing evaluation and management of these nodules, significant variability exists in the information that is collected and reported to clinicians from diagnostic imaging. The aim of this study was to evaluate the impact of thyroid ultrasound standardization on thyroid cancer detection in a community practice setting.

DESIGN

As part of a physician-driven quality improvement project, a multidisciplinary team created an electronic worksheet to be utilized by sonographers to capture suspicious findings based on societal guidelines and agreed on institutional criteria for recommending fine needle aspiration (FNA) of thyroid nodules.

PATIENTS

For a one-year period prior to and after the intervention, all ultrasounds performed for suspected thyroid pathology, excluding patients undergoing follow-up imaging, were reviewed at two affiliated community hospitals served by a single radiology and pathology group.

MEASUREMENTS

The number of fine needle biopsies recommended and performed, as well as the percentage of FNAs positive for malignancy were evaluated.

RESULTS

A total of 608 and 675 ultrasounds were reviewed in pre- and post-standardization periods, respectively. Following standardization, there was a similar percentage of FNAs recommended (35% vs. 37%, p = .68), fewer FNAs per total ultrasounds performed (36% vs. 31%, p = .03), fewer FNAs performed when FNA was not explicitly recommended (9.9% vs. 2.8%, p = .000046) and an increased detection of cytology consistent with, or suspicious for, malignancy (5% vs. 11.5%, p = .0028).

CONCLUSIONS

Standardization of thyroid imaging protocol and management recommendations can reduce the number of FNAs performed and increase the percentage of positive tests in a community setting.

The Usefulness of the Thyroid Imaging Reporting and Data System in Determining Thyroid Malignancy

OBJECTIVES/HYPOTHESIS

To determine the effect of a modified Thyroid Imaging and Reporting Data System (TIRADS) in predicting malignancy in surgically treated nodules.

STUDY DESIGN

Retrospective review.

METHODS

This study was carried out at a tertiary care center from July 2016 to July 2017. Patients were included if they had a thyroid nodule that had an ultrasound assessment with subsequent fine-needle aspiration biopsy (FNAB) as well as surgical resection. Patients were excluded if they had previous head and neck surgery. Patients were stratified into those who had a formal modified TIRADS report by the radiologist versus those who had an ultrasound report without TIRADS reporting. FNAB results were reported as per Bethesda Thyroid Cytology Criteria, and the final pathology report was nominalized as malignant or benign.

RESULTS

One hundred twenty-four consecutive patients who met the inclusion criteria listed above were included within the study. Thirty one patients (25%) had a modified TIRADS report from the radiologist, whereas 93 patients (75%) did not. There was no statistical significance between the two groups in terms of: gender (P = .24), age (P = .77), FNAB results (P = .95), final surgical pathology (P = .90), or incidental findings of malignancy (P = .09). Comparative analysis showed no statistically significant difference between the two groups in terms of the concordance of FNAB and a final pathological diagnosis of malignancy (P = .91).

CONCLUSIONS

Despite the known diagnostic utility of the TIRADS in relation to FNAB results and its widespread use, this study shows that the overall detection of malignancy is not statistically different in those who received a modified TIRADS report.

LEVEL OF EVIDENCE

3 Laryngoscope, 130: 2087-2091, 2020.