Post-thyroidectomy emergency room visits and readmissions: Assessment from the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP)

Cost-Effectiveness of Parathyroid Cryopreservation and Autotransplantation

Importance

Delayed autotransplantation of cryopreserved parathyroid tissue (DACP) is the only surgical treatment for permanent postoperative hypoparathyroidism. Studies suggest that only a small minority of cryopreserved samples are ultimately autotransplanted with highly variable outcomes. For these reasons, many have questioned the economic utility of the process, although, to the authors' knowledge, this has never been formally studied.

Objective

To report the clinical outcomes of parathyroid cryopreservation and DACP at a large academic institution and to determine the cost-effectiveness of this treatment.

Design, Setting, and Participants

An institutional review board-approved, retrospective review of patients at a single institution who underwent DACP over a 17-year period was conducted with a median follow-up of 48.2 months. A forward-looking cost-utility analysis was then performed to determine the economic utility of cryopreservation/DACP vs usual care (monitoring and supplementation). Patients who had parathyroid tissue in cryopreserved storage between August 2005 to September 2022 at a single-center, academic, quaternary care center were identified.

Exposure

Parathyroid cryopreservation and DACP.

Main Outcomes and Measures

Graft functionality, clinical outcomes, and cost utility using a willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY).

Results

A total of 591 patients underwent cryopreservation. Of these, 10 patients (1.7%; mean [SD] age, 45.6 [17.9] years; 6 male [60%]) underwent DACP. A minority of autografts (2 [20%]) were subsequently fully functional, one-half (5 [50%]) were partially functional, and 3 (30%) were not functional. The cost-utility model estimated that at a large academic center over 10 years, the additional cost of 591 patients undergoing cryopreservation and 10 patients undergoing autotransplantation would be $618 791.64 (2022 dollars) and would add 8.75 QALYs, resulting in a cost per marginal QALY of $70 719.04, which is less than the common willingness-to-pay threshold of $100 000/QALY.

Conclusions and Relevance

The reimplantation rate of cryopreserved tissue was low (<2%), but when implanted, autografts were at least partially functional 70% of the time. In the first-ever, to the authors' knowledge, formal cost analysis for this treatment, results of the current model suggest that cryopreservation and autotransplantation were cost-effective compared with the usual care for hypoparathyroidism at a large, academic institution. It is recommended that each surgical center consider whether the economic and logistical commitments necessary for cryopreservation are worthwhile for their individual needs.

Increased Risk of Complications Associated With Concurrent Parathyroidectomy in Patients Undergoing Total Thyroidectomy

INTRODUCTION

We sought to investigate the association of concurrent parathyroidectomy (PTX) with risks of total thyroidectomy (TTX) through analysis of Collaborative Endocrine Surgery Quality Improvement Program data. TTXis a common operation with complications including recurrent laryngeal nerve injury, neck hematoma, and hypoparathyroidism. A subset of patients undergoing thyroidectomy undergoes planned concurrent PTX for treatment of primary hyperparathyroidism. There are limited data on the risk profile of TTX with concurrent PTX (TTX + PTX).

METHODS

We queried the Collaborative Endocrine Surgery Quality Improvement Program database for patients who underwent TTX or TTX + PTX from January 2014 through April 2020. Multivariable logistic regression was performed to predict hypoparathyroidism, vocal cord dysfunction, neck hematoma, and postoperative emergency department visit. Covariates included patient demographics, patient body mass index, indication for surgery, central neck dissection, anticoagulation use, and surgeon volume.

RESULTS

Thirteen thousand six hundred forty seven patients underwent TTX and 654 patients underwent TTX + PTX. Unadjusted rates of hypoparathyroidism were higher in TTX + PTX patients at 30 d (9.6% versus 7.4%, P = 0.04) and 6 mo (7.9% versus 3.1%, P < 0.001). On multivariable regression, TTX + PTX was associated with an increased risk of hypoparathyroidism at 30 d (odds ratio [OR] 2.09, 95% confidence interval [CI] 1.57-2.79) and 6 mo (OR 4.63, 95% CI 3.06-7.00) and an increased risk of postoperative emergency department visit (OR 1.66, 95% CI 1.20-2.31). TTX + PTX was not associated with recurrent laryngeal nerve injury or neck hematoma.

CONCLUSIONS

Concurrent PTX in patients undergoing TTX is associated with increased risk of immediate and long-term hypoparathyroidism, which should be considered in informed consent discussions and operative decision-making.

A comparison of NSQIP and CESQIP in data quality and ability to predict thyroidectomy outcomes

BACKGROUND

The Collaborative Endocrine Surgery Quality Improvement Program tracks thyroidectomy outcomes with self-reported data, whereas the National Surgical Quality Improvement Program uses professional abstractors. We compare completeness and predictive ability of these databases at a single-center and national level.

METHOD

Data consistency in the Collaborative Endocrine Surgery Quality Improvement Program and the National Surgical Quality Improvement Program at a single institution (2013-2020) was evaluated using McNemar's test. At the national level, data from the Collaborative Endocrine Surgery Quality Improvement Program and the National Surgical Quality Improvement Program (2016-2019) were used to compare predictive capability for 4 outcomes within each data source: thyroidectomy-specific complication, systemic complication, readmission, and reoperation, as measured by area under curve.

RESULTS

In the single-center analysis, 66 cases were recorded in both the Collaborative Endocrine Surgery Quality Improvement Program and the National Surgical Quality Improvement Program. The reoperation variable had the most discrepancies (2 vs 0 in the National Surgical Quality Improvement Program versus the Collaborative Endocrine Surgery Quality Improvement Program, respectively; χ² = 2.00, P = .16). At the national level, there were 24,942 cases in the National Surgical Quality Improvement Program and 17,666 cases in the Collaborative Endocrine Surgery Quality Improvement Program. In the National Surgical Quality Improvement Program, 30-day thyroidectomy-specific complication, systemic complication, readmission, and reoperation were 13.25%, 2.13%, 1.74%, and 1.39%, respectively, and in the Collaborative Endocrine Surgery Quality Improvement Program 7.27%, 1.95%, 1.64%, and 0.81%. The area under curve of the National Surgical Quality Improvement Program was higher for predicting readmission (0.721 [95% confidence interval 0.703-0.737] vs 0.613 [0.581-0.649]); the area under curve of the Collaborative Endocrine Surgery Quality Improvement Program was higher for thyroidectomy-specific complication (0.724 [0.708-0.737] vs 0.677 [0.667-0.687]) and reoperation (0.735 [0.692-0.775] vs 0.643 [0.611-0.673]). Overall, 3.44% vs 27.22% of values were missing for the National Surgical Quality Improvement Program and the Collaborative Endocrine Surgery Quality Improvement Program, respectively.

CONCLUSION

The Collaborative Endocrine Surgery Quality Improvement Program was more accurate in predicting thyroidectomy-specific complication and reoperation, underscoring its role in collecting granular, disease-specific variables. However, a higher proportion of data are missing. The National Surgical Quality Improvement Program infrastructure leads to more rigorous data capture, but the Collaborative Endocrine Surgery Quality Improvement Program is better at predicting thyroid-specific outcomes.

Etiology and Pathophysiology of Hypoparathyroidism: A Narrative Review

The approach utilized a systematic review of the medical literature executed with specifically designed criteria that focused on the etiologies and pathogenesis of hypoparathyroidism. Enhanced attention by endocrine surgeons to new knowledge about parathyroid gland viability are reviewed along with the role of intraoperative parathyroid hormone (ioPTH) monitoring during and after neck surgery. Nonsurgical etiologies account for a significant proportion of cases of hypoparathyroidism (~25%), and among them, genetic etiologies are key. Given the pervasive nature of PTH deficiency across multiple organ systems, a detailed review of the skeletal, renal, neuromuscular, and ocular complications is provided. The burden of illness on affected patients and their caregivers contributes to reduced quality of life and social costs for this chronic endocrinopathy. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Post-thyroidectomy hypocalcemia: Is a routine preferable over a selective supplementation?

BACKGROUND

Comparative studies among protocols for the management of post-total thyroidectomy (TT) hypocalcemia are lacking. We compared the effectiveness of PTH-driven selective supplementation (PD-SS) and routine calcium and calcitriol supplementation with preoperative calcitriol administration in preventing symptomatic hypocalcemia (SH) and readmission.

METHODS

Three-hundred consecutive patients undergoing TT were assigned to 3 groups: the PD-SS group, the high-dose routine supplementation (HD-RS) group and the low-dose routine supplementation (LD-RS) group.

RESULTS

Mean post-operative stay was shorter in HD-RS patients when compared to PD-SS and LD-RS (p < 0.001). Significantly more patients in the PD-SS group experienced SH (p = 0.042). The rate of post-operative hypocalcemia was not significantly different among the groups (p = 0.063). No readmission for SH or hypercalcemia occurred.

CONCLUSIONS

HD-RS emerged as the most effective treatment to prevent SH, without increasing the risk of readmission for calcitriol-related hypercalcemia. Basing on the present results, HD-RS should be recommended as the preferable protocol.

Appropriate selection of candidates for outpatient thyroidectomy

PURPOSE OF REVIEW

Although traditionally an inpatient procedure, outpatient thyroidectomy has gained traction as a viable and well tolerated alternative for selected patients, with an added benefit of cost savings.

RECENT FINDINGS

Research on outpatient thyroidectomy has focused on establishing its noninferiority in outcomes compared to the standard inpatient or overnight observation. Numerous studies have found comparable low rates of postoperative complications and no increase in readmission. Selection criteria have been well established by professional societies and research studies support the selection bias benefitting appropriately selected patients. The primary benefit of outpatient thyroidectomy reported is a decrease in cost, though additional theoretical benefits such as decreased exposure to nosocomial infections.

SUMMARY

Outpatient thyroidectomy is a well tolerated approach in appropriately selected candidates, with cost reduction benefits. Adherence to societal guidelines for patient selection is paramount.

Etiology and Diagnosis of Permanent Hypoparathyroidism after Total Thyroidectomy

Postoperative parathyroid failure is the commonest adverse effect of total thyroidectomy, which is a widely used surgical procedure to treat both benign and malignant thyroid disorders. The present review focuses on the scientific gap and lack of data regarding the time period elapsed between the immediate postoperative period, when hypocalcemia is usually detected by the surgeon, and permanent hypoparathyroidism often seen by an endocrinologist months or years later. Parathyroid failure after thyroidectomy results from a combination of trauma, devascularization, inadvertent resection, and/or autotransplantation, all resulting in an early drop of iPTH (intact parathyroid hormone) requiring replacement therapy with calcium and calcitriol. There is very little or no role for other factors such as vitamin D deficiency, calcitonin, or magnesium. Recovery of the parathyroid function is a dynamic process evolving over months and cannot be predicted on the basis of early serum calcium and iPTH measurements; it depends on the number of parathyroid glands remaining in situ (PGRIS)—not autotransplanted nor inadvertently excised—and on early administration of full-dose replacement therapy to avoid hypocalcemia during the first days/weeks after thyroidectomy.