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Influence of Care Pathway on Thyroid Nodule Surgery Relevance: A Historical Cohort Study. J Clin Med 2020; 9:jcm9072271. [PMID: 32708905 PMCID: PMC7408692 DOI: 10.3390/jcm9072271] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 07/15/2020] [Indexed: 01/21/2023] Open
Abstract
Background: Guidelines recommend using fine-needle aspiration cytology (FNAC) to guide thyroid nodule surgical indication. However, the extent to which these guidelines are followed remains unclear. This study aimed to analyze the quality of the preoperative care pathway and to evaluate whether compliance with the recommended care pathway influenced the relevance of surgical indications. Methods: Nationwide historical cohort study based on data from a sample (1/97th) of French health insurance beneficiaries. Evaluation of the care pathway of adult patients operated on between 2012 and 2015 during the year preceding thyroid nodule surgery. The pathway containing only FNAC was called “FNAC”, the pathway including an endocrinology consultation (ENDO) with FNAC was called “FNAC+ENDO”, whereas the no FNAC pathway was called “NO FNAC”. The main outcome was the malignant nature of the nodule. Results: Among the 1080 patients included in the study, “FNAC+ENDO” was found in 197 (18.2%), “FNAC” in 207 (19.2%), and “NO FNAC” in 676 (62.6%) patients. Cancer diagnosis was recorded in 72 (36.5%) “FNAC+ENDO” patients and 66 (31.9%) “FNAC” patients, against 119 (17.6%) “NO FNAC” patients. As compared to “NO FNAC”, the “FNAC+ENDO” care pathway was associated with thyroid cancer diagnosis (OR 2.67, 1.88–3.81), as was “FNAC” (OR 2.09, 1.46–2.98). Surgeries performed in university hospitals were also associated with thyroid cancer diagnosis (OR 1.61, 1.19–2.17). Increasing the year for surgery was associated with optimal care pathway (2015 vs. 2012, OR 1.52, 1.06–2.18). Conclusions: The recommended care pathway was associated with more relevant surgical indications. While clinical guidelines were insufficiently followed, compliance improved over the years.
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Isik A, Firat D, Yilmaz I, Peker K, Idiz O, Yilmaz B, Demiryilmaz I, Celebi F. A survey of current approaches to thyroid nodules and thyroid operations. Int J Surg 2018; 54:100-104. [PMID: 29709542 DOI: 10.1016/j.ijsu.2018.04.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 04/19/2018] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Thyroid nodules are commonly seen. Our aim is to learn the behaviors and operational attitudes of surgeons approaching the thyroid nodules. In a literature search, our study is the first and only study performed merely on surgeons. MATERIALS- METODS This cross-sectional study was done between June 2014-January 2015. The questionnaire consists of 25 questions. Initially, general questions consisting of demographic findings were asked. In step 2, questions consisting of the index case and case variants were asked. Results were compared with American Thyroid Association, European Thyroid Association guidelines, and Australia survey results. In the last step, questions about thyroid operations were asked. RESULTS A total of 301 surgeons responded to the survey. The response rate was approximately 20%. Thirty nine were female and 262 were male. For the question that asks the diameter of the thyroid nodule that will require a thyroid fine needle aspiration biopsy (TFNAB), 47.5% of the surgeons will require a TFNAB for 1-2 cm solid nodules. 40.15% of the surgeons required a TFNAB regardless of size. 46.1% of the surgeons who required a TFNAB between 1 and 2 cm solid nodules also required scintigraphy at diagnosis of suppressed TSH case variant. CONCLUSION In this survey, we identified differences from up-to-date guidelines about approaching thyroid nodules and perioperative thyroid surgery. From our perspective, surgeons need updated training requirements. This can be done with updated seminars across the country. Thereby approaches may become standard and consequently patients may have qualified services.
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Affiliation(s)
- Arda Isik
- Magee Womens Hospital of UPMC, Breast Surgery Clinic, Pittsburgh, USA.
| | - Deniz Firat
- Erzincan University, Faculty of Medicine, General Surgery Clinic, Erzincan, Turkey
| | - Ismayil Yilmaz
- Erzincan University, Faculty of Medicine, General Surgery Clinic, Erzincan, Turkey
| | - Kemal Peker
- Erzincan University, Faculty of Medicine, General Surgery Clinic, Erzincan, Turkey
| | - Oguz Idiz
- Istanbul Teaching and Research Hospital, General Surgery Clinic, Istanbul, Turkey
| | - Bahri Yilmaz
- Duzce Ataturk State Hospital, General Surgery Clinic, Duzce, Turkey
| | - Ismail Demiryilmaz
- Erzincan University, Faculty of Medicine, General Surgery Clinic, Erzincan, Turkey
| | - Fehmi Celebi
- Erzincan University, Faculty of Medicine, General Surgery Clinic, Erzincan, Turkey
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Likhterov I, Tuttle RM, Haser GC, Su HK, Bergman D, Alon EE, Bernet V, Brett E, Cobin R, Dewey EH, Doherty G, Dos Reis LL, Klopper J, Lee SL, Lupo MA, Machac J, Mechanick JI, Milas M, Orloff L, Randolph G, Ross DS, Rowe ME, Smallridge R, Terris D, Tufano RP, Urken ML. Improving the adoption of thyroid cancer clinical practice guidelines. Laryngoscope 2016; 126:2640-2645. [PMID: 27074952 DOI: 10.1002/lary.25986] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS To present an overview of the barriers to the implementation of clinical practice guidelines (CPGs) in thyroid cancer management and to introduce a computer-based clinical support system. DATA SOURCES PubMed. REVIEW METHODS A review of studies on adherence to CPGs was conducted. RESULTS Awareness and adoption of CPGs is low in thyroid cancer management. Barriers to implementation include unfamiliarity with the CPGs and financial concerns. Effective interventions to improve adherence are possible, especially when they are readily accessible at the point of care delivery. Computerized clinical support systems show particular promise. The authors introduce the clinical decision making modules (CDMMs) of the Thyroid Cancer Care Collaborative, a thyroid cancer-specific electronic health record. These computer-based modules can assist clinicians with implementation of these recommendations in clinical practice. CONCLUSION Computer-based support systems can help clinicians understand and adopt the thyroid cancer CPGs. By integrating patient characteristics and guidelines at the point of care delivery, the CDMMs can improve adherence to the guidelines and help clinicians provide high-quality, evidence-based, and individualized patient care in the management of differentiated thyroid cancer. Laryngoscope, 126:2640-2645, 2016.
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Affiliation(s)
- Ilya Likhterov
- Department of Otolaryngology - Head and Neck Surgery, Mount Sinai Beth Israel, New York, New York
| | | | - Grace C Haser
- Department of Otolaryngology - Head and Neck Surgery, Thyroid, Head and Neck Cancer (THANC) Foundation, New York, New York.
| | - Henry K Su
- Department of Otolaryngology - Head and Neck Surgery, Thyroid, Head and Neck Cancer (THANC) Foundation, New York, New York
| | - Donald Bergman
- Division of Endocrinology, Diabetes and Bone Diseases, and the Division of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Eran E Alon
- Department of Otolaryngology - Head and Neck Surgery, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Victor Bernet
- Department of Endocrinology, Mayo Clinic Jacksonville, Jacksonville, Florida, U.S.A
| | - Elise Brett
- Division of Endocrinology, Diabetes and Bone Diseases, and the Division of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rhoda Cobin
- Division of Endocrinology, Diabetes and Bone Diseases, and the Division of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Eliza H Dewey
- Department of Otolaryngology - Head and Neck Surgery, Thyroid, Head and Neck Cancer (THANC) Foundation, New York, New York
| | - Gerard Doherty
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts, U.S.A
| | - Laura L Dos Reis
- Department of Otolaryngology - Head and Neck Surgery, Thyroid, Head and Neck Cancer (THANC) Foundation, New York, New York
| | - Joshua Klopper
- Division of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Stephanie L Lee
- Section of Endocrinology, Diabetes, and Nutrition, Department of Medicine, Boston Medical Center, Boston, Massachusetts, U.S.A
| | - Mark A Lupo
- Thyroid & Endocrine Center of Florida, Florida State University College of Medicine, Sarasota, Florida, U.S.A
| | - Josef Machac
- Division of Endocrinology, Diabetes and Bone Diseases, and the Division of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeffrey I Mechanick
- Division of Endocrinology, Diabetes and Bone Diseases, and the Division of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mira Milas
- Section of Endocrine Surgery, Department of Surgery, Banner-University Medical Center Phoenix, Phoenix, Arizona, U.S.A
| | - Lisa Orloff
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Gregory Randolph
- Department of Otolaryngology and the Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Douglas S Ross
- Department of Otolaryngology and the Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Meghan E Rowe
- Department of Otolaryngology - Head and Neck Surgery, Thyroid, Head and Neck Cancer (THANC) Foundation, New York, New York
| | - Robert Smallridge
- Department of Endocrinology, Mayo Clinic Jacksonville, Jacksonville, Florida, U.S.A
| | - David Terris
- Department of Otolaryngology, Georgia Regents University, Augusta, Georgia, U.S.A
| | - Ralph P Tufano
- Department of Otolaryngology, Johns Hopkins School of Medicine, Baltimore, Maryland, U.S.A
| | - Mark L Urken
- Department of Otolaryngology - Head and Neck Surgery, Mount Sinai Beth Israel, New York, New York
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Goffredo P, Roman SA, Sosa JA. Have 2006 ATA practice guidelines affected the treatment of differentiated thyroid cancer in the United States? Thyroid 2014; 24:463-71. [PMID: 23978295 DOI: 10.1089/thy.2013.0319] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is wide variability in the degree of adherence to guideline recommendations among caregivers. Our aim was to determine the clinical impact of the 2006 guidelines from the American Thyroid Association (ATA) on the management of differentiated thyroid cancer (DTC) in the United States. METHODS The Surveillance, Epidemiology and End Results (SEER) database (2004-2009) was employed. Patients were divided into two groups based on receipt of care before (DTC 04-06) and after (DTC 07-09) the release of the 2006 ATA guidelines. Adherence was determined with a chi-square test and binary logistic regression. Survival was analyzed with the Kaplan-Meier method and log-rank test. RESULTS A total of 12,816 patients with DTC were identified between 2004 and 2006, and 14,514 between 2007 and 2009 (DTC 07-09). Adherence to Recommendation 26 (surgery) tended to increase in DTC 07-09 (82.2% vs. 83.2%, p=0.083). Factors associated with discordant practice among the DTC 07-09 group were older age, treatment in the Northeast, having more than one primary cancer, tumor size >4 cm, and follicular and Hürthle cell histologies. Factors associated with accordance were treatment in the Midwest, level II-VI metastases, having lymph nodes examined, AJCC Stage III, and presenting with distant metastases. Patients treated in accordance with Recommendation 26 showed prolonged disease-specific survival (p<0.001). A trend toward more adherence to Recommendation 27 (lymphadenectomy) was observed over time (68.4% vs. 69.7%, p=0.065). Adherence to Recommendation 27 was not associated with disease-specific survival (p=0.539). Less discordance from guidelines was seen for cancers that were 2.1-4 cm, extrathyroidal, and greater than Stage I. Overall accordance with Recommendation 32 (radioactive iodine [RAI] ablation) increased in DTC 07-09 compared to DTC 04-06 (61.7% vs. 57.5% respectively, p<0.001), and this was associated with improved disease-specific survival in DTC 07-09 (p<0.001). Predictors of care discordant with guidelines were patient age ≥ 65 years, living in the Northeast, and not undergoing total thyroidectomy. Factors associated with RAI use in accordance with guidelines were married status, treatment in the South, and having more than one lymph node examined. CONCLUSIONS Care in accordance with evidence-based guidelines for DTC is associated with improved patient outcomes. Ongoing efforts should be undertaken to propagate guidelines to reduce variation in care and improve overall quality of care.
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Affiliation(s)
- Paolo Goffredo
- 1 Department of Surgery, University of Milano-Bicocca , Monza, Italy
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Bonnema SJ, Fast S, Hegedüs L. Non-surgical approach to the benign nodular goiter: new opportunities by recombinant human TSH-stimulated 131I-therapy. Endocrine 2011; 40:344-53. [PMID: 21971931 DOI: 10.1007/s12020-011-9542-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2011] [Accepted: 09/05/2011] [Indexed: 10/17/2022]
Abstract
The optimal treatment strategy in a goiter patient depends--among other factors--on goiter size, the degree of cosmetic or compressive symptoms, the age of the patient, the impact on the upper airways, the wish to maintain normal thyroid function, the ability of the thyroid gland to take up (131)I, and the possibility of thyroid malignancy. When treatment is warranted in a patient with benign goiter, the choice usually stands between surgery and (131)I-therapy. Focal destructive treatment, by ethanol sclerotherapy or interstitial laser photocoagulation, may be considered in patients with a solitary benign nodule. If thyroid hyperfunction due to nodular autonomy is the dominant problem, life-long anti-thyroid drug treatment may be relevant in elderly individuals. With the advent of recombinant human TSH (rhTSH) stimulation the goiter reduction following (131)I-therapy is significantly enhanced and this treatment is of particular benefit, as compared with conventional (131)I-therapy, in patients with a low baseline thyroid (131)I uptake and a large goiter. If the rhTSH dose does not exceed 0.1 mg the risk of temporary hyperthyroidism and acute thyroid swelling is low. Since patient satisfaction seemingly is not improved by the greater goiter reduction obtained by rhTSH-stimulated (131)I-therapy, and permanent hypothyroidism is more frequent, it may be more relevant to reduce the administered radioactivity equivalent to the rhTSH-induced increase in the thyroid (131)I uptake. Future large-scale well-controlled studies should explore this strategy, with focus on cost-benefit and quality of life. A major hindrance of widespread and routine use of rhTSH-stimulated (131)I-therapy is its present status as an off-label treatment.
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Affiliation(s)
- Steen Joop Bonnema
- Department of Endocrinology, Odense University Hospital, 5000, Odense C, Denmark.
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Yousef A, Clark J, Doi SAR. Thyroxine suppression therapy for benign, non-functioning solitary thyroid nodules: a quality-effects meta-analysis. Clin Med Res 2010; 8:150-8. [PMID: 20739581 PMCID: PMC3006560 DOI: 10.3121/cmr.2010.881] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Levothyroxine (LT4) suppressive therapy for solitary thyroid nodules is not popularly advocated presently because its clinical efficacy and safety are currently considered controversial. This meta-analysis aims to address efficacy issues by using rigorous methods to arrive at a pooled estimate. On the basis of the analysis, it is estimated that LT4 therapy is clearly associated with up to a two-fold increase in the chance of nodule reduction. This translates to a number needed to treat (NNT) of 6 or a 50% decrease in the risk of cancer given nodule reduction. Keeping this definition of efficacy in mind and a low incidence of adverse events with low level LT4 suppression, such an intervention might be appropriate in patients selected on the basis of a low risk for adverse effects.
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Affiliation(s)
- Altayyeb Yousef
- Department of Medicine, Mubarak Al-Kabeer Teaching Hospital, Kuwait
| | - Justin Clark
- Herston Health Sciences Library, University of Queensland, Brisbane, Australia
| | - Suhail A. R. Doi
- Clinical Epidemiology Unit, School of Population Health, University of Queensland, Brisbane, Australia
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Famakinwa OM, Roman SA, Wang TS, Sosa JA. ATA practice guidelines for the treatment of differentiated thyroid cancer: were they followed in the United States? Am J Surg 2010; 199:189-98. [PMID: 20113699 DOI: 10.1016/j.amjsurg.2009.04.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Revised: 04/29/2009] [Accepted: 04/29/2009] [Indexed: 12/20/2022]
Abstract
BACKGROUND The aim of this study was to benchmark national practice patterns against American Thyroid Association guidelines for thyroidectomy, lymphadenectomy, and radioactive iodine (RAI) for differentiated thyroid cancer (DTC). METHODS A cross-sectional analysis of patients with DTC in Surveillance, Epidemiology, and End Results was performed. Outcomes were practice accordance with guidelines for extent of surgery and RAI treatment. Predictors of accordance were identified. RESULTS A total of 52,964 patients with DTC were included. Seventy-six percent were women, and 83% white. There was 71% accordance with surgery recommendations; among these, 15% underwent central lymphadenectomy, 31% had RAI but no lymphadenectomy, and 25% had RAI and lymphadenectomy. The highest accordance with guidelines was for patients aged <45 years with stage II disease (80%); the lowest accordance was for patients aged > or = 45 years with stage II disease (52%). Patients aged >65 years and of black race had the lowest accordance (P < .001). CONCLUSIONS Variation in practice suggests variation in the quality of care for DTC. Greater dissemination of evidence-based recommendations is needed for elderly and minority patients.
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