Primary versus Tertiary Care Follow-Up of Low-Risk Differentiated Thyroid Cancer: Real-World Comparison of Outcomes and Costs for Patients and Health Care Systems

Morbidity profile and pharmaceutical management of adult outpatients between primary and tertiary care levels in Sri Lanka: a dual-centre, comparative study

BACKGROUND

Outpatient care is central to both primary and tertiary levels in a health system. However, evidence is limited on outpatient differences between these levels, especially in South Asia. This study aimed to describe and compare the morbidity profile (presenting morbidities, comorbidities, multimorbidity) and pharmaceutical management (patterns, indicators) of adult outpatients between a primary and tertiary care outpatient department (OPD) in Sri Lanka.

METHODS

A comparative study was conducted by recruiting 737 adult outpatients visiting a primary care and a tertiary care facility in the Kandy district. A self-administered questionnaire and a data sheet were used to collect outpatient and prescription data. Following standard categorisations, Chi-square tests and Mann‒Whitney U tests were employed for comparisons.

RESULTS

Outpatient cohorts were predominated by females and middle-aged individuals. The median duration of presenting symptoms was higher in tertiary care OPD (10 days, interquartile range: 57) than in primary care (3 days, interquartile range: 12). The most common systemic complaint in primary care OPD was respiratory symptoms (32.4%), whereas it was dermatological symptoms (30.2%) in tertiary care. The self-reported prevalence of noncommunicable diseases (NCDs) was 37.9% (95% CI: 33.2-42.8) in tertiary care OPD and 33.2% (95% CI: 28.5-38.3) in primary care; individual disease differences were significant only for diabetes (19.7% vs. 12.8%). The multimorbidity in tertiary care OPD was 19.0% (95% CI: 15.3-23.1), while it was 15.9% (95% CI: 12.4-20.0) in primary care. Medicines per encounter at primary care OPD (3.86, 95% CI: 3.73-3.99) was higher than that at tertiary care (3.47, 95% CI: 3.31-3.63). Medicines per encounter were highest for constitutional and respiratory symptoms in both settings. Overall prescribing of corticosteroids (62.7%), vitamin supplements (45.8%), anti-allergic (55.3%) and anti-asthmatic (31.3%) drugs was higher in the primary care OPD, and the two former drugs did not match the morbidity profile. The proportion of antibiotics prescribed did not differ significantly between OPDs. Subgroup analyses of drug categories by morbidity largely followed these overall differences.

CONCLUSIONS

The morbidities between primary and tertiary care OPDs differed in duration and type but not in terms of multimorbidity or most comorbidities. Pharmaceutical management also varied in terms of medicines per encounter and prescribed categories. This evidence supports planning in healthcare and provides directions for future research in primary care.

Real-World Cost-Effectiveness Analysis: How Much Uncertainty Is in the Results?

Cost-effectiveness analyses of new cancer treatments in real-world settings (e.g., post-clinical trials) inform healthcare decision makers about their healthcare investments for patient populations. The results of these analyses are often, though not always, presented with statistical uncertainty. This paper identifies five ways to characterize statistical uncertainty: (1) a 95% confidence interval (CI) for the incremental cost-effectiveness ratio (ICER); (2) a 95% CI for the incremental net benefit (INB); (3) an INB by willingness-to-pay (WTP) plot; (4) a cost-effectiveness acceptability curve (CEAC); and (5) a cost-effectiveness scatterplot. It also explores their usage in 22 articles previously identified by a rapid review of real-world cost effectiveness of novel cancer treatments. Seventy-seven percent of these articles presented uncertainty results. The majority those papers (59%) used administrative data to inform their analyses while the remaining were conducted using models. Cost-effectiveness scatterplots were the most commonly used method (34.3%), with 40% indicating high levels of statistical uncertainty, suggesting the possibility of a qualitatively different result from the estimate given. Understanding the necessity for and the meaning of uncertainty in real-world cost-effectiveness analysis will strengthen knowledge translation efforts to improve patient outcomes in an efficient manner.

Outcomes of Early Transition of Low-Risk Thyroid Cancer Patients from Specialist to Primary Care

BACKGROUND

Recently published clinical pathways for management of thyroid cancer outlined the criteria for transitioning low-risk patients to primary care within one to five years from diagnosis. However, discharge patterns among endocrinologists remain heterogeneous as there lacks a consensus regarding post-treatment care for thyroid cancer patients.

OBJECTIVE

This study described general characteristics and outcomes of thyroid cancer patients who were discharged from specialist care and transitioned to a primary care-based follow-up clinic.

METHODS

Thyroid cancer patients seen in the After Cancer Treatment Transition (ACTT) clinic at Women's College Hospital (Toronto, Canada) were included in the study. Electronic medical records were reviewed between May and October 2021 to collect patient characteristics and outcomes. Descriptive statistics were calculated.

RESULTS

The study cohort included 148 thyroid cancer patients and 76% were female. All cases were papillary thyroid cancer and most diagnoses were classified as T₂ (42%), N₀ (55%), M₀ (91%), and stage 1 (83%). Nearly all patients (n = 147) had complete thyroidectomy. Levels of thyroglobulin and thyroglobulin antibodies (TgAb) were low overall, with only 5% of the study cohort deemed TgAb positive. Mean levels of thyroid stimulating hormone (TSH) measured at 2 time points (1.37 mIU/L, 1.42 mIU/L) were within normal range. About 91% of the study cohort had normal TSH levels and 82% met target TSH levels. There were 2 cases of recurrence; however, investigation determined that they were not initially appropriate candidates for transition to primary care. Nearly 99% (n = 146) of patients had excellent response to therapy, showed no evidence of disease recurrence, and have not required re-referral to specialist care.

CONCLUSIONS

These findings may reassure specialists that low-risk, stable thyroid cancer patients can be safely transitioned to primary care for post-treatment follow-up.

Rapid Review of Real-World Cost-Effectiveness Analyses of Cancer Interventions in Canada

Cost-effectiveness analysis (CE Analysis) provides evidence about the incremental gains in patient outcomes costs from new treatments and interventions in cancer care. The utilization of "real-world" data allows these analyses to better reflect differences in costs and effects for actual patient populations with comorbidities and a range of ages as opposed to randomized controlled trials, which use a restricted population. This rapid review was done through PubMed and Google Scholar in July 2022. Relevant articles were summarized and data extracted to summarize changes in costs (in 2022 CAD) and effectiveness in cancer care once funded by the Canadian government payer system. We conducted statistical analyses to examine the differences between means and medians of costs, effects, and incremental cost effectiveness ratios (ICERs). Twenty-two studies were selected for review. Of those, the majority performed a CE Analysis on cancer drugs. Real-world cancer drug studies had significantly higher costs and effects than non-drug therapies. Studies that utilized a model to project longer time-horizons saw significantly smaller ICER values for the treatments they examined. Further, differences in drug costs increased over time. This review highlights the importance of performing real-world CE Analysis on cancer treatments to better understand their costs and impacts on a general patient population.

Treatment strategies for low-risk papillary thyroid carcinoma: a position statement from the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM)

Increasingly sensitive diagnostic methods, better understanding of molecular pathophysiology, and well-conducted prospective studies have changed the current approach to patients with thyroid cancer, requiring the implementation of individualized management. Most patients with papillary thyroid carcinoma (PTC) are currently considered to have a low risk of mortality and disease persistence/recurrence. Consequently, current treatment recommendations for these patients include less invasive or intensive therapies. We used the most recent evidence to prepare a position statement providing guidance for decisions regarding the management of patients with low-risk PTC (LRPTC). This document summarizes the criteria defining LRPTC (including considerations regarding changes in the TNM staging system), indications and contraindications for active surveillance, and recommendations for follow-up and surgery. Active surveillance may be an appropriate initial choice in selected patients, and the criteria to recommend this approach are detailed. A section is dedicated to the current evidence regarding lobectomy versus total thyroidectomy and the potential pitfalls of each approach, considering the challenges during long-term follow-up. Indications for radioiodine (RAI) therapy are also addressed, along with the benefits and risks associated with this treatment, patient preparation, and dosage. Finally, this statement presents the best follow-up strategies for LRPTC after lobectomy and total thyroidectomy with or without RAI.

Economic Evaluation of Long-Term Survivorship Care for Cancer Patients in OECD Countries: A Systematic Review for Decision-Makers

Long-term cancer survivorship care is a crucial component of an efficient healthcare system. For numerous reasons, there has been an increase in the number of cancer survivors; therefore, healthcare decision-makers are tasked with balancing a finite budget with a strong demand for services. Decision-makers require clear and pragmatic interpretation of results to inform resource allocation decisions. For these reasons, the impact and importance of economic evidence are increasing. The aim of the current study was to conduct a systematic review of economic evaluations of long-term cancer survivorship care in Organization for Economic Co-operation and Development (OECD) member countries and to assess the usefulness of economic evidence for decision-makers. A systematic review of electronic databases, including MEDLINE, PubMed, PsycINFO and others, was conducted. The reporting quality of the included studies was appraised using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Each included study’s usefulness for decision-makers was assessed using an adapted version of a previously published approach. Overall, 3597 studies were screened, and of the 235 studies assessed for eligibility, 34 satisfied the pre-determined inclusion criteria. We found that the majority of the included studies had limited value for informing healthcare decision-making and conclude that this represents an ongoing issue in the field. We recommend that authors explicitly include a policy statement as part of their presentation of results.

Endocrinologist-Perceived Factors Affecting the Transition of Thyroid Cancer Patients from Specialist to Primary Care Postcancer Treatment in Ontario, Canada

Background: Thyroid cancer patient discharge patterns from specialists are heterogeneous, with some specialists following patients for a longer period of time than others. With no well-established transitional plan, such as in breast and colorectal cancer, primary care physicians play a variable role in long-term thyroid cancer care. The objective of this study was to examine endocrinologist-perceived factors affecting the transition of care for thyroid cancer patients through a qualitative and quantitative survey of practicing endocrinologists in Ontario, Canada. Methods: All eligible practicing endocrinologists in Ontario were invited to participate in the study, via an email with an embedded survey link. Consent was assumed if the physician completed the survey. The survey collected physician demographics and asked a series of Likert-scale and open-ended questions on their views regarding transitioning care of their thyroid cancer patients. Quantitative analysis was based on mode and variability. Qualitative analysis was completed using inductive thematic analysis. Results: Seventy physicians completed the survey, with a response rate of 35.5%. Based on the responses to the Likert-scale questions, there was a lack of consensus in terms of discharging criteria for patients who had low-risk papillary thyroid cancer, stable thyrotropin levels, multiple nonthyroid-related comorbidities, and hemithyroidectomy with no disease recurrence. The majority of endocrinologists responded that the main factors affecting discharge included whether the primary care physician was able to follow their recommendations, whether the primary care physician could appropriately adjust levothyroxine doses, and whether the patient was confident that their primary care physician could manage their thyroid cancer follow-up. Themes extracted from the open-ended question also indicated that the main factors affecting the transition of care were related to the primary care physician, the patient, the imaging interpretation, and the discharge guidelines. Conclusion: The lack of consensus among endocrinologists affects the transition of patient care, and there is a need to provide clear and accurate information to primary care physicians and thyroid cancer patients on postcancer treatment care. Efforts should be sought to standardize discharge and long-term care.

A Meta-Analysis of Risk Factors for Transient and Permanent Hypocalcemia After Total Thyroidectomy

Background

As hypocalcemia is the most common complication of total thyroidectomy, identifying its risk factors should guide prevention and management. The purpose of this study was to determine the risk factors for postthyroidectomy hypocalcemia.

Methods

We searched PubMed, Web of Science and EMBASE through January 31, 2019, and assessed study quality using the Newcastle–Ottawa Scale.

Results

Fifty studies with 22,940 patients met the inclusion criteria, of which 24.92% (5716/22,940) had transient hypocalcemia and 1.96% (232/11,808) had permanent hypocalcemia. Significant (P < 0.05) predictors of transient hypocalcemia were: younger age, female, parathyroid autotransplantation (PA), inadvertent parathyroid excision (IPE), Graves’ disease (GD), thyroid cancer, central lymph node dissection, preoperative severe Vitamin D deficiency, preoperative Vitamin D deficiency and a lower postoperative 24 h parathyroid hormone (PTH) level. Preoperative magnesium, preoperative PTH and Hashimoto’s thyroiditis were not significant predictors of transient hypocalcemia. IPE, GD, and thyroid cancer were associated with an increased rate of permanent hypocalcemia, but gender and PA did not predict permanent hypocalcemia.

Conclusion

Important risk factors for transient and permanent hypocalcemia were identified. However, given the limited sample size and heterogeneity of this meta-analysis, further studies are required to confirm our preliminary findings.

Hemithyroidectomy for Thyroid Cancer: A Review

Thyroid cancer incidence is on the rise; however, fortunately, the death rate is stable. Most persons with well-differentiated thyroid cancer have a low risk of recurrence at the time of diagnosis and can expect a normal life expectancy. Over the last two decades, guidelines have recommended less aggressive therapy for low-risk cancer and a more personalized approach to treatment of thyroid cancer overall. The American Thyroid Association (ATA) and National Comprehensive Cancer Network (NCCN) thyroid cancer guidelines recommend hemithyroidectomy as an acceptable surgical treatment option for low-risk thyroid cancer. Given this change in treatment paradigms, an increasing number of people are undergoing hemithyroidectomy rather than total or near-total thyroidectomy as their primary surgical treatment of thyroid cancer. The postoperative follow-up of hemithyroidectomy patients differs from those who have undergone total or near-total thyroidectomy, and the long-term monitoring with imaging and biomarkers can also be different. This article reviews indications for hemithyroidectomy, as well as postoperative considerations and management recommendations for those who have undergone hemithyroidectomy.