L. Jiang1, C. Lee1, D. Sloan1, R. Randle1 1University Of Kentucky,Department Of General Surgery,Lexington, KY, USA
Introduction:
While thyroid nodules are very common, they need an appropriate evaluation given the increasing incidence of thyroid cancer. We hypothesized that most patients do not receive high-quality, streamlined thyroid nodule evaluations. The objective of this study was to describe and characterize the quality of thyroid nodule evaluations prior to surgical referral.
Methods:
We reviewed all consecutive surgical referrals for thyroid nodules from October to December 2017 at a single institution. We defined an efficient initial laboratory investigation as one that obtained a thyroid stimulating hormone (TSH) level without additional thyroid related labs. We defined a high-quality ultrasound as one that included commentary on nodule structure, echogenicity, 3-dimensional size, and lymph nodes since these features help stratify the risk of malignancy.
Results:
The study cohort included 64 patients, with a median age of 51.5 years. Primary care providers referred most patients (51.6%), followed by endocrinologists (40.6%), and other specialists (7.8%). Patients saw a mean of 1.63 providers for their nodule prior to surgical referral. In total, 35.9% of evaluations did not include a TSH value, and 53.1% included additional, unnecessary thyroid labs. Only 14.1% met our definition of an efficient initial laboratory investigation with a TSH as the only thyroid related lab obtained. Almost all evaluations (95.3%) included a thyroid ultrasound, but these were of varying quality. The Figure shows the proportion of ultrasound reports that noted specific characteristics of the dominant nodule. Only12.3% of ultrasound reports commented on the 4 criteria indicative of a high-quality thyroid ultrasound. Of the 6 evaluations (9.4%) that included a thyroid uptake scan, only 2 (33.3%) were indicated, and 4 patients with a suppressed TSH did not receive a thyroid uptake scan as indicated. Overall, 93.1% of biopsy reports appropriately classified thyroid nodule cytology according to the Bethesda System.
Conclusion:
There are marked discrepancies in the quality of thyroid nodule evaluations prior to surgical referral. Even though a TSH is necessary in the work-up of all thyroid nodules, over a third of evaluations did not include one. Additionally, most ultrasound reports do not include sufficient commentary on the sonographic features necessary to stratify the risk of malignancy. Therefore, quality improvement initiatives targeting laboratory testing and ultrasound imaging might promote efficiency and quality in thyroid nodule evaluations.
