High-volume endocrine surgeons perform thyroid surgery at decreased cost despite increased case relative value units.

BACKGROUND: Healthcare systems are transitioning to value-based payment models based on analysis of quality over cost. To gain an understanding of the relationship between surgeon volume and health care costs, we compared the direct costs of thyroidectomy performed by dedicated high-volume endocrine surgeons and low-volume surgeons within a large health care system. METHODS: We evaluated all thyroid surgeries performed within a single billing year at a single health care system. We defined high-volume surgeons as those who treated >50 thyroid cases yearly and compared them to low-volume surgeons. To account for multicomponent procedures, we added the relative value units for the components of the cases. Then, we divided them into low-relative value units, intermediate-relative value units, and high-relative value units groups. We analyzed categorical and continuous variables using the χ2 analysis and Wilcoxon rank sum test, respectively. RESULTS: We identified 674 thyroidectomy procedures performed by 27 surgeons, of whom 6 high-volume surgeons performed 79% of cases. Relative value unit distribution differed between the groups, with high-volume surgeons performing more intermediate-relative value unit (58% vs 34.7%, P < .01) and high-relative value unit (24.6% vs 20.6%, P < .01) cases, whereas low-volume surgeons performed more low-relative value unit cases (45% vs 17%, P < .01). Overall, high-volume surgeons incurred a 26% reduction in total costs (P < .01) and a 33% reduction in discretionary expenses (P < .01) across all relative value unit groups. CONCLUSION: High-volume endocrine surgeons perform thyroid procedures at a lower cost than their low-volume counterparts, a difference that is magnified when stratified by relative value unit groups.

Are 99mTC-Sestamibi Single Photon Emission Computed Tomography Scan Results Associated to the Parathyroid Cell Type in Primary Hyperparathyroidism?

INTRODUCTION: 99mTC-sestamibi scintigraphy (SPECT-CT) is a common imaging modality for parathyroid localization in primary hyperparathyroidism (PHPT). Prior studies have suggested that the cellular composition of parathyroid adenomas influences SPECT-CT imaging results. Other biochemical and anatomical factors may also play a role in false negative results. Therefore, after controlling for confounding variables, we sought to determine whether the histologic composition of parathyroid adenomas is associated to SPECT-CT results in patients with single gland disease causing PHPT. METHODS: A retrospective review of patients with PHPT due to confirmed single gland disease was performed over a 2-y period. A 1:1 propensity score matching was done between patients with positive and negative SPECT-CT results with regard to demographical, biochemical, and anatomical characteristics followed by blinded pathologic examination of cell composition in the matched pairs. RESULTS: Five hundred forty two patients underwent routine four gland exploration and 287 (53%) patients were found to have a single adenoma. Of those, 26% had a negative SPECT-CT result. There were significant differences between groups with regards to biochemical profile, gland location, and gland size. All of which became nonsignificant after propensity score matching. Adenomas were primarily composed of chief cells, with no difference between groups (95% versus 97%, P = 0.30). In the positive SPECT-CT group, chief cells were the dominant cell type in 68% of the cases, followed by mixed type (13%), oxyphil cells (12%), and clear cells (7%). This was similar to the negative SPECT-CT group (P = 0.22). CONCLUSIONS: While certain patient's clinical characteristics are associated with SPECT-CT imaging results, histologic cell type is not significantly associated.

EUS-guided management of anastomotic stricture: A case report.

INTRODUCTION AND IMPORTANCE: Anastomotic stenosis after low anterior resection is a serious complication and at times even requires surgical revision of the anastomosis. CASE PRESENTATION AND CLINICAL DISCUSSION: The patient presented with a 4.0 cm tubulovillous adenoma of the proximal rectum and underwent low anterior resection with loop ileostomy and subsequent reversal. The case was complicated by complete anastomotic stenosis. A novel technique was utilized to create an Endoscopic Ultrasound (EUS)-guided neo-anastomosis endoscopically. CONCLUSION: EUS-guided creation of a neo-colorectal anastomosis is a safe and effective alternative to surgical anastomosis revision of a completely stenosed anastomosis.

Parathyroidectomy trends and surgical trainee parathyroidectomy experience based on the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) database.

BACKGROUND: The parathyroidectomy approach has shifted over the last few decades from routine bilateral to more commonly focused exploration. The purpose of this study is to assess the operative experience in parathyroidectomy for surgical trainees as well as overall parathyroidectomy trends. METHODS: Data from the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) were analyzed between 2014 and 2019. RESULTS: The overall distribution of focused versus bilateral parathyroidectomy remained stable (2014: 54 % focused and 46 % bilateral approach; 2019: 55 % focused and 45 % bilateral). Ninety three percent of procedures involved a trainee (fellow or resident) in 2014, this dropped to 74 % in 2019 (P < 0.005). Fellow involvement decreased significantly from 31 % to 17 % (P < 0.05) over the six-year period. CONCLUSIONS: Resident exposure to parathyroidectomies mirrored that of practicing endocrine surgeons. This works highlights the opportunities to capture more information regarding the surgical trainee experience in endocrine surgeries.

Outcomes of Thyroidectomy During the COVID-19 Pandemic: A NSQIP Analysis.

BACKGROUND: The coronavirus disease 19 (COVID-19) has had a profound impact on our healthcare system. Surgery in particular faced significant challenges related to allocation of resources and equitable patient selection, resulting in a delay in non-emergent procedures. We sought to study the impact of the COVID-19 pandemic on patient outcomes after thyroidectomy. METHODS: This was a cross-sectional study using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database that included all thyroidectomies from 2018 to 2020. The primary outcome evaluated was surgical outcomes during 2020, the first year of the pandemic, compared to years preceding the pandemic. Factors associated with adverse postoperative outcomes during the study period were included in a multivariate analysis. RESULTS: The volume of thyroidectomy procedures in 2020 decreased 16.4% when compared to the preceding years. During 2020, there was a significant increase in mortality (0.14% vs. 0.07%, p = 0.03), unplanned intubation (0.45% vs. 0.27%, p < 0.01) and cardiac arrest (0.11% vs. 0.03%, p < 0.01), while other complications remained stable. Undergoing surgery in 2020 remained as a risk factor for mortality in a multivariate analysis (OR 2.4 95% CI 1.3-4.4). CONCLUSION: The first year of the COVID-19 pandemic had a significant impact on outcomes after thyroidectomy resulting in increased mortality. As the world recovers, there will likely be an increase number of patients seeking care who were unable to obtain it during the pandemic. Close attention should be placed on the outcomes which were altered during the pandemic.

Managing Up: Approaching Mentoring From a Mentee's Perspective.

OBJECTIVE: Discuss the evolution of mentorship models in surgical training and how educating the surgical trainees with the concepts from "manage up" theory can empower them to maximize the benefits afforded by mentoring relationships. METHODS: "Manage up" theory is derived from the business world where the subordinate takes ownership of the mentoring relationship with their superior by assessing the strengths and weaknesses of both parties and applying that information in managing a productive relationship. DISCUSSION: Surgery residency programs implement a variety of structured and unstructured mentorship programs to promote mentoring relationships and to encourage professional development. Mentees in successful mentoring relationships demonstrate characteristics and skills that residency programs can promote through formal training. Components of "manage up" theory can be applied by surgical trainees in approaching their mentors and in managing their mentor-mentee relationships. CONCLUSIONS: The benefits gained from a successful mentoring relationship for both the mentor and the mentee depend on active roles played by both parties. Strong evidence supports the need for educating mentees through formal curricula to empower them to assume an active role in their mentoring relationships.

Quantifying disease-specific symptom improvement after parathyroid and thyroid surgery using patient-reported outcome measures.

BACKGROUND: Patient-reported outcome measures for parathyroid and thyroid disease (PROMPT) is a 30-question, previously validated, survey assessing symptoms on a scale from 0 to 100. Using PROMPT, we aimed to assess symptom improvement for patients undergoing thyroidectomy and parathyroidectomy. METHODS: Single-center prospective study in which PROMPT was used to assess symptom improvement in patients undergoing parathyroidectomy or thyroidectomy. A postoperative assessment was performed approximately 6 months after surgery and compared to its baseline preoperative assessment. RESULTS: A total of 144 patients completed both assessments (71 parathyroidectomy, 73 thyroidectomy). Parathyroidectomy patients demonstrated significant improvements in all hyperparathyroidism domains (38.2-28.3, p < 0.001) regardless of preoperative calcium and parathyroid hormone levels. Thyroidectomy patients experienced improvement in their compressive symptoms (25.6-16.5, p < 0.001). CONCLUSIONS: PROMPT objectively demonstrates the clinical effectiveness of parathyroidectomy and thyroidectomy in alleviating subjective patient symptoms. PROMPT offers promising use as a standardized metric to assess quality of life improvement within endocrine surgery.

Time to Completion of Breast Cancer Treatment and Survival.

BACKGROUND: Breast cancer treatment delays are common. This study was designed to examine the association between the time interval from time of diagnosis to completion of all acute breast cancer treatment modalities (surgery, chemotherapy, and radiation therapy) and survival. METHODS: A retrospective analysis was performed utilizing data from the National Cancer Database (NCDB) to determine an association between the duration of time from diagnosis to completing all acute breast cancer treatment (surgery, chemotherapy, and radiation therapy) and survival. Secondary survival analysis evaluated whether delay in treatment completion varied by differences in tumor receptor status. RESULTS: We analyzed 2010 NCDB data of stage I-III breast cancer patients. A subset of 28,284 patients received all three modalities (surgery, chemotherapy, and radiation) as their acute treatment. Median follow-up was 5.8 years. Cox proportional hazards model identified a cut-off showing the risk of delaying completion of all treatment beyond 38 weeks was associated with a decrease in overall survival (hazard ratio [HR] 1.21). This decrease in survival was significant regardless of the major tumor receptor status: triple-negative (HR 1.188, 95% confidence interval [CI] 1.06-1.34), estrogen receptor (ER)+/progesterone receptor (PR)+/human epidermal growth factor receptor 2 (HER2)- (HR 1.22, 95% CI 1.09-1.36), ER-/PR-/HER2+ (HR 1.29, 95% CI 1.004-1.67), and ER+/PR+/HER2+ (HR 1.32, 95% CI 1.01-1.72). CONCLUSION: Efforts to improve the efficiency of multimodality breast cancer treatment and reduce treatment delays should be a priority to optimize breast cancer patient outcomes.

Analysis of a thyroid nodule care pathway: Opportunity to improve compliance and value of care.

BACKGROUND: Care pathways facilitate standardized, evidence-based treatment to improve outcomes and value of care. Care pathways consist of multiple nodes representing decision points. Few studies investigate care pathway compliance. We demonstrate nodal care pathway analysis by reviewing compliance with our institutional multidisciplinary, evidence-based care pathways on the treatment of thyroid nodule to generate strategies to increase care pathway adherence and value of care. METHODS: Patients undergoing workup and treatment of structural thyroid disease between January 2018 and June 2018 were included in a retrospective analysis of enterprise-wide compliance with the following 3 care pathway nodes: (1) laboratory testing: only patients with abnormal results from thyroid-stimulating hormone testing should have T3/T4 measured. (2) imaging: neck computed tomography, magnetic resonance imaging, and positron emission tomography ordered for the workup of nodules were reviewed to determine clinical appropriateness. (3) operative treatment: the first 200 thyroid resections conducted in 2018 were reviewed to determine whether the indication and extent of the operation complied with the care pathway. Medicare fee schedules were used for financial calculations. RESULTS: Care pathway nonadherence occurred in 48% of the thyroid-stimulating hormone studies and 38% of the imaging studies obtained, with annual costs exceeding $120,000. Substantial care pathway nonadherence occurred in 3% of nodule-related operations. CONCLUSION: Care pathway nodal analysis can identify areas of care pathway nonadherence. Nodal analysis should be considered for care pathway maintenance and generation of strategies of quality improvement.

Validation of a novel patient-reported outcome measure for parathyroid and thyroid disease (PROMPT).

BACKGROUND: Patient-reported outcome measures are being used increasingly to assess disease severity and response to surgery. The purpose of this study was to create and validate a patient-reported outcome measure for symptoms of thyroid enlargement and hyperparathyroidism, 2 conditions where the presence of preoperative symptoms and response to surgery is often questioned. METHODS: A questionnaire reviewing common symptoms was developed from a literature review and expert opinion. Internal validity, reliability, and initial responsiveness to surgery were evaluated. RESULTS: Patient-Reported Outcome Measure for Parathyroid and Thyroid Disease (PROMPT) consists of 30 items: 10 compressive items and 20 hyperparathyroidism items; we evaluated 302 surveys collected over 10 months. PROMPT showed high internal consistency for compressive and hyperparathyroid constructs (Cronbach's α 0.84 and 0.95). Constructs were scored from 0-100, with greater scores corresponding to increased severity of symptoms. Preoperatively, patients with a goiter demonstrated greater compressive scores compared with other thyroid patients and hyperparathyroid patients (goiter, 47.5; nodule/other, 38.4; hyperparathyroid, 29.8; P < .0001). PROMPT demonstrated high test-retest reliability with acceptable intraclass correlation coefficients for both compressive score and hyperparathyroid score (0.840 and 0.646). Hyperparathyroid scores improved 2 weeks after (48.6 postop, 44.0 preop, P = .0470). CONCLUSION: We validated a novel measure for symptoms of hyperparathyroidism and goiter. PROMPT demonstrates high internal consistency, test-retest reliability, and preliminary analysis, which suggests that it is sensitive to change after surgery.