A Dwindling Matter: An Analysis of Medicare Reimbursement for Endocrine Surgery Procedures from 2000-23.

OBJECTIVE: To evaluate Medicare reimbursement trends for endocrine surgeries from 2000-23. BACKGROUND: As the population ages, demand for endocrine surgeries is expected to increase. Understanding reimbursement trends is essential to ensure the financial sustainability of endocrine surgery. METHODS: Data were extracted from Medicare Inpatient and Outpatient Hospital datasets, National Summary, and Physician Fee Look-up Files for nine common thyroid, parathyroid and adrenal surgeries. Data were adjusted for inflation. Descriptive statistics, compound annual growth rate (CAGR), and linear regression models were built to evaluate practice and reimbursement trends. RESULTS: From 2000-23, there was a 63.8% increase in endocrine surgery volume. However, inflation-adjusted average procedure reimbursements decreased by 43.2% from $1709 to $972 (CAGR -2.4%), which is the largest decrease for any surgical subspecialty reported in the published literature. At the current CAGR, the average estimated reimbursement is projected to decrease to $868 by 2030 (P<0.001). Average facility reimbursements for inpatient and outpatient hospitalizations increased. However, substantial practice pattern shifts in the study period led to decreased overall facility reimbursements, with a $17.9 million decrease in total inpatient reimbursements between 2016-21 that was only partially offset by a $3.2 million increase in outpatient hospital reimbursements. CONCLUSION: Medicare procedure reimbursements for endocrine surgeries have been outpaced by inflation, with large decreases since 2000. Concurrent changes in practice patterns have also resulted in markedly fewer inpatient stays leading to lower total facility reimbursements. Our data raise concern over the financial sustainability of the endocrine surgery field as the demand for endocrine surgery procedures increases.

Guideline Adherence and Practice Patterns in the Management of Medullary Thyroid Cancer.

INTRODUCTION: Little is known about nationwide practice patterns for the management medullary thyroid cancer (MTC) in relation to the 2015 American Thyroid Association guidelines and their impact on survival. METHODS: Using the Surveillance, Epidemiology, and End Results Program database (2000-2018), MTC treatment patterns were evaluated in terms of adherence to the 2015 American Thyroid Association guidelines across three time periods (2000-2009, 2010-2015, and 2016-2018). Outcomes of interest were guideline concordance, treatment utilization trends, disease-specific survival (DSS), and overall survival (OS). RESULTS: A total of 3332 patients with MTC were identified. Of which, 53.8%, 33.2%, and 11.4% of patients had localized, regional, and distant disease, respectively. In patients with locoregional disease, the rate of guideline-concordant surgery improved over time from 63.0% in 2000-2009 to 76.0% in 2016-2018 (P < 0.001). Guideline-concordant care was associated with increased OS (HR = 1.85, 95% CI: 1.42-2.43, P < 0.001) in patients with localized disease and increased DSS (HR = 1.65, 95% CI: 1.01-2.54, P < 0.001) and OS (HR = 1.89, 95% CI: 1.35-2.58, P < 0.001) in patients with regional disease. The median OS and DSS in patients with distant disease were 31 and 55 mo, respectively, and the rate of chemotherapy use rose from 21.6% to 39.2% (P = 0.003). CONCLUSIONS: The rate of guideline-concordant surgery for locoregional MTC increased after guideline publication in 2015, with an observed prolongment in OS and DSS. Chemotherapy use among patients with distant disease has increased over time, but their prognosis remains variable.

Salvage Cryoablation for Local Recurrences of Thyroid Cancer Inseparable from the Trachea and Neurovascular Structures.

PURPOSE: To demonstrate safety, feasibility, and effectiveness of cryoablation of recurrent papillary thyroid cancer ineligible for reoperation because of scarring, eligible for focal ablation as defined within 2015 American Thyroid Association guideline sections C16 and C17. MATERIALS AND METHODS: With multidisciplinary consensus, cryoablation was performed with curative intent for 15 tumors in 10 patients between January 2019 and July 2021. Demographics, procedural details, and serial postprocedural imaging findings were analyzed. RESULTS: The mean age was 72.5 years (range, 57-88 years), and 80% of the patients were women. The tumors (mean size, 16 mm ± 6; range, 9-29 mm) received 1 session of cryoablation with 100% technical success. The mean and median postcryoablation tumor volumetric involution rates were 88% and 99%, respectively, with 9 (60%) of 15 tumors involuting completely or down to the scar and 6 (40%) involuting partially at the end of the study period. Tumor size did not increase after cryoablation (0% local progression rate). All tumors abutted the trachea, skin, and/or vascular structures, and hydrodissection failed in all cases because of scarring. The major adverse event rate was 20% (3/15), with 2 cases of voice change and 1 case of Horner syndrome; all resolved at 6 months with no permanent sequelae. No vascular, tracheal, dermal, or infectious adverse events occurred during a mean follow-up of 242 days (range, 114-627 days). One patient died at 386 days after cryoablation because of unrelated cholangiocarcinoma. CONCLUSIONS: Cryoablation of local recurrences of papillary thyroid cancer abutting the trachea and/or neurovascular structures in the setting of hydrodissection failure because of scarring yielded a mean volumetric involution of 88%, primary efficacy of 60%, and objective response rate of 100% with no local recurrences or permanent complications during a mean follow-up of 242 days. The secondary efficacy and longer-term outcomes remain forthcoming.

Severe Hypocalcemia After Thyroidectomy: An Analysis of 7366 Patients.

OBJECTIVE: The aim of the study was to determine severe hypocalcemia rate following thyroidectomy and factors associated with its occurrence. BACKGROUND: Hypocalcemia is the most common complication after thyroidectomy. Severe post-thyroidectomy hypocalcemia can be life-threatening; data on this specific complication are scarce. METHODS: Patients who underwent thyroidectomy in the American College of Surgeons-National Surgical Quality Improvement Program thyroidectomy-targeted database (2016-2017) were abstracted. A severe hypocalcemic event was defined as hypocalcemia requiring intravenous calcium, emergent clinic/hospital visit, or a readmission for hypocalcemia. Multivariable regression was used to identify factors independently associated with occurrence of severe hypocalcemia. RESULTS: Severe hypocalcemia occurred in 5.8% (n = 428) of 7366 thyroidectomy patients, with 83.2% necessitating intravenous calcium treatment. Rate of severe hypocalcemia varied by diagnosis and procedure (0.5% for subtotal thyroidectomy to 12.5% for thyroidectomy involving neck dissections). Overall, 38.3% of severe hypocalcemic events occurred after discharge; in this subset, 59.1% experienced severe hypocalcemia despite being discharged with calcium and vitamin D. Severe hypocalcemia patients had higher rates of recurrent laryngeal nerve injury (13.4% vs 6.6%), unplanned reoperations (4.4% vs 1.3%), and longer hospital stay (30.4% vs 6.2% ≥3 days (all P < 0.01). After multivariate adjustment, severe hypocalcemia was associated with multiple factors including Graves disease [odds ratio (OR) = 2.06], lateral neck dissections (OR: 3.10), and unexpected reoperations (OR = 3.55); all P values less than 0.01. CONCLUSIONS: Severe hypocalcemia and suboptimal hypocalcemia management after thyroidectomy are common. Patients who experienced severe hypocalcemia had higher rates of nerve injury and unexpected reoperations, indicating surgical complexity and provider inexperience. More biochemical surveillance particularly a parathyroid hormone-based protocol, fine-tuned supplementation, and selective referral could reduce occurrence of this morbid complication.

Postoperative Surveillance in Older Adults With T1N0M0 Low-risk Papillary Thyroid Cancer.

BACKGROUND: The frequency and cost of postoperative surveillance for older adults (>65 y) with T1N0M0 low-risk papillary thyroid cancer (PTC) have not been well studied. METHODS: Using the SEER-Medicare (2006-2013) database, frequency and cost of surveillance concordant with American Thyroid Association (ATA) guidelines (defined as an office visit, ≥1 thyroglobulin measurement, and ultrasound 6- to 24-month postoperatively) were analyzed for the overall cohort of single-surgery T1N0M0 low-risk PTC, stratified by lobectomy versus total thyroidectomy. RESULTS: Majority of 2097 patients in the study were white (86.7%) and female (77.5%). Median age and tumor size were 72 y (interquartile range 68-76) and 0.6 cm (interquartile range 0.3-1.1 cm), respectively; 72.9% of patients underwent total thyroidectomy. Approximately 77.5% of patients had a postoperative surveillance visit; however, only 15.9% of patients received ATA-concordant surveillance. Patients who underwent total thyroidectomy as compared with lobectomy were more likely to undergo surveillance testing, thyroglobulin (61.7% versus 24.8%) and ultrasound (37.5% versus 29.2%) (all P < 0.01), and receive ATA-concordant surveillance (18.5% versus 9.0%, P < 0.001). Total surveillance cost during the study period was $621,099. Diagnostic radioactive iodine, ablation, and advanced imaging (such as positron emission tomography scans) accounted for 55.5% of costs ($344,692), whereas ATA-concordant care accounted for 44.5% of costs. After multivariate adjustment, patients who underwent total thyroidectomy as compared with lobectomy were twice as likely to receive ATA-concordant surveillance (adjusted odds ratio 2.0, 95% confidence interval: 1.5-2.8, P < 0.001). CONCLUSIONS: Majority of older adults with T1N0M0 low-risk PTC do not receive ATA-concordant surveillance; discordant care was costly. Total thyroidectomy was the strongest predictor of receiving ATA-concordant care.

Unplanned reoperations after vascular surgery.

OBJECTIVE: Existing literature on unplanned reoperation (UR) after vascular surgery is limited. The frequency of 30-day UR and its association with other adverse outcomes was analyzed. METHODS: Patients who underwent vascular procedures in the American College of Surgeons National Surgical Quality Improvement Program (2012) were abstracted. UR, captured by a distinct variable now available in the data set, and its association with complications, readmissions, mortality, and failure to rescue (FTR) were analyzed using bivariate and multivariate methods. RESULTS: Among 35,106 patients, 3545 URs were performed on 2874 patients. The overall UR rate was 10.1%. Among patients who underwent URs, approximately 80.4%, 15.8%, and 3.8% had one, two, and three or more reoperations, respectively; 39.4% of URs occurred after initial discharge. Median time to UR was 7 days but varied by procedure. Procedures with the highest UR rates were embolectomy (18.2%), abdominal bypass (14.4%), and open procedures for peripheral vascular disease (13.8%). Common indications for UR were hemorrhage, graft failure or infection, thromboembolic events, and wound complications. Patients with URs had higher rates of subsequent complications (49.9% vs 19.9%; P < .001), readmission (41.8% vs 7.0%; P < .001), and mortality (8.0% vs 2.5%; P < .001) than those not undergoing URs. FTR was more likely among patients who had a UR (13.6% vs 9.3%; P < .001); this varied within procedure groups. After multivariate adjustment, UR was independently associated with mortality in an incremental fashion (for one UR: adjusted odds ratio, 2.0; 95% confidence interval, 1.7-2.5; for two or more URs: adjusted odds ratio, 3.1; 95% confidence interval, 2.2-4.2). CONCLUSIONS: URs within 30 days are frequent among patients undergoing vascular surgery and are associated with worse outcomes, including mortality and FTR.

The significance of atrial fibrillation in patients aged ≥ 55 years undergoing abdominal surgery.

BACKGROUND: The Institute of Medicine has identified atrial fibrillation (AF) among national priorities for research. We examine the incidence of AF and its association with outcomes of patients undergoing abdominal surgery. METHODS: Patients ≥ 55 years who underwent abdominal surgery captured in a State Inpatient Database, 2008-2010. Three patient groups were created: (1) No diagnosis of AF (No-AF), (2) Pre-existing AF (Hx-AF), and (3) New-onset AF (New-AF). Outcomes were analysed using bivariate and multivariate methods. RESULTS: AF incidence among 116,477 patients was 8.6 %; approximately one in four patients aged ≥ 85 years had AF. 26.6 % of patients with AF experienced New-AF; the latter was more likely after pancreas resection (43.0 %) and least common after cholecystectomy (20.2 %). Complications (71.1, 47.3 vs. 26.5 %), mortality (8.0, 5.7 vs. 2.0 %), longer hospital stays (8.8, 5.6 vs. 3.8 days), and higher hospitalization cost ($41,427, $26,312 vs. $18,310) were more likely in patients with AF (New-AF, Hx-AF vs. No-AF respectively) (all p < 0.001). After adjustment, New-AF was among factors independently associated with mortality (OR 2.0, 95 % CI 1.7-2.4, p < 0.001); each case of New-AF increased cost of care by $4,482. Factors independently associated with New-AF included ≥ 1 complication, electrolyte imbalance, and procedure-type. Whereas 2.0 % of patients who developed New-AF were admitted from a long-term care facility, 23.8 % of patients with New-AF were discharged to a long-term care facility. CONCLUSIONS: AF is common among abdominal surgery patients, particularly the elderly; New-AF is a serious, potentially avoidable adverse event that could serve as an important quality of care indicator for abdominal surgery patients.

Patient-Reported Outcome Measures Within a National Multispecialty Surgical Quality Improvement Program.

Importance: Patient-reported outcome measures (PROMs) are increasingly recognized for their ability to promote patient-centered care, but concerted health information technology (HIT)-enabled PROM implementations have yet to be achieved for national surgical quality improvement. Objective: To evaluate the feasibility of collecting PROMs within a national surgical quality improvement program. Design, Setting, and Participants: This was a pragmatic implementation cohort study conducted from February 2020 to March 2023. Hospitals in the US participating in the American College of Surgeons National Surgical Quality Improvement Program and their patients were included in this analysis. Exposures: Strategies to increase PROM collection rates were identified using the Institute for Healthcare Improvement (IHI) Framework for Spread and the Consolidated Framework for Implementation Research and operationalized with the IHI Model for Improvement's Plan-Do-Study-Act (PDSA) cycles. Main Outcomes and Measures: The primary goal was to accrue more than 30 hospitals and achieve collection rates of 30% or greater in the first 3 years. Logistic regression was used to identify hospital-level factors associated with achieving collection rates of 30% or greater and to identify patient-level factors associated with response to PROMs. Results: At project close, 65 hospitals administered PROMs to 130 365 patients (median [IQR] age, 60.1 [46.2-70.0] years; 77 369 female [59.4%]). Fifteen PDSA cycles were conducted to facilitate implementation, primarily targeting the Consolidated Framework for Implementation Research domains of Inner Setting (ie, HIT platform) and Individuals (ie, patients). The target collection rate was exceeded in quarter 3 (2022). Fifty-eight hospitals (89.2%) achieved collection rates of 30% or greater, and 9 (13.8%) achieved collection rates of 50% or greater. The median (IQR) maximum hospital-level collection rate was 40.7% (34.6%-46.7%). The greatest increases in collection rates occurred when both email and short-message service text messaging were used, communications to patients were personalized with their surgeon's and hospital's information, and the number of reminders increased from 2 to 5. No identifiable hospital characteristic was associated with achieving the target collection rate. Patient age and insurance status contributed to nonresponse. Conclusions and Relevance: Results of this cohort study suggest that the large-scale electronic collection of PROMs into a national multispecialty surgical registry was feasible. Findings suggest that HIT platform functionality and earning patient trust were the keys to success; although, iterative opportunities to increase collection rates and address nonresponse remain. Future work to drive continuous surgical quality improvement with PROMs are ongoing.

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.

Medullary thyroid cancer with RET V804M mutation: more indolent than expected?

BACKGROUND: Significant genotype-phenotype variability among multiple endocrine neoplasia type 2A patients with a RET V804M mutation has been reported. METHODS: Patients with a RET V804M mutation treated at a single center were identified (January 1996-December 2020). The baseline characteristics, operative details, pathology, biochemical, and long-term data were analyzed. RESULTS: There were 79 patients; none developed pheochromocytoma or hyperparathyroidism or died in the study period. The mean age was 41.5 years (range = 1.0-81.0 years); 46.8% were men. Of 68 surgical patients, 53 (77.9%) underwent total thyroidectomy and 15 (22.1%) underwent total thyroidectomy with central neck dissection with or without lateral neck dissection. Twenty-four patients had elevated preoperative calcitonin, of whom 12 underwent total thyroidectomy (median = 7.5; range = 5.0-237.0 pg/mL), 10 underwent total thyroidectomy + central neck dissection (median = 27.6; range = 5.1-147.0 pg/mL), and 2 underwent total thyroidectomy + central neck dissection + lateral neck dissection (median = 3182.0; range = 361.0-6003.0 pg/mL). Pathology was benign (27.9%), papillary thyroid cancer alone (1.5%), C-cell hyperplasia (23.5%), and medullary thyroid cancer (47.1%; median tumor size = 3.0 mm). Three patients had elevated calcitonin postoperatively (median follow-up time = 60.0 months). In adjusted modeling, a preoperative calcitonin >5 pg/mL was associated with having medullary thyroid cancer on final pathology (odds ratio = 13.3; 95% confidence interval, 3.2-56.3; P < .001). CONCLUSION: In this large United States cohort of surgical patients with a RET V804M mutation, most had indolent disease and were without classic multiple endocrine neoplasia type 2A features. Calcitonin >5 pg/mL may serve as a meaningful value to guide surveillance and timing of surgery.

Medullary thyroid microcarcinoma: a population-level analysis of 310 patients.

BACKGROUND: Medullary thyroid microcarcinomas (microMTCs) are medullary thyroid carcinomas (MTCs) that measure ≤1 cm in size for which there is a paucity of data on incidence, characteristics, and clinical significance. METHODS: Patients who had a diagnosis of microMTC were abstracted from the Surveillance, Epidemiology, and End Results database (1988-2007). The data were analyzed using chi-square tests, t tests, and log-rank tests; multivariate logistic regression was used to identify factors that were associated independently with lymph node metastases. Tests for diagnostic accuracy, including likelihood ratio tests and post-test probability tests, were computed to evaluate the size-specific likelihood of developing lymph node metastases among patients with microMTC. RESULTS: In total, 310 patients had microMTC; its incidence increased during the study period (P(trend) = .033), and microMTC as a proportion of all MTCs increased by 39%. The mean tumor size was 5.7 mm. Thirty-one percent of tumors were multifocal, and 7.8% had extrathyroid extension. Lymph node metastases occurred in nearly 37% of patients who had any lymph nodes removed (65 of 176 patients). Nearly 20% of patients had regional disease, and 5% had distant metastases. The overall 10-year survival rates for patients with localized, regional, and distant disease stages were 96%, 87%, and 50%, respectively (P < .001). After adjustment, extrathyroid extension (odds ratio [OR], 41.9; P < .001) and tumor size (OR, 1.2; P = .008) retained an independent association with lymph node metastases. MTCs that measured ≤5 mm were associated with a probability of lymph node metastases of approximately 23%, and the probability increased for patients who had tumors >5 mm. CONCLUSIONS: The current results indicated that microMTCs have significant rates of poor prognostic features known to impact the survival of patients with MTC. These microcarcinomas are an important clinical entity that requires comprehensive evaluation and surgical management.

Insular thyroid cancer: a population-level analysis of patient characteristics and predictors of survival.

BACKGROUND: Insular thyroid cancer (ITC) is an uncommon, poorly differentiated thyroid malignancy. To date, there have been no population-level studies of the characteristics and outcomes of patients with ITC. METHODS: The authors used the Surveillance, Epidemiology, and End Results (SEER) database from 1999 to 2007 to compare the characteristics and prognosis of patients who had ITC with those of patients who had well differentiated thyroid cancer (WDTC) and anaplastic thyroid cancer (ATC). Data analyses were performed using chi-square tests, analyses of variance, log-rank tests, and multivariate regression. RESULTS: There were 114 patients with ITC, 497 patients with ATC, and 34,021 patients with WDTC. The mean age of patients with ITC was 62.1 years versus 48.1 years for patients with WDTC and 69.5 years for patients with ATC (P < .001). The mean ITC tumor size was 5.9 cm versus 2.0 cm for WDTC and 6.4 cm for ATC (P < .001). Distant metastasis occurred in 31% of patients with ITC versus 4.5% of patients with WDTC and 59.1% of patients with ATC (P < .001). Insular histology was associated independently with compromised survival in the overall study sample (hazard ratio [HR], 2.1; P = .001). The 5-year disease-specific survival rate was 72.6%, 97.2%, and 9.1% for patients with ITC, WDTC, and ATC, respectively (P < .001). After adjustment, radioiodine therapy (HR, 0.15; 95% confidence interval, 0.04-0.5) and distant metastasis (HR, 15.3; 95% confidence interval, 3.7-62.2) were associated independently with ITC survival. The mortality rate was 7.1%, 12%, and 54.3% for patients with localized, regional, and distant stage ITC, respectively (P < .001). For patients who had ITC with distant metastasis, thyroidectomy and radioiodine therapy independently improved survival. CONCLUSIONS: ITC is rare and aggressive. The current results indicated that its treatment should include total thyroidectomy and high-dose radioiodine for all patients and neck dissections for patients with lymph node disease. Early diagnosis and close surveillance are essential in the management of patients with ITC.

Aggressive variants of papillary thyroid cancer: incidence, characteristics and predictors of survival among 43,738 patients.

BACKGROUND: The diffuse sclerosing (DSV) and tall cell (TCV) variants are considered aggressive subtypes of papillary thyroid cancer (PTC) for which data are limited. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database (1988-2008) was used to compare the incidence and clinical/pathologic characteristics of DSV and TCV with classic PTC. Prognostic factors associated with survival were analyzed by chi-square test, analysis of variance, log rank test, and Cox multivariate regression. RESULTS: There were 261 DSV, 573 TCV, and 42,904 PTC patients. Compared to a 60.8% increase in classic PTC incidence, DSV and TCV incidence increased by 126% (P (trend) = 0.052) and 158% (P (trend) = 0.002), respectively. Aggressive variants were associated with higher rates of extrathyroidal extension, multifocality, and nodal and distant metastasis (all P < 0.001) compared to classic PTC. Nodal metastasis was more likely with DSV (72.2% vs. 66.8% TCV vs. 56.3% PTC, P < 0.001); distant metastasis was most common with TCV (11.1% vs. 7.3% DSV vs. 4.3% PTC, P < 0.001). After adjustment, DSV [hazard ratio (HR) 1.8, P = 0.007] and TCV (HR 1.9, P < 0.001) histologies were associated with significantly reduced survival (5-year overall: 87.5% DSV, 80.6% TCV vs. 93.5% PTC, P < 0.001). Tumor size independently predicted worse prognosis for TCV (HR 1.29, P < 0.001) but not DSV patients. Thyroid surgery and radioiodine improved survival of DSV and TCV patients (all P < 0.05). Patients with aggressive variants who received external-beam radiotherapy did not experience improved survival. CONCLUSIONS: DSV and TCV are rare, increasing in incidence, and have a worse prognosis than classic PTC. Patients with these variants should be treated aggressively with thyroidectomy and radioiodine, regardless of tumor size.

Simultaneous medullary and differentiated thyroid cancer: a population-level analysis of an increasingly common entity.

BACKGROUND: Simultaneous medullary thyroid carcinoma (MTC) and differentiated thyroid carcinoma (DTC) is a rare entity. This is the first population-level analysis of the characteristics and outcomes of simultaneous MTC/DTC. METHODS: In the Surveillance, Epidemiology, and End Results (SEER) database (1988-2008), patients with simultaneous MTC/DTC were retrospectively compared with those with MTC alone using χ(2), ANOVA, log-rank tests, Cox multivariate regression, and Kaplan-Meier analyses. RESULTS: A total of 162 patients had simultaneous MTC/DTC; 1,699 had MTC alone. MTC was diagnosed first in 67.9 % of simultaneous MTC/DTC cases. Simultaneous MTC/DTC increased from 2.7 % of all MTCs in 1988-1997 to 12.3 % in 2003-2008. Compared with MTC alone, simultaneous MTC/DTC had smaller mean MTC tumor size (2.9 vs. 2.2 cm; p = 0.005) and lower rates of MTC extrathyroidal extension (25.4 vs. 16.8 %; p = 0.015) and distant metastases (15.7 vs. 9.3 %; p = 0.032). Patients diagnosed with DTC first had smaller mean MTC tumor sizes (p = 0.01), whereas patients diagnosed with MTC first had tumor sizes similar to those of MTC alone. Compared with MTC alone, patients with simultaneous MTC/DTC were more likely to receive thyroidectomy (84.7 vs. 93.2 %; p = 0.003) and radioisotopes (4.4 vs. 25 %; p < 0.001). On Kaplan-Meier analysis, disease-specific survival rates were higher for simultaneous MTC/DTC than for MTC alone (10-year survival rates 87 vs. 81 %; p = 0.056). CONCLUSIONS: Simultaneous MTC/DTC is diagnosed earlier in tumor development than MTC alone, with a trend toward better prognosis. This entity likely represents a primary tumor with an incidental pathologic finding of a second malignancy. Each malignancy should be treated according to its respective stage and current guidelines.

The resident as surgeon: an analysis of ACS-NSQIP.

BACKGROUND: Data on the characteristics and outcomes of patients operated on by surgical residents are limited. METHODS: Using ACS-NSQIP (2005-2008), characteristics and outcomes of patients who underwent cholecystectomy, appendectomy, or inguinal hernia repair by a resident (R) without an attending scrubbed in the operating room, a scrubbed attending with resident (AR), or an attending without resident (A) were pooled and compared. Data analyses involved χ(2), ANOVA, and multivariate regression. RESULTS: The R group performed <1% of ACS-NSQIP cases; the 10 most common procedures represented 69.1% of cases. There were 912 cases of cholecystectomy, appendectomy, or inguinal hernia repair performed by R. Compared with A/AR patients, R patients were more likely to have inpatient (42.6%, 48.9% versus 64.8%), emergent (28.6%, 30.8% versus 35.5%) , and open procedures (27.0%, 29.4% versus 28.9%) (all P < 0.001). In unadjusted analyses, R patients had higher complication rates (4.8% versus 4.4%, 3.4%, P < 0.001) and longer operating time (64.4 min versus 62.2 min, 44.7 min, P < 0.001) than AR/A patients respectively. After risk adjustment, a resident operating without an attending scrubbed in the operating room was not independently associated with increased complications risk (odds ratio 1.2, 95% CI: 0.8-1.8, P = 0.2). Compared with A/AR patients, there was a 1-min difference in adjusted operating time for patients who underwent surgery by R (P < 0.001). CONCLUSIONS: In ACS-NSQIP, a resident rarely performs surgery without an attending scrubbed in the operating room; surgical attendings appear to exercise good judgment in determining the appropriate extent of resident supervision in the operating room without compromising patient outcomes.

Role of Thyroid RFA in the Treatment of Autonomously Functioning Thyroid Nodules.

Autonomously functioning thyroid nodules (AFTN) are a common cause of hyperthyroid symptoms. While hemithyroidectomy or radioactive iodine ablation have historically been used to treat AFTNs, percutaneous thyroid radiofrequency ablation (RFA) is emerging as a promising option for outpatient therapy. The technique is compared to medical therapy, radioactive iodine therapy, and surgery, with an emphasis on technical differences in the ablation procedure for AFTN vs other benign thyroid nodules.

Outcomes of concurrent parathyroidectomy and thyroidectomy among CESQIP surgeons.

BACKGROUND: Studies comparing endocrine-specific outcomes following parathyroidectomy (PTx) versus concurrent parathyroidectomy and thyroidectomy (PTx + Tx) are few. METHODS: 10,019 patients were selected from the Collaborative Endocrine Surgery Quality Improvement Program (2014-2019). Baseline characteristics and short-term (≤30 days) outcomes for PTx + Tx vs PTx patients were compared using bivariate and multivariable methods. RESULTS: PTx + Tx patients were more likely to experience clinical hypoparathyroidism (6.7% vs 0.5%, p < 0.001), recurrent laryngeal nerve transection, (0.4% vs 0.1%, p = 0.002) and hematoma requiring evacuation (1.0% vs 0.2%, p < 0.001). Readmissions and ED visits for hypocalcemia were more frequent after PTx + Tx vs PTx. Concurrent surgery was associated with an 8-fold increase in risk of short-term complications (Odds Ratio (OR): 8.0, 95% Confidence Interval (CI): 5.7-11.1, p < 0.001). CONCLUSIONS: Patients undergoing PTx + Tx have increased rates of postoperative complications, ED visits, and readmissions compared to patients undergoing parathyroidectomy alone. These findings could help guide surgeon-patient discussions on the risks of concurrent surgery.

Patient-Reported Outcomes Following Total Thyroidectomy for Graves' Disease.

Background: Graves' disease accounts for ∼80% of all cases of hyperthyroidism and is associated with significant morbidity and decreased quality of life. Understanding the association of total thyroidectomy with patient-reported quality-of-life and thyroid-specific symptoms is critical to shared decision-making and high-quality care. We estimate the change in patient-reported outcomes (PROs) before and after surgery for patients with Graves' disease to inform the expectations of patients and their physicians. Methods: PROs using the MD Anderson Symptom Inventory (MDASI) validated questionnaire were collected prospectively from adult patients with Graves' disease from January 1, 2015, to November 20, 2020, on a longitudinal basis. Survey responses were categorized as before surgery (≤120 days), short term after surgery (<30 days; ST), and long term after surgery (≥30 days; LT). Negative binomial regression was used to estimate the association of select covariates with PROs. Results: Eighty-five patients with Graves' disease were included. The majority were female (83.5%); 47.1% were non-Hispanic white and 35.3% were non-Hispanic black. The median thyrotropin (TSH) value before surgery was 0.05, which increased to 0.82 in ST and 1.57 in LT. In bivariate analysis, the Total Symptom Burden Score, a composite of all patient-reported burden, significantly reduced shortly after surgery (before surgery mean of 56.88 vs. ST 39.60, p < 0.001), demonstrating improvement in PROs. Furthermore, both the Thyroid Symptoms Score, including patient-reported thermoregulation, palpitations, and dysphagia, and the Quality-of-Life Symptom Score improved in ST and LT (thyroid symptoms, before surgery 13.88 vs. ST 8.62 and LT 7.29; quality of life, before surgery 16.16 vs. ST 9.14 and LT 10.04, all p < 0.05). After multivariate adjustment, the patient-reported burden in the Thyroid Symptom Score and the Quality-of-Life Symptom Score exhibited reduction in ST (thyroid symptoms, rate ratio [RR] 0.55, confidence interval [CI]: 0.42-0.72; quality of life, RR 0.57, CI: 0.40-0.81) and LT (thyroid symptoms, RR 0.59, CI: 0.44-0.79; quality of Life, RR 0.43, CI: 0.28-0.65). Conclusions: Quality of life and thyroid-specific symptoms of Graves' patients improved significantly from their baseline before surgery to both shortly after and longer after surgery. This work can be used to guide clinicians and patients with Graves' disease on the expected outcomes following total thyroidectomy.

Scaling and spreading the electronic capture of patient-reported outcomes using a national surgical quality improvement programme: a feasibility study protocol.

INTRODUCTION: Patient-reported outcomes (PROs) are important for research, patient care and quality assessment; however, large-scale collection among the US surgical patient population has been limited. A structured implementation and dissemination programme focused on electronic PRO collection could improve the use of PROs data to improve surgical care. This study aims to (1) evaluate the feasibility of PRO collection among a larger volume of surgical patients through the stepwise implementation of PRO collection processes in a sample of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) hospitals; (2) identify best practices and barriers to PRO collection through qualitative study of participating hospitals and patients; and (3) evaluate the utility of PROs at detecting differences in the quality of care among surgical patients. METHODS AND ANALYSIS: ACS NSQIP-participating hospitals are being recruited, and patients at participating hospitals who undergo elective surgical procedures receive invitations via e-mail or short message service 'text'message to complete PROs after surgery. Validated PRO measures which evaluate physical and mental health-related quality of life, pain, fatigue, physical function and shared decision-making were selected. The scalability of PRO collection will be assessed by site enrolment, patient accrual and response rates. Qualitative interviews and focus groups will be performed with patients and hospital personnel to identify best practices and barriers to successful enrolment and PRO collection. Multivariable hierarchical regression models will be used to evaluate the distinctness of PROs from clinical outcomes captured in ACS NSQIP and the ability of PROs to detect differences in hospital performance. ETHICS AND DISSEMINATION: This study was reviewed by the Advarra Institutional Review Board (IRB) and deemed to be exempt from IRB oversight. Findings will be disseminated through peer-reviewed manuscripts, reports and presentations.