Health-Related Quality of Life in Patients with Low-Risk Differentiated Thyroid Cancer: A Systematic Review Examining the Extent of Thyroidectomy.

Background: Total thyroidectomy (TT) and hemithyroidectomy (HT) are acceptable surgical options for the treatment of low-risk differentiated thyroid cancer (DTC). While previous data suggest similar disease-free and disease-specific survival regardless of initial surgical treatment, the effect of the extent of surgery on health-related quality of life (HRQOL) is less clear. This systematic review aimed to examine HRQOL in low-risk DTC survivors after TT compared with HT. Methods: A search of PubMed, CINAHL, Cochrane, PsycINFO, and Scopus databases was conducted to identify studies published between January 1, 2011, and December 31, 2022, that assessed HRQOL predominantly in patients with low-risk DTC who underwent open thyroid surgery. Covidence™ software was used to apply the inclusion criteria, and a validated instrument was used to assess study quality. Results: Sixteen of the 1402 identified studies were included: 5 prospective and 11 retrospective cohort studies. The majority of included studies were of good quality (n = 14) and were from Asia and the Middle East (n = 11). Overall, six studies concluded that HT led to a better HRQOL than TT, two concluded that HT only resulted in better HRQOL compared with TT with central neck dissection (CND), and two concluded HT resulted in better short-term HRQOL that dissipated by 6 months postoperatively. The HRQOL domains found across all studies to be most consistently improved after HT included physical health, psychological/emotional, and social function. Factors found to be associated with HRQOL in more than one study included age, stage, and marital status. Conclusion: Differences in HRQOL after HT and TT tended to favor HT particularly when measured <6 months after surgery or when compared with TT with CND. Additional prospective and ideally randomized data are needed to fully determine the impact of the extent of surgery on HRQOL in patients with low-risk thyroid cancer.

Identifying Intraoperative Behaviors Associated With Surgical Resident Teachability.

OBJECTIVE: The resident-attending dyad influences the intraoperative training of surgery residents. To better understand the role of trainees within the dyad, we hypothesized there is a measurable concept of "teachability," a combination of the trainee's observed skills and behaviors with their performance. This study aims to define teachability and identify discrete intraoperative behaviors that contribute to this concept. We posit that residents who are active learners as demonstrated by asking questions, proposing next steps, and initiating purposeful actions have higher teachability. DESIGN, SETTING, PARTICIPANTS: Previously recorded videos from 26 laparoscopic inguinal hernia repairs performed by two PGY-5 general surgery residents at a Midwest tertiary care center were qualitatively reviewed for intraoperative behaviors. A summative content analysis identified behaviors associated with increased teachability and improved operative performance assessment scores. RESULTS: Average frequencies of intraoperative behaviors for resident 1 and 2 (R1 and R2) were not significantly different, although R2 asked more medical knowledge and technical questions. While the rate of attending feedback was similar for both residents (x=3.82 vs 3.40, p=0.646), R1 consistently incorporated feedback (x=2.27 vs 0.40, p=0.001) whereas R2 needed frequent prompting (x=2.45 vs 1.55, p=0.239). R1 scored higher in all but one operative performance assessment category, including overall performance (x=4.17 vs 2.93, p=0.007), but R2 had a larger magnitude of overall improvement (+1 vs +2). CONCLUSIONS: Teachability is a dynamic component of the resident-attending dyad. While intraoperative active learning behaviors do not appear to be associated with teachability, asking questions may increase the magnitude of improvement in performance. Most importantly, the ability to incorporate intraoperative feedback in real time seems to be a critical aspect of teachability and warrants further research.

Enhancing Surgical Teaching Effectiveness: A Needs Assessment Study Using a Modified Delphi Process.

INTRODUCTION: As methods of measuring surgical resident competency become more defined, how can faculty know that they are effectively guiding residents toward increasing entrustment? The goal of this study was to use a systematic process to identify effective teaching behaviors, understand discrepancies between learner and teacher perception of behaviors, and provide an insight into areas for improvement in surgical teaching. MATERIALS AND METHODS: A modified Delphi process was used to create a list of critical teaching behaviors for surgical resident education in four domains: Operating Room, Clinic, Inpatient Rounds, and Didactics. Round One surveyed residents and faculty to identify critical teaching behaviors. In Rounds Two and Three, stakeholders narrowed the list to five behaviors in each domain. A needs assessment survey was created and used to identify (1) areas for improvement in residency education and (2) differences in perception of teaching behavior use between faculty and residents. RESULTS: Eighty one faculty and 56 residents in the Department of Surgery completed the survey. All teaching behaviors in the Operating Room, Clinic, and Rounds domains had a significant difference in response distribution between residents and faculty. Except in Didactics, residents perceived that teaching behaviors were performed less often by attending surgeons than was reported by the faculty members. CONCLUSIONS: A modified Delphi process is an effective way to create a needs assessment survey relating to how surgical education is delivered. Future steps will involve directed interventions aimed at improving the use of certain surgical teaching behaviors in our department.

Surgery Acting Internship Individual Learning Plans: Fostering Mentorship in the COVID-19 Era.

OBJECTIVE: Mentorship facilitates successful matching for surgical specialties. A formal mentorship plan may counteract restricted mentorship opportunities due to the COVID-19 pandemic. DESIGN: We surveyed medical students applying to surgery specialties who participated in our formalized mentorship program (MF) and those of a prior cohort who were informally mentored (MI). Epistemic Network Analysis was used to model qualitative responses. SETTING: University of Wisconsin School of Medicine and Public Health. PARTICIPANTS: Fourth-year medical students who matched into ACGME-accredited surgical specialties. RESULTS: MF students (n = 12) met with their mentors more frequently than MI students (n = 13; p = 0.03). Both groups received career guidance, letters of recommendation and application preparation. However, the MI cohort reported greater psychological and emotional support whereas the MF cohort reported more assistance with skills development. CONCLUSIONS: A formalized mentorship program fostered successful mentoring relationships despite limitations from the COVID-19 pandemic.

What is the experience of our patients with transient hypoparathyroidism after total thyroidectomy?

BACKGROUND: We sought to better understand the experience of patients with transient hypoparathyroidism using patient interviews and quality of life surveys. METHODS: This is a prospective analysis of 62 patients after total thyroidectomy at a high-volume institution. Semistructured patient interviews and quality of life surveys were conducted preoperatively and postoperatively at 2 weeks, 6 weeks, 6 months, and 1 year and compared based on postoperative parathyroid hormone levels. RESULTS: Postoperative parathyroid hormone levels were <10 pg/mL in 32% of patients (n = 20), 10 to 20 pg/mL in 19% (n = 12), and >20 pg/mL in 48% (n = 30). Hypocalcemic symptoms at 2 weeks were reported in 28 of 55 patients (51%), but patients felt "well prepared" and reported it "wasn't a big deal." If symptoms persisted at 6 weeks, they became more bothersome. At 6 months and 1 year, patients reported calcium supplementation prevented most symptoms and did not interfere with daily activities. Quality of life as measured by the European Organization for Research and Treatment of Cancer and the 12-Item Short Form Survey demonstrated a slight improvement at 1 year postoperatively regardless of parathyroid hormone level. CONCLUSION: Early postoperative transient hypoparathyroidism is common but when appropriately managed did not have a substantial negative impact on the overall quality of life.

Surgical Trainees' Sense of Responsibility for Patient Outcomes: A Multi-institutional Appraisal.

BACKGROUND: Surgeon educators express concern about trainees' sense of patient ownership. We aimed to compare resident and faculty perceptions on residents' sense of personal responsibility for patient outcomes and to correlate patient ownership with resident and residency characteristics. METHODS: An anonymous electronic questionnaire surveyed 373 residents and 390 faculty at seven academic surgery residencies across the United States. We modified an established psychological ownership scale to measure patient ownership among surgical trainees. RESULTS: Respondents included 123 residents and 136 faculty (response rate 33% and 35%, respectively). Overall, 78.0% of faculty agreed that residents took personal responsibility for patient outcomes, but only 26.4% thought residents felt a similar or higher degree of patient ownership compared with themselves. Faculty underestimated the proportion of residents that routinely checked on their patients when off-duty (36.8 versus 92.6%, P < 0.001). Higher means on the patient ownership scale correlated with female sex (5.9 versus. 5.5 for males, P = 0.009), advanced post graduate year level (5.3, 5.5, 5.7, 5.8, 6.1, for post graduate year 1-5, respectively, P = 0.02), and the sense that patient outcomes affected the resident respondent's mood (5.8 versus 4.8 for those whose mood was not affected, P < 0.001). In addition, trainees who perceived better resident camaraderie (P = 0.004), faculty mentorship (P < 0.001), and that their program provided appropriate autonomy (P = 0.03) felt greater responsibility for patient outcomes. CONCLUSIONS: Most faculty agree that residents assume personal responsibility for patient outcomes, but many still underestimate residents' sense of patient ownership. Certain modifiable aspects of residency culture including camaraderie, mentorship, and autonomy are associated with patient ownership among trainees.

Assessing American Thyroid Association Guidelines for Total Thyroidectomy in Graves' Disease.

BACKGROUND: The American Thyroid Association (ATA) issued specific preoperative preparatory guidelines for patients undergoing thyroidectomy for treatment of Graves' disease. Our goal is to determine if compliance with these guidelines is associated with better outcomes. METHODS: A retrospective review of a prospectively maintained database identified 228 patients with Graves' disease who underwent total thyroidectomy between August 2007 and May 2015. Patients treated in compliance with ATA guidelines were compared with those not in full compliance with the current preparatory guidelines. RESULTS: At the time of surgery, 52% of all patients followed ATA guidelines. Patients who were prepped per ATA guidelines had fewer episodes of intraoperative tachycardia (0.3 versus 4.5, P = 0.04) but had no difference in peak systolic blood pressure or in number of episodes of systolic blood pressure > 180 mmHg. ATA prepped and nonprepped patients had similar mean operating room time and length of stay. ATA prepped and nonprepped patients had similar complication rates, including transient hypocalcemia (30.4% versus 25.5%, P = 0.45), prolonged hypoparathyroidism (0.98% versus 4.3%, P = 0.15), hoarse voice (10.8% versus 7.5%, P = 0.42), permanent recurrent laryngeal nerve paralysis (2.9% versus 2.1%, P = 0.71), and hematoma (2.9% versus 0%, P = 0.09). CONCLUSIONS: Our data suggest that compliance with ATA guidelines for thyroidectomy preparation is not essential for a successful surgical outcome. Although preparation per the guidelines decreased the frequency of intraoperative tachycardia, it did not impact intraoperative hypertension, operating room time, or postoperative complications.

Evaluation of Thyroid Nodules.

This is a brief overview of the initial workup of patients with thyroid nodules. Most nodules are incidentally discovered, benign, and do not require surgery, but the clinician's job is to determine which nodules are concerning and what the appropriate workup should be. Ultrasound examination is the best imaging modality to evaluation thyroid nodules and, when biopsy is indicated, fine needle aspiration is the proper technique to sample thyroid nodules.

Dr Google: The readability and accuracy of patient education websites for Graves' disease treatment.

BACKGROUND: National guidelines emphasize the importance of incorporating patient preferences into the recommendations for the treatment of Graves' disease. Many patients use the Internet to obtain health information, and search results can affect their treatment decisions. This study compares the readability and accuracy of patient-oriented online resources for the treatment of Graves' disease by website affiliation and treatment modality. METHODS: A systematic Internet search was used to identify the top websites discussing the treatment of Graves' disease. Readability was measured using 5 standardized tests. Accuracy was assessed by a blinded, expert panel, which scored the accuracy of sites on a scale of 1 to 5. Mean readability and accuracy scores were compared among website affiliations and treatment modalities. RESULTS: We identified 13 unique websites, including 2 academic, 2 government, 5 nonprofit, and 4 private sites. There was a difference in both readability (mean 13.2, range 9.1-15.7, P = .003) and accuracy (mean 4.04, range 2.75-4.50, P = .019) based on website affiliation. Government sites (mean readability 11.1) were easier to read than academic (14.3, P < .01), nonprofit (13.9, P < .01), and private sites (13.5, P < .05). Academic sites (mean accuracy 4.50) were more accurate than private sites (3.56, P < .05). CONCLUSION: Online patient resources for the treatment of Graves' disease are written at an inappropriately high reading level. Academic sites contain both the most accurate and the most difficult to read information. Private sites represented the majority of our top results but contained the least accurate information.

Encapsulated follicular variant of papillary thyroid cancer: are these tumors really benign?

BACKGROUND: Recent studies suggest that the encapsulated form of follicular variant of papillary thyroid cancer (eFVPTC) behaves more similarly to benign lesions and can be treated with thyroid lobectomy alone instead of total thyroidectomy. To distinguish aggressive cancers from more benign lesions more clearly, the objective of this study was to determine if the eFVPTC behaves less aggressively than the nonencapsulated variant (neFVPTC). METHODS: A prospectively collected endocrine surgery database in our institution was reviewed for all patients with FVPTC on surgical pathology from 1999 to 2012. Samples were rereviewed to determine if the tumor was eFVPTC or neFVPTC, which were correlated with patient outcomes. RESULTS: Of the 68 patients, 59 (87%) had eFVPTC and 9 (13%) had neFVPTC. The mean age was 48 y and 63% were female. Fifty-four of 64 patients (84%) who had a total thyroidectomy received radioactive iodine. The eFVPTC group had lower rates of cervical LN involvement (5% versus 22%, P = 0.2504). The median follow-up time was 3 y (0-13 y) and only two patients had recurrence, one with eFVPTC and one with neFVPTC. None of the patients had distant metastasis or died of their disease. CONCLUSIONS: eFVPTCs appear to have a lower rate of cervical lymph node metastases compared with neFVPTCs, but recurrent disease may be seen in both subtypes. These findings suggest eFVPTC can be managed more conservatively.

GAUGING THE EXTENT OF THYROIDECTOMY FOR INDETERMINATE THYROID NODULES: AN ONCOLOGIC PERSPECTIVE.

OBJECTIVE: Increasing emphasis is being placed on appropriateness of care and avoidance of over- and under-treatment. Indeterminate thyroid nodules (ITNs) present a particular risk for this problem because cancer found via diagnostic lobectomy (DL) often requires a completion thyroidectomy (CT). However, initial total thyroidectomy (TT) for benign ITN results in lifelong thyroid hormone replacement. We sought to measure the accuracy and factors associated with the extent of initial thyroidectomy for ITN. METHODS: We queried a single institution thyroid surgery database for all adult patients undergoing an initial operation for ITN. Multivariate logistic regression identified factors associated with either oncologic under- or overtreatment at initial operation. RESULTS: There were 639 patients with ITN. The median age was 52 (range, 18 to 93) years, 78.4% were female, and final pathology revealed a cancer >1 cm in 24.7%. The most common cytology was follicular neoplasm (45.1%) followed by Hürthle cell neoplasm (20.2%). CT or initial oncologic undertreatment was required in 58 patients (9.3%). Excluding those with goiters, 19.0% were treated with TT for benign final pathology. Multivariate analysis failed to identify any factor that independently predicted the need for CT. Female gender was associated with TT in benign disease (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.0 to 4.5; P = .05). Age >45 years predicted correct initial use of DL (OR, 2.6; 95% CI, 1.2 to 5.7; P = .02). Suspicious for papillary thyroid carcinoma (OR, 5.7; 95% CI, 2.1 to 15.3; P<.01) and frozen section (OR, 9.7; 95% CI, 2.5 to 38.6; P<.01) were associated with oncologically appropriate initial TT. The highest frequency of CT occurred in patients with follicular lesion of undetermined significance (11.6%). TT for benign final pathology occurred most frequently in patients with a Hürthle cell neoplasm (24.8%). CONCLUSION: In patients with ITN, nearly 30% received an inappropriate extent of initial thyroidectomy from an oncologic standpoint. Tools to pre-operatively identify both benign and malignant disease can assist in the complex decision making to gauge the proper extent of initial surgery for ITN. ABBREVIATIONS: ATA = American Thyroid Association AUS = atypia of undetermined significance CI = confidence interval CT = completion thyroidectomy FLUS = follicular lesion of undetermined significance ITN = indeterminate thyroid nodule OR = odds ratio PTC = papillary thyroid carcinoma TT = total thyroidectomy.

The changing pattern of diagnosing primary hyperparathyroidism in young patients.

BACKGROUND: Primary hyperparathyroidism (PHPT) is increasing in adults but rarely reported in young patients where routine blood work is obtained more judiciously. We aim to determine how PHPT is currently being diagnosed in young patients and examine surgical outcomes. METHOD: We retrospectively analyzed PHPT patients 24 years of age or less who underwent parathyroidectomy from 2001 to 2014. Patients were divided into 2 time periods: 2001 to 2007 (A) and 2008 to 2014 (B). Incidentally, diagnosed patients lacked objective symptoms of PHPT and had no family history. RESULTS: Forty young patients met inclusion criteria: 16 in group A and 24 in group B. Those in group A compared with group B had similar mean age, preoperative calcium, and parathyroid hormone (P > .05). Incidental diagnosis was more common in the contemporary group (42% vs 25%, P = .001). CONCLUSIONS: Current diagnosis of PHPT in young patients is increasingly incidental. This trend may be attributed to the more liberal use of labs in younger patients.

Confidence Crisis Among General Surgery Residents: A Systematic Review and Qualitative Discourse Analysis.

Importance: In the surgical community, there is concern that general surgery residents are choosing subspecialty training in large numbers because of a crisis in confidence at the end of training. Confidence is an essential quality of surgeons, and recent studies have attempted to quantify and measure it in graduating general surgery residents. Objectives: To systematically review the quality of evidence provided and to critically analyze the language used to describe the findings using quantitative methods. Evidence Review: A systematic review of the PubMed indexed literature on general surgery resident confidence was performed in March 2015. A summative table of each study's hypothesis, definition of confidence, quality using the Medical Education Research Study Quality Instrument, influence using Web of Science citations, results, and conclusions was created, and qualitative coding was applied to identify emerging themes. No date restrictions were used in the search. Findings: Fifteen survey studies have been performed that measure confidence or readiness to practice. Although 5 studies had neutral or positive conclusions, most studies reported low confidence in general surgery graduates. There are conflicting data about definitions of confidence. The relationships between confidence, autonomy, and competence are varied and complex. Comparisons with the past are frequent. Conclusions and Relevance: Confidence is difficult to define and measure. Despite limitations, survey studies are used to shape discourse and influence policies. Social and cultural factors influence self-efficacy, and focusing on operative volume and autonomy alone may not address all of the reasons that some residents express concerns about readiness to practice.

Thyroidectomy for Graves' disease in children: Indications and complications.

BACKGROUND: The utilization of thyroidectomy for Graves' disease remains controversial; we aim to evaluate the indications for and complications of thyroidectomy for Graves' in children. METHODS: A retrospective analysis was performed on all Graves' patients who underwent thyroidectomy from 2009 to 2013 at a high volume academic center. Pediatric patients were <18years old, and a comparative analysis of indications for surgery and complications was performed. RESULTS: 167 patients underwent thyroidectomy: 31 pediatric patients and 136 adults. Failure of antithyroid medications was the indication for surgery in 55% of the children vs 36% of adults (p=0.05). Mean duration of medications prior to surgery was similar. No children had failed RAI therapy prior to surgery, but 12.5% of the adult population had (p=0.04). Surgical outcomes were similar. CONCLUSION: Clinicians may be more likely to refer children who fail medical treatment to surgery over RAI. Thyroidectomy at a high volume hospital should be discussed as a treatment option for children with Graves'.

When patients call their surgeon's office: an opportunity to improve the quality of surgical care and prevent readmissions.

BACKGROUND: Little is known about care coordination and communication with outpatient endocrine surgery patients. This study evaluated phone calls between office nurses and surgical patients to identify common issues addressed and their effect on patient care. METHODS: Qualitative analysis of preoperative and postoperative phone conversations between office nurses and endocrine surgery patients. RESULTS: We identified 183 thyroidectomy patients with 38% contacting our office before surgery and 54% within 30 days after surgery. Common reasons for preoperative calls included questions about preoperative evaluation (21%), medications (18%), and insurance and/or work paperwork (12%). Postoperatively, common topics included medications (23%), laboratory results (23%), and concerns about wounds (12%). Nursing staff prevented unnecessary readmission in 7 patients (4%) whereas appropriately referring 16 (9%) for early evaluation. CONCLUSIONS: Patients frequently contact their surgeons before and after endocrine surgery cases. Our findings suggest several areas for improving communication with patients.

Substernal goiter: when is a sternotomy required?

BACKGROUND: Sternotomy for substernal goiters (SSG) is associated with greater morbidity than a cervical approach to thyroidectomy. We sought to identify predictors for sternotomy as a surgical approach for the removal of SSG and analyzed the preoperative and postoperative characteristics of patients with SSG compared with those with large goiters contained entirely within the neck or a cervical goiter. METHODS: A retrospective review of a surgical database was performed. We included patients with large (>100 g) thyroids or SSG, regardless of size. Between 1995 and 2013, 220 patients met these criteria. Comparisons were made between patients who had an SSG and patients who had a cervical goiter with particular focus on those who required sternotomy. RESULTS: Of the 220 patients, 127 patients (58%) had SSG, of whom 7 (5.5%) required sternotomy. All patients who underwent sternotomy underwent preoperative computed tomography scanning and were more likely to have preoperative symptoms of chest pressure and voice complaints and have extension of the thyroid gland below the aortic arch. Sternotomy took an average of 2 hours longer than a cervical incision, was associated with significantly more blood loss (600 versus 190 mL, P = 0.04), and a longer length of stay (3.1 versus 1.8 d, P = 0.03) than cervical thyroidectomy. CONCLUSIONS: Sternotomy for SSG is rare. All patients necessitating sternotomy had extension below the aortic arch and were more likely to present complaining of chest pressure and voice issues.

Faculty evaluations of resident medical knowledge: can they be used to predict American Board of Surgery In-Training Examination performance?

BACKGROUND: The American Board of Surgery In-Training Examination (ABSITE) offers annual assessment of resident medical knowledge. We sought to determine if ongoing end-of-rotation evaluations by faculty of residents' medical knowledge correlate with ABSITE performance. METHODS: Retrospective cross-sectional study was conducted over 3 years at 2 institutions. Faculty rated residents' clinical knowledge as part of a global summative evaluation. The intraclass correlation coefficient and convergent validity between faculty evaluations and ABSITE performance were assessed. RESULTS: A total of 1,562 faculty evaluations were completed for about 147 residents. There was poor agreement among faculty for each resident, with intraclass correlation coefficients of less than 0.2. Spearman's correlation coefficient was calculated for evaluations and ABSITE scores and were found to be weakly correlative at one institution and not correlated at all at the other. Finally, evaluations across quartiles of resident ABSITE scores were examined and show no correlation. CONCLUSION: Faculty evaluations of resident medical knowledge correlate poorly with resident ABSITE performance, and should not be used as an ongoing predictive tool.

Is intraoperative parathyroid hormone testing in patients with renal insufficiency undergoing parathyroidectomy for primary hyperparathyroidism accurate?

BACKGROUND: Our aim was to determine whether chronic renal insufficiency (CRI) impacted intraoperative parathyroid hormone (ioPTH) monitoring during parathyroidectomy. We hypothesized that ioPTH monitoring in patients with CRI would show slower decline, but would still accurately predict cure. METHODS: A retrospective review was conducted of patients with primary hyperparathyroidism who underwent curative single adenoma parathyroidectomy. The percentage of patients reaching 50% decline of ioPTH was compared between groups stratified by renal function. RESULTS: Between 2000 and 2013, 950 patients met inclusion criteria. At 5 minutes, 66% of patients with CRI met curative criteria versus 77% of normal renal function patients (P = .001). At 10 minutes, 89% vs 92% met criteria (P = .073), and by 15 minutes, the gap narrowed to 95% vs 97% (P = .142), respectively. CONCLUSIONS: Despite CRI patients with primary hyperparathyroidism having slower ioPTH decline after curative parathyroidectomy, 95% met ioPTH criteria by 15 minutes. Standard ioPTH criteria can be used with CRI patients.

Clinical and socioeconomic factors influence treatment decisions in Graves' disease.

BACKGROUND: Definitive treatment of Graves' disease includes radioactive iodine (RAI) and thyroidectomy, but utilization varies. We hypothesize that, in addition to clinical reasons, there are socioeconomic factors that influence whether a patient undergoes thyroidectomy or RAI. METHODS: Patients treated for Graves' disease between August 2007 and September 2013 at our university hospital were included. A comparative analysis of clinical and socioeconomic factors was completed. RESULTS: Of 427 patients, 300 (70 %) underwent RAI, whereas 127 (30 %) underwent surgery. Multiple factors were associated with surgery: younger age (mean 36 vs. 41 years, p < 0.01), female gender (33 vs. 19 % males, p = 0.01), black race (56 vs. 28 % nonblack, p < 0.01), Medicaid or uninsured (43 vs. 27 % private insurance or Medicare, p < 0.01), ophthalmopathy (38 vs. 26 %, p < 0.01), goiter (35 vs. 23 %, p < 0.01), and lowest quartile of median household income (38 vs. 27 % upper three quartiles, p = 0.03). Thyroidectomy increased annually, with 52 % undergoing surgery during the final year (p < 0.01). Adjusting for confounding, younger age (odds ratio [OR] 1.04; 95 % confidence interval [CI] 1.02, 1.05), female gender (OR 2.06; 95 % CI 1.06, 4.01), ophthalmopathy (OR 2.35; 95 % CI 1.40, 3.96), and later year of treatment (OR 1.66; 95 % CI 1.41, 1.95) remained significantly associated with surgery. CONCLUSIONS: Surgery has now become the primary treatment modality of choice for Graves' disease at our institution. Clinical factors are the main drivers behind treatment choice, but patients with lower SES are more likely to have clinical features best treated with surgery, underlying the importance of improving access to quality surgical care for all patients.