Trends in Operative Case Logs of Chief Residents in Surgery by Sex and Race: A 5 - Year National Study.

OBJECTIVES: A recent study of 21 institutions noted significant differences between number of cases reported during general surgery residency by trainees who are Underrepresented in Medicine (URiM) versus trainees who are not Underrepresented in Medicine (non-URiM). This study also identified differences between female residents and male residents. We partnered with the Accreditation Council for Graduate Medical Education to examine case logs reported from all accredited general surgery programs in the United States. This is the first time this data has been examined nationally. METHODS: We examined total case logs submitted by graduating residents between 2017 and 2022. Group differences in mean reported case logs were examined using paired t- tests for female versus male and URiM versus non- URiM overall case numbers. RESULTS: A total of 6,458 residents submitted case logs from 319 accredited programs. Eight-hundred and fifty-four (13%) were URiM and 5,604 (87%) were non-URiM. Over the 5-year study period, URM residents submitted 1096.95 (SD +/- 160.57) major cases versus 1115.96 (+/- 160.53) for non-URiM residents (difference =19 cases, P=0.001). Case logs were submitted by 3,833 (60.1%) male residents and 2,625 (39.9%) female residents over the five-year study period. Male residents reported 1128.56 (SD +/- 168.32) cases versus 1091.38 (+/- 145.98) cases reported by females (difference=37.18, P<0.001). When looking at Surgeon Chief and Teaching Assistant cases, there was no significant difference noted between cases submitted by URiM versus non- URiM residents. However, male residents reported significantly more in both categories than their female peers (P<0.001). CONCLUSIONS: Overall, URiM residents submitted fewer cases in the five- year study period than their non-URiM peers. The gap in submitted cases between male and female residents was more pronounced, with male residents submitting significantly more cases than their female counterparts. This finding was consistent and statistically significant throughout the entire study period, in most case categories, and without narrowing of difference over time. A difference of 30-40 cases can amount to 1-3 months of surgical training and is a concerning national trend deserving the attention of every training program and our governing institutions.

Key Issues in Surgical Residency Education: Recommendations of the Blue Ribbon II Committee Residency Education Subcommittee.

In September 2022, a summit was convened by the American Board of Surgery (ABS) to discuss competency-based reform in surgical education. A key output of that summit was the recommendation that the prior work of the Blue Ribbon I Committee convened 20 years earlier be revived. With leadership from the American College of Surgeons (ACS) and the American Surgical Association (ASA) , the Blue Ribbon Committee (BRC) II was subsequently convened. This paper describes the output of the Residency Education Subcommittee of the BRC II Committee. The Subcommittee organized its work around prioritized themes including curriculum, assessment, and transition to practice. Top recommendations, time-based action steps, potential barriers, and required resources were detailed and vetted through group discussion, broader Committee review and critique, and subsequent refinement. Primary concluding emphases included transitioning to a competency-based training model, facilitating dynamically capable curricular reform emphasizing the digital transformation of surgical care, using predictive analytic assessment strategies to optimize training effectiveness and efficiency, and creating mentorship strategies to govern the transition from training to independent practice in an outcomes-accountable fashion. It was recognized that coordinated efforts across existing organizational structures will be required, informed by dataset integration strategies that meaningfully measure educational and related patient outcomes.

Treatment of Hypercalcemic Hyperparathyroidism After Kidney Transplantation Is Associated With Improved Allograft Survival.

BACKGROUND: Hyperparathyroidism (HPT) and malignancy are the most common causes of hypercalcemia. Among kidney transplant (KT) recipients, hypercalcemia is mostly caused by tertiary HPT. Persistent tertiary HPT after KT is associated with allograft failure. Previous studies on managing tHPT were subjected to survivor treatment selection bias; as such, the impact of tertiary HPT treatment on allograft function remained unclear. We aim to assess the association between hypercalcemic tertiary HPT treatment and kidney allograft survival. MATERIALS AND METHODS: We identified 280 KT recipients (2015-2019) with elevated post-KT adjusted serum calcium and parathyroid hormone (PTH). KT recipients were characterized by treatment: cinacalcet, parathyroidectomy, or no treatment. Time-varying Cox regression with delayed entry at the time of first elevated post-KT calcium was conducted, and death-censored and all-cause allograft failure were compared by treatment groups. RESULTS: Of the 280 recipients with tHPT, 49 underwent PTx, and 98 received cinacalcet. The median time from KT to first elevated calcium was 1 month (IQR: 0-4). The median time from first elevated calcium to receiving cinacalcet and parathyroidectomy was 0(IQR: 0-3) and 13(IQR: 8-23) months, respectively. KT recipients with no treatment had shorter dialysis vintage (P = .017) and lower PTH at KT (P = .002), later onset of hypercalcemia post-KT (P < .001). Treatment with PTx (adjusted hazard ratio (aHR) = 0.18, 95%CI 0.04-0.76, P = .02) or cinacalcet (aHR = 0.14, 95%CI 0.004-0.47, P = .002) was associated with lower risk of death-censored allograft failure. Moreover, receipt of PTx (aHR = 0.28, 95%CI 0.12-0.66, P < .001) or cinacalcet (aHR = 0.38, 95%CI 0.22-0.66, P < .001) was associated with lower risk of all-cause allograft failure. CONCLUSIONS: This study demonstrates that treatment of hypercalcemic tertiary HPT post-KT is associated with improved allograft survival. Although these findings are not specific to hypercalcemia of malignancy, they do demonstrate the negative impact of hypercalcemic tertiary HPT on kidney function. Hypercalcemic HPT should be screened and aggressively treated post-KT.

An Evaluation of Health Literacy in Patients Undergoing Surgical Evaluation for Thyroid Disease.

INTRODUCTION: Health literacy (HL) is the ability to comprehend and apply health information to make informed health-care decisions. Poor HL results in the inability to provide informed consent, medication noncompliance, inconsistent follow-up, and delayed seeking of care. Data about HL in endocrine surgery is currently lacking. In this study, we aimed to evaluate the HL of patients with thyroid disease and identify risk factors for limited HL. METHODS: We evaluated a total of 172 patients with thyroid disease in a single endocrine surgery clinic. HL was determined by the Brief Health Literacy Screening Tool, a validated HL screening questionnaire in which patient scores correlate to limited, marginal, or adequate HL. Demographic data including age, sex, race, diagnosis, employment status, and median annual income were obtained. Analysis of variance, t-test, and Chi-square test were used to compare HL between and within each demographic domain. P < 0.05 was considered significant. RESULTS: Of the 172 patients, 77% had adequate HL, 16% had marginal HL, and 7% had limited HL. Patients with higher education exhibited greater HL (P < 0.001). Ninety-three percent of patients with college/postgraduate degree had adequate HL, while of those with some college only 79% had adequate HL and of those with high school or less only 48.6% had adequate HL. There was minimal variation among age, sex, race, diagnosis, employment status, or income. CONCLUSIONS: Most patients with thyroid diseases from the endocrine surgery clinic at our institution have adequate HL. Limited education is a risk factor for low HL.

Feasibility of an Online Patient-Driven International Parathyroid Registry.

INTRODUCTION: Traditional parathyroid registries are labor-intensive and do not always capture long-term follow-up data. This study aimed to develop a patient-driven international parathyroid registry and leverage community connections to improve patient-centered care for hyperparathyroidism. METHODS: An anonymous voluntary online survey was developed using Qualtrics and posted in an international patient and advocate-run social media group affiliated with over 11,700 members. The survey was developed from a literature review, expert opinion, and discussion with the social media group managers. It consists of seven sections: patient demographics, past medical history, preoperative symptoms, laboratory evaluation, preoperative imaging studies, operative findings, and operative outcomes. RESULTS: From July 30, 2022, to October 1, 2022, 89 complete responses were received. Participants were from 12 countries, mostly (82.0%) from the United States across 31 states. Most participants were female (91.4%), White (96.7%) with a mean (±standard deviation) age of 58 ± 12 y. The most common preoperative symptoms were bone or joint pain (84.3%) and neuropsychiatric symptoms: including fatigue (82.0%), brain fog (79.8%), memory loss (79.8%), and difficulty with concentration (75.3%). The median (interquartile range) length from symptom onset to diagnosis was 40.0 (6.8-100.5) mo. Seventy-one percent of participants had elevated preoperative serum calcium, and 73.2% had elevated preoperative parathyroid hormone. All participants obtained preoperative imaging studies (88.4% ultrasound, 86.0% sestabimi scan, and 45.3% computed tomography). Among them, 48.8% of participants received two, and 34.9% had three imaging studies. The median (interquartile range) time from diagnosis to surgical intervention was 3 (2-9) mo. Twenty-two percent of participants traveled to different cities for surgical intervention. Forty-seven percent of participants underwent outpatient parathyroidectomy. Eighty-four percent of participants reported improved symptoms after parathyroidectomy, 12.4% required oral calcium supplementation for more than 6 mo, 32.6% experienced transient hoarseness after parathyroidectomy, and 14.6% required reoperation after initial parathyroidectomy. CONCLUSIONS: This international online parathyroid registry provides a valuable collection of patient-entered clinical outcomes. The high number of responses over 10 wk demonstrates that participants were willing to be involved in research on their disease. The creation of this registry allows global participation and is feasible for future studies in hyperparathyroidism.

Evaluating Patients' Health Literacy to Improve Thyroid Pathology Reports.

INTRODUCTION: As our growing population demonstrates a significant increase in the incidence of thyroid cancer, so does patient access to their medical records. Poor health literacy and understanding of disease severity, underscores the importance of effective and accessible patient-doctor communication. No previous studies on patient understanding of thyroid pathology reports exist; therefore, we sought to characterize health literacy in this population. METHODS: Using a modified Delphi technique, a 12-question multiple-choice survey regarding common pathology terms with possible definitions for each term was synthesized and administered to patients in a high-volume endocrine surgery clinic. Survey results, patient demographics, history of prior thyroid procedure (biopsy or surgery), and self-reported health literacy were collected. Data analysis included t tests, chi-squared, and multivariable linear regression using R. RESULTS: The survey was completed by 54 patients (response rate: 69.8%). On univariate analysis, White race, previous thyroid procedure, and at least a high school level education were all more likely to score higher on the survey than their counterparts (P < 0.05). On multivariable logistic regression for predicting a higher survey score, only race (est: 2.48 [95% confidence interval: 1.01-3.96]) and higher educational attainment (est: 3.98 [95% confidence interval: 2.32-5.64]) remained predictive (P < 0.05). The remaining demographic groups (age, health literacy confidence, and previous thyroid procedure) did not show a statistically significant difference. CONCLUSIONS: Overall, terms on a thyroid pathology report are poorly understood by patients. This is exacerbated by non-White race and low educational attainment. There is a need for patient-facing pathology education.

Does Graves' Disease Truly Increase the Risk of Complications After Total Thyroidectomy?

INTRODUCTION: Total thyroidectomy (TTx) has been reported to be more challenging in patients with Graves' disease, especially in those who are hyperthyroid at the time of surgery. Our aim was to compare outcomes in patients undergoing TTx for Graves' disease compared to other thyroid diseases at a large academic institution with high-volume fellowship-trained endocrine surgeons. METHODS: In our retrospective analysis from December 2015 to May 2023, patients undergoing TTx for Graves' disease were compared to those undergoing TTx for all other indications excluding advanced malignancy (poorly differentiated thyroid cancer and concomitant neck dissections). Patient demographics, biochemical values, and postoperative outcomes were compared. A subgroup analysis was performed comparing hyperthyroid to euthyroid patients at the time of surgery. RESULTS: There were 589 patients who underwent TTx, of which 227 (38.5%) had Graves' disease compared to 362 (61.5%) without. Intraoperatively in Graves' patients, nerve monitoring was used more frequently (65.6% versus 57.1%; P = 0.04) and there was a higher rate of parathyroid autotransplantation (32.0% versus 14.4%; P < 0.01). Postoperatively, transient voice hoarseness occurred less frequently (4.8% versus 13.6%; P < 0.01) and there was no difference in temporary hypocalcemia rates or hematoma rates. In our subgroup analysis, 83 (36%) of Graves' patients were hyperthyroid (thyroid-stimulating hormone < 0.45 and free T4 > 1.64) at the time of surgery and there were no differences in postoperative complications compared to those who were euthyroid. CONCLUSIONS: At a high-volume endocrine surgery center, TTx for Graves' disease can be performed safely without significant differences in postoperative outcomes. Hyperthyroid patients demonstrated no differences in postoperative outcomes.

Young and resilient: Unraveling papillary thyroid cancer outcomes in males under 40.

BACKGROUND: While males present with more adverse clinicopathologic features in papillary thyroid carcinoma (PTC), younger age has previously been shown to be a favorable prognostic factor. We examined the combined effect of male sex and young age on PTC outcomes. METHODS: We conducted a retrospective analysis of a prospectively maintained database of thyroid cancer surgery patients (2000-2020) at a single quaternary care institution. We included papillary thyroid carcinoma cases and excluded those with prior cancer-related thyroid surgery. We examined demographics, cancer stage, surgical outcomes, and complications by age and sex, analyzing groups below and above the age of 40 years. RESULTS: A total of 680 patients with PTC were included. Females constituted 68% (age ≥40 years: 44% and <40 years: 24%) and males 32% (≥40 years: 24% and <40 years: 8%). A significant difference (p < 0.001) of N1 disease distribution was found between the groups. N1a metastasis was greater in patients younger than 40 regardless of sex ((M < 40 (15%), F < 40 (15%), M ≥ 40 (12%), and F ≥ 40 (9%)). While, M < 40 had greater N1b metastasis (36%) than all other groups (M ≥ 40 (28%), F < 40 (22%), and F ≥ 40 (10%)). There was no significant difference in the distribution of T stages between groups. Groups showed no differences in 30-day outcomes, recurrence at 1 year, reoperation, mortality, nerve injury, or hypocalcemia. CONCLUSIONS: Young males with PTC face increased occurrence of nodal metastasis yet experience similar recurrence rates as their female and older counterparts. Subgroup analysis underscores the predictive role of sex and age in advanced PTC cases.

The Effects of Parathyroidectomy vs Medical Treatments for Secondary Hyperparathyroidism in Patients Undergoing Dialysis: A Meta-Analysis.

OBJECTIVE: The management of secondary hyperparathyroidism in patients undergoing dialysis is debated, with uncontrolled parathyroid hormone (PTH) levels becoming more common despite the expanded use of medical treatments like cinacalcet. This study examines the clinical benefits of parathyroidectomy vs medical treatment in reducing mortality and managing key laboratory parameters in patients undergoing dialysis. METHODS: PubMed, Embase, Cochrane, Scopus, and Web of Science databases were searched for cohort studies or randomized controlled trials published before August 18, 2023. We included studies with comparative arms, specifically medical treatment vs surgical intervention. Patients with a history of kidney transplant were excluded. Outcomes were analyzed using hazard ratios (HRs) for mortality and weighted mean differences (WMD) for laboratory parameters. RESULTS: Twenty-three studies involving 24 398 patients were analyzed. The pooled meta-analysis has shown a significant reduction in all-cause (HR, 0.47; 95% confidence interval [CI], 0.35-0.61) and cardiovascular mortality (HR, 0.58; 95% CI, 0.40-0.84) for parathyroidectomy vs medical treatments. Subgroup analysis showed that parathyroidectomy was associated with a greater reduction in mortality in patients with a PTH level over 585 pg/mL (HR, 0.37; 95% CI, 0.24-0.58). No mortality difference was found when all patients in the medical group received cinacalcet alongside standard medical treatment (HR, 1.02; 95% CI, 0.49-2.11). Parathyroidectomy also led to a larger decrease in PTH (WMD, 1078 pg/mL; 95% CI, 587-1569), calcium (WMD, 0.86 mg/dL; 95% CI, 0.43-1.28), and phosphate (WMD, 0.74 mg/dL; 95% CI, 0.32-1.16). CONCLUSION: Parathyroidectomy may offer a survival advantage compared to medical management in patients with severe secondary hyperparathyroidism.

Implementation of Entrustable Professional Activities in General Surgery: Results of a National Pilot Study.

OBJECTIVE: The ongoing complexity of general surgery training has led to an increased focus on ensuring the competence of graduating residents. Entrustable professional activities (EPAs) are units of professional practice that provide an assessment framework to drive competency-based education. The American Board of Surgery convened a group from the American College of Surgeons, Accreditation Council for Graduate Medical Education (ACGME) Surgery Review Committee, and Association of Program Directors in Surgery to develop and implement EPAs in a pilot group of residency programs across the country. The objective of this pilot study was to determine the feasibility and utility of EPAs in general surgery resident training. METHODS: 5 EPAs were chosen based on the most common procedures reported in ACGME case logs and by practicing general surgeons (right lower quadrant pain, biliary disease, inguinal hernia), along with common activities covering additional ACGME milestones (performing a consult, care of a trauma patient). Levels of entrustment assigned (1 to 5) were observation only, direct supervision, indirect supervision, unsupervised, and teaching others. Participating in site recruitment and faculty development occurred from 2017 to 2018. EPA implementation at individual residency programs began on July 1, 2018, and was completed on June 30, 2020. Each site was assigned 2 EPAs to implement and collected EPA microassessments on residents for those EPAs. The site clinical competency committees (CCC) used these microassessments to make summative entrustment decisions. Data submitted to the independent deidentified data repository every 6 months included the number of microassessments collected per resident per EPA and CCC summative entrustment decisions. RESULTS: Twenty-eight sites were selected to participate in the program and represented geographic and size variability, community, and university-based programs. Over the course of the 2-year pilot programs reported on 14 to 180 residents. Overall, 6,272 formative microassessments were collected (range, 0 to 1144 per site). Each resident had between 0 and 184 microassessments. The mean number of microassessments per resident was 5.6 (SD = 13.4) with a median of 1 [interquartile range (IQR) = 6]. There were 1,763 summative entrustment ratings assigned to 497 unique residents. The average number of observations for entrustment was 3.24 (SD 3.61) with a median of 2 (IQR 3). In general, PGY1 residents were entrusted at the level of direct supervision and PGY5 residents were entrusted at unsupervised practice or teaching others. For each EPA other than the consult EPA, the degree of entrustment reported by the CCC increased by resident level. CONCLUSIONS: These data provide evidence that widespread implementation of EPAs across general surgery programs is possible, but variable. They provide meaningful data that graduating chief residents are entrusted by their faculty to perform without supervision for several common general surgical procedures and highlight areas to target for the successful widespread implementation of EPAs.

Resolution of Secondary Hyperparathyroidism After Kidney Transplantation and the Effect on Graft Survival.

OBJECTIVE: Hyperparathyroidism (HPT) is nearly universal in patients with end-stage kidney disease. Kidney transplantation (KT) reverses HPT in many patients, but most studies have only focused on following calcium and not parathyroid hormone (PTH) levels. We sought to study the prevalence of persistent HPT post-KT at our center and its effect on graft survival. METHODS: Patients who underwent KT from January 2015 to August 2021 were included and characterized by post-KT HPT status at the most recent follow-up: resolved (achieving normal PTH post-KT) versus persistent HPT. Those with persistent HPT were further stratified by the occurrence of hypercalcemia (normocalcemic versus hypercalcemic HPT). Patient demographics, donor kidney quality, PTH and calcium levels, and allograft function were compared between groups. Multivariable logistic regression and Cox regression with propensity score matching were conducted. RESULTS: Of 1554 patients, only 390 (25.1%) patients had resolution of renal HPT post-KT with a mean (±SD) follow-up length of 40±23 months. The median (IQR) length of HPT resolution was 5 (0-16) months. Of the remaining 1164 patients with persistent HPT post-KT, 806 (69.2%) patients had high PTH and normal calcium levels, while 358 (30.8%) patients had high calcium and high PTH levels. Patients with persistent HPT had higher parathyroid hormone (PTH) at the time of KT [403 (243-659) versus 277 (163-454) pg/mL, P <0.001] and were more likely to have received cinacalcet treatment before KT (34.9% vs. 12.3%, P <0.001). Only 6.3% of patients with persistent HPT received parathyroidectomy. Multivariable logistic regression showed race, cinacalcet use pre-KT, dialysis before KT, receiving an organ from a deceased donor, high PTH, and calcium levels at KT were associated with persistent HPT post-KT. After adjusting for patient demographics and donor kidney quality by propensity score matching, persistent HPT (HR 2.5, 95% CI 1.1-5.7, P =0.033) was associated with a higher risk of allograft failure. Sub-analysis showed that both hypercalcemic HPT (HR 2.6, 95% CI 1.1-6.5, P =0.045) and normocalcemic HPT (HR 2.5, 95% CI 1.3-5.5, P =0.021) were associated with increased risk of allograft failure when compared with patients with resolved HPT. CONCLUSION: Persistent HPT is common (75%) after KT and is associated with a higher risk of allograft failure. PTH levels should be closely monitored after kidney transplantation so that patients with persistent HPT can be treated appropriately.

Association Between Surgical Indication and Outcomes for Outpatient Adrenalectomy.

INTRODUCTION: Despite a favorable risk-benefit profile, inpatient admission postoperatively for minimally invasive adrenalectomy (MIA) has remained common. Prior studies have shown that outpatient MIA was not associated with an increased 30-day complications or readmission. However, this has not been explored in-depth by adrenalectomy indication. We aimed to examine whether the safety profile of outpatient MIA varies by adrenal indication. MATERIALS AND METHODS: Clinicopathologic parameters were examined for all MIAs entered into an adrenal database at our institution from 2012 to 2021. Predictor variables included patient demographics, surgical indication, and operative time. Outcomes were 30-day emergency department visit, readmission, and complication rates between surgical indications, comparing outpatient and inpatient groups. Statistical analyses were performed using Kruskal-Wallis, Wilcoxon, Mann-Whitney, and Chi-squared tests, as appropriate. RESULTS: A total of 185 MIA patients were included. Outpatient MIA was performed in 53 patients (28.6%). Outpatient discharge post-MIA was related to both surgical indication and operative time. Pheochromocytoma (PC) patients were less likely to be discharged as an outpatient postoperatively when compared to all other indications (13.0% versus 33.8%, P = 0.007). Among all patients with operations 2-3 h in length, PC patients were less likely to be discharged home as an outpatient (10% versus 33.3%, P = 0.040). No significant differences were identified between outpatient and inpatient MIA groups for complications, emergency department visits, or readmission (P > 0.05 for all). Only six outpatient MIA patients had any complication (11.3%) and six were readmitted (11.3%). CONCLUSIONS: Outpatient MIA was demonstrated to be associated with similar, low complication and readmission rates compared to inpatient MIA, although it was used less often for patients with PC or prolonged operative times. Our study highlights potential evidence that outpatient MIA can be safely used in selected patients across all indications for adrenal surgery.

Time to Symptom Resolution After Total Thyroidectomy for Graves' Disease.

INTRODUCTION: Total thyroidectomy (TT) has been shown to be a safe and effective treatment for Graves' disease. However, the time course for improvement of symptoms has not been defined. METHODS: With an institutional review board approval, we prospectively gathered survey data of all patients (n = 79) undergoing TT for Graves' disease at a single institution from 2019 to 2021. After informed consent was obtained, patients completed surveys preoperatively and at 2 wk followed by monthly postoperative visits/phone calls. Patient demographics and survey results were collected and analyzed. Symptom recovery time was evaluated using Kaplan-Meier analysis. RESULTS: A total of 50 patients completed the survey on postoperative follow-up (response rate 63%). Average age was 38 y (range 12-80 y) and 88% of patients were female. The most common preoperative symptoms were fatigue (90%) and heat/cold intolerance (88%). Tremor (median time to resolution: 1 wk; interquartile range [IQR] 1-3), diarrhea (median 1 wk [IQR 1-3]), and palpitations (median 1 wk [IQR 1-3]) resolved the most rapidly followed by eye symptoms (median 3 wk [IQR 1-6]), heat/cold intolerance (median 3 wk [IQR 3-30]), memory deficits (median 3 wk [IQR 1-undefined]), and fatigue (median: 3 wk [IQR 1-14]). There were no significant differences in time to resolution of symptoms by gender or age (less than versus 40 y and older). Those with uncontrolled Graves' had more severe symptoms but no difference in time to resolution from the euthyroid Graves' patients. CONCLUSIONS: Many Graves' disease symptoms improve rapidly following TT, with a median time to improvement of less than 1 mo.

Getting Your Foot in the Door: Access to Surgical Care for Thyroid Disease.

INTRODUCTION: Access to specialty care can be challenging for patients, often involving multiple evaluations, laboratory tests, and referrals. To better understand the different pathways to specialty care, we examined the outcomes of patients evaluated for surgical thyroid disease at a single tertiary referral clinic. METHODS: We reviewed 691 patients seen in the endocrine surgery clinic for thyroid disease (2018-2021). Patient demographics, referral source, referral reason, and reason for not receiving an operation were collected. The number of days from referral to initial clinic visit and from initial clinic visit to an operation were also collected. The Chi-square test, the independent t-test, the Kruskal-Wallis test, the Dunn-Bonferroni post hoc test, and multiple logistic regression tests were performed using SPSS. RESULTS: The top reasons for referral were thyroid nodules (54.4%), hyperthyroidism (26.5%), and multinodular goiter (10.3%). Specialty clinic referrals came from endocrinologists (56.0%), self-referrals (15.5%), and primary care physicians (PCP; 14.4%). Self-referred patients had a shorter waiting time for an appointment than those referred by endocrinologists and PCPs. [median (IQR) (days) 12 (6-17) versus 16 (9-24) versus 16 (9-25), P < 0.001]. Overall, 450 (72.7%) patients underwent thyroid surgery. For those who underwent thyroidectomy, self-referred patients had a shorter time between initial clinic visit and the operation compared to those referred by endocrinologists and PCPs [median (IQR) (days) 2 (1-19) versus 19 (8-33) versus 16 (1-48), P < 0.001]. Patients referred for hyperthyroidism (odds ratio [OR] = 2.2, 95% confidence interval [CI] 1.3-10.5, P = 0.012 were more likely to undergo an operation than those referred for other reasons. CONCLUSIONS: Access to specialty care for thyroid disease is facilitated and optimized when self-referrals are permitted. Reducing or eliminating the requirement for a provider referral may improve patients' access.

Down the Rabbit Hole: Evaluation of Internet Information Quality in Parathyroid and Thyroid Surgery.

INTRODUCTION: Patients often discuss information obtained from Internet sources during clinic visits, which can be of variable quality and depth. We sought to review and assess information on the Internet regarding common operations within endocrine surgery. METHODS: Using Google's search engine, the top 100 websites from the search phrase "parathyroid surgery," and the top 100 websites from the phrase "thyroid surgery" were identified. Each website was evaluated for accessibility, accuracy, and completeness of information about gland hormone function, associated disease processes, and surgery itself. Results were stratified based on the website type, and bivariate analysis was performed to determine accuracy by category. Presence of author credentials, last webpage update, and presence of advertisements were also assessed. Inter-rater reliability was calculated for each variable. RESULTS: For parathyroid surgery, at least two-thirds of all websites included information about surgery, hormone function, and disease processes. For thyroid surgery, 71% of websites included procedure information, but only 52% included information about hormone function and 56% about disease processes. Less than 30% of all websites included advertisements and less than 25% listed author credentials or provided references. Academic or research-affiliated sources were most likely to have zero inaccuracies, but 44% of all websites had at least one potential inaccuracy. Inter-rater reliability achieved at least moderate agreement (>0.41) for 56% of variables. CONCLUSIONS: There is a wide array of information available to patients online, and accuracy varies based on multiple factors including the type of website. Endocrine surgeons and related practitioners must be cognizant of this fact when discussing treatment plans with patients.

Postoperative Hypocalcemia in Hyperthyroid Patients: The Parathyroids Aren't Always to Blame.

INTRODUCTION: Hypocalcemia is commonly reported after thyroidectomy and has multiple possible etiologies including: parathyroid devascularization, reactive hypoparathyroidism from relative hypercalcemia in thyrotoxicosis, and abrupt reversal of thyrotoxic osteodystrophy. In patients that are actively hyperthyroid and undergoing thyroidectomy, it is not known how many experience hypocalcemia from nonhypoparathyroidism etiologies. Therefore, our aim was to examine the relationship among thyrotoxicosis, hypocalcemia, and hypoparathyroidism. METHODS: A retrospective review was performed of prospectively-collected data from all patients undergoing thyroidectomy for hyperthyroidism by 4 surgeons from 2016 to 2020. All patients carried a diagnosis of Graves' disease or toxic multinodular goiter. Patient demographics, preoperative medications, laboratory reports, and postoperative medications were reviewed. Hypocalcemia within the first month of surgery despite a normal parathyroid hormone (PTH) level was the primary outcome of interest and was compared between patients with and without thyrotoxicosis. Secondary outcomes were duration of postoperative calcium use and the relationship between preoperative calcium supplementation and postoperative calcium supplementation. Descriptive statistics, Wilcoxon rank-sum, and chi-square tests were used for bivariate analysis, as appropriate. RESULTS: A total of 191 patients were identified, with mean age of 40.5 y (range 6-86). Most patients were female (80%) and had Graves' disease (80%). At the time of surgery, 116 (61%) had uncontrolled hyperthyroidism (thyrotoxic group, Free Thyroxine >1.64 ng/dL or Free Triiodothyronine > 4.4 ng/dL), with the remaining 75 (39%) considered euthyroid. Postoperative hypocalcemia (calcium < 8.4 mg/dL) developed in 27 (14%), while hypoparathyroidism (PTH < 12 pg/mL) was observed in 39 (26%). Thyrotoxic patients comprised a majority of those with hypocalcemia (n = 22, 81%, P = 0.01) and hypoparathyroidism immediately following surgery (n = 14, 77%, P = 0.04). However, a majority of initially hypocalcemic, thyrotoxic patients had normal PTH values within the first month after surgery (n = 17, 85%), pointing to a potential nonparathyroid etiology. On bivariate analysis, no significant relationship was found for thyrotoxic patients with initial postoperative hypocalcemia (18%) and hypoparathyroidism <1-month after surgery (29%, P = 0.29) or between 1 and 6 mo after surgery (2%, P = 0.24). Of the 19 patients in the nonhypoparathyroidism group, 17 (89%) were off all calcium supplements by 6 mo postop. CONCLUSIONS: In patients with hyperthyroidism, those in active thyrotoxicosis at time of surgery have a higher rate of postoperative hypocalcemia compared to euthyroid patients. When hypocalcemia lasts >1 mo postoperatively, data from this study suggest that hypoparathyroidism may not be the primary etiology in many of these patients, who typically require calcium supplementation no more than 6 mo postoperatively.

The Association of Socioeconomic Factors and Well-Differentiated Thyroid Cancer.

INTRODUCTION: Well-differentiated thyroid cancer (WDTC) is the most common thyroid malignancy, and the worldwide incidence is increasing. Early stage disease is curable with surgery. We hypothesized that patients who live at greater distances from health care institutions or have complicating socioeconomic barriers may present with more advanced diseases and have worse outcomes. METHODS: The National Cancer Database (NCDB) was used to identify patients who were diagnosed with WDTC between 2004 and 2018. Race, ethnicity, insurance status, income status, and distance from residence to health care clinic of diagnosis (great circle distance [GCD]) were analyzed with respect to the severity of disease at presentation (stage) and outcomes. Binary logistic regression and Cox regression were used to determine associations between socioeconomic variables and tumor stage or survival. RESULTS: The Hispanic (OR: 1.49, CI: 1.45-1.54, P < 0.001) and Asian (OR: 1.49, CI: 1.43-1.55, P < 0.001) populations had higher odds of developing an advanced disease when compared to the White population separately. Patients without insurance displayed higher odds of developing an advanced disease at diagnosis compared to those with insurance (OR: 1.39, CI: 1.31-1.47, P < 0.001). Adjusted-Cox regression analysis of survival revealed that Black patients had detrimental survival outcomes when compared to White patients (HR: 1.24, P < 0.001), and patients with private insurance had improved survival outcomes when compared to those without insurance (HR: 0.58, P < 0.001). CONCLUSIONS: Hispanic and Asian patients were found to be more likely to present with an advanced disease but also displayed greater overall survival when compared to the White population. The Black population, patients without insurance, and patients with lower income status exhibited worse survival outcomes.

Physician-Targeted Interventions Reduce Surgical Expense and Improve Value-Driven Health Outcomes.

INTRODUCTION: Increasing health-care costs in the United States have not translated to superior outcomes in comparison to other developed countries. The implementation of physician-targeted interventions to reduce costs may improve value-driven health outcomes. This study aimed to evaluate the effectiveness of physician-targeted interventions to reduce surgical expenses and improve care for patients undergoing total thyroidectomies. METHODS: Two separate face-to-face interventions with individual surgeons focusing on surgical expenses associated with thyroidectomy were implemented in two surgical services (endocrine surgery and otolaryngology) by the surgical chair of each service in Jun 2016. The preintervention period was from Dec 2014 to Jun 2016 (19 mo, 352 operations). The postintervention period was from July 2016 to January 2018 (19 mo, 360 operations). Descriptive statistics were utilized, and differences-in-differences were conducted to compare the pre and postintervention outcomes including cost metrics (total costs, fixed costs, and variable costs per thyroidectomy) and clinical outcomes (30-d readmission rate, days to readmission, and total length of stay). RESULTS: Patient demographics and characteristics were comparable across pre- and post-intervention periods. Post-intervention, both costs and clinical outcomes demonstrated improvement or stability. Compared to otolaryngology, endocrine surgery achieved additional savings per surgery post-intervention: mean total costs by $607.84 (SD: 9.76; P < 0.0001), mean fixed costs by $220.21 (SD: 5.64; P < 0.0001), and mean variable costs by $387.82 (SD: 4.75; P < 0.0001). CONCLUSIONS: Physician-targeted interventions can be an effective tool for reducing cost and improving health outcomes. The effectiveness of interventions may differ based on specialty training. Future implementations should standardize these interventions for a critical evaluation of their impact on hospital costs and patient outcomes.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism.

OBJECTIVE: To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism. BACKGROUND: Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT. METHODS: Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content. RESULTS: These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation. CONCLUSIONS: Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.