A Quality Assessment of Current Care Practices in Differentiated Thyroid Cancer at an Academic Tertiary Medical Center
Presentation Number: SUN 288
Date of Presentation: April 2nd, 2017
Saumya Saini*, Julia McNeil, Jiyong Lee and Ted Yamamoto
Dartmouth Hitchcock Medical Center, Lebanon, NH
Purpose: We sought to evaluate the adherence to American Thyroid Association (ATA) 2015 Differentiated Thyroid Cancer Management Guidelines at a rural New England academic tertiary medical center. We looked at rates of pre-operative evaluation with TSH, thyroid ultrasonography with lateral neck imaging, or imaging with CT/MRI/PET. We also evaluated the adherence to post-thyroidectomy guideline recommendations of thyroglobulin monitoring within 6 months of surgery, and post-operative thyroid bed and lateral neck compartment ultrasounds within 1 year of surgery.
Methods: Consecutive patients diagnosed from 2011 to 2015 with thyroid cancer were identified using pathology reports generated during tumor board discussions. Charts were retrospectively reviewed using a standardized protocol to identify: 1) FNA thyroid nodule cytopathology as well as histologic subtype of differentiated thyroid carcinoma 2) Presence or absence of lymph node spread and or distant metastases (as per American Joint Committee on Cancer 7th Edition TNM Classification) 3) Rates of in-house pre-operative TSH assessment, pre-operative ultrasound with lateral neck compartment visualization and pre-operative imaging with CT/MRI/PET 4) Rates of post-operative follow-up, thyroglobulin measurement, and repeat post-operative thyroid ultrasound including lateral neck compartments within 6 months of surgery.
Results: Our analysis included all the identified 287 consecutive patients diagnosed with thyroid cancer during 2011-2015. Two third (67%) of patients had a TSH level checked prior to surgery. Pre-operative ultrasounds were performed in 94% of patients. Of those which had ultrasounds performed, 64% included lateral neck compartment imaging. 20% of patients underwent pre-operative imaging with CT/MRI/PET. Post-operative adherence rates were high: within 6 months of surgery, 81% of patients were seen in Endocrinology clinic, 90% of patients underwent a post-operative thyroglobulin assessment, and 50% of patients underwent repeat thyroid ultrasound.
Discussion: We evaluated practice patterns from 2011-2015 in terms of adherence to the 2015 ATA guidelines to see if current practices needed to be modified to reflect updates in management recommendations. Our analysis found that 33% of patients undergoing thyroidectomies did not have a pre-operative TSH levels checked in-house. This may reflect patients who had TSH labs performed externally prior to referral, as TSH levels are requested as part of the intake process. Lateral neck imaging prior to surgery is not a standardized practice and was performed in 64% of ultrasounds. Otherwise, the rates of adherence to guidelines was high, with rates ranging from 81-90%. Our work has identified specific areas that would benefit from targeted quality improvement initiatives to ensure that current practices adhere to the most recent ATA recommendations.
Nothing to Disclose: SS, JM, JL, TY