Thyroidectomy rates vary dramatically across the United States, surpassing even that of prostatectomies, new research indicates.
The findings, from a cross-sectional analysis of Medicare data, were published online October 12, 2017 in JAMA Otolaryngology – Head & Neck Surgery by David O Francis, MD, of Wisconsin surgical outcomes research group and department of surgery, University of Wisconsin, Madison, and colleagues.
Rates of thyroidectomies across regions of the US among Medicare beneficiaries varied six-fold in 2014, the study reveals. That’s higher than the 5.6-fold variation for prostatectomies, which are generally offered as the standard example of wide variation in surgical practice patterns across the country.
Moreover, thyroidectomy rates didn’t align with healthcare availability, regional socioeconomic status, or number of surgeons per capita.
This, the authors say, suggests “widely divergent local beliefs and practice patterns surrounding the management of thyroid nodules” and indicates that “thyroidectomy does not enjoy broad agreement surrounding treatment indications.”
Old Habits Die Hard
Asked to comment, Ralph P Tufano, MD, director of the division of head and neck endocrine surgery at Johns Hopkins University School of Medicine, Baltimore, Maryland, agreed with those assessments, noting “practice patterns and behavior are influenced by years of tradition with something that is typically comfortable and acceptable to all stakeholders in the care process.”
“If you have been doing [everything] the same way for many years and it has worked relatively well for everyone, then why disrupt the proverbial apple cart unless there is groundbreaking new evidence to irrefutably suggest a better way to do things?”
Of course, the 2015 American Thyroid Association (ATA) guidelines for thyroid nodule and cancer management are state-of-the-art and evidence-based.
However, Dr Tufano notes, “the ATA guidelines are a wonderfully comprehensive and informative document, but they may not be having the impact they should.”
“Their comprehensiveness may compromise their utility to a busy clinician who may not have time to read the entire document and then disseminate that information to all stakeholders in patient care to effect a possible change in management.”
Regardless, he advised, physicians need to inform patients of all treatment options without bias.
“It is important for the patient to be able to make their own value determination about what’s best for them, but if all options are not presented, then they will be limited [in their choices].”
It also puts the onus on the patient to be better informed “and to actually question their doctors, which may be uncomfortable for some patients, and there may be variation in this by region as well,” Dr Tufano suggested.
More Variation Than Prostatectomy, Hip Fracture Hospitalizations
The new results show 15,888 thyroidectomies (7506 partial and 8382 total) were performed on Medicare beneficiaries in 2014, a national rate of 60 per 100,000.
But across regions, the rate varied from 22 to 139 per 100,000. The extremal ratio (highest rate divided by lowest) was 6.2 for thyroidectomies, compared with 5.6 for radical prostatectomy and just 2.2 for hip fracture hospitalizations (the latter is known to vary little across the United States).
“The dramatic variation in rates is even higher than the patterns seen for prostate cancer, which has a similar subclinical reservoir of asymptomatic disease and where the option of surveillance rather than immediate intervention has been discussed for over 20 years,” Dr Francis and colleagues point out.
Higher thyroidectomy rates were seen in southern, central, and some urban regions of the United States.
In an example of the widest disparity, Medicare beneficiaries in Joplin, Missouri were six times more likely to undergo thyroidectomy than those in Hackensack, New Jersey. The rate in Manhattan was 76 per 100,000, whereas in San Francisco the rate “is so low that estimates are unstable.”
More research is now needed to gain a “better understanding” of the reasons underlying the variation in thyroidectomies, the authors conclude.
The study was supported by funding from the Department of Veterans Affairs and Dartmouth Institute for Health Policy and Clinical Practice. Salary support for Dr Francis was provided by the National Institute for Deafness and Communication Disorders of the National Institutes of Health. Dr Tufano is a consultant for Medtronic, Ethicon, and Hemostatix.
JAMA Otolaryngol Head Neck Surg. Published online October 12, 2017. Abstract
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