A national analysis of trends, outcomes and volume–outcome relationships in thyroid surgery

Abstract

Objectives: Thyroid conditions are common and their incidence is increasing. Surgery is the mainstay treatment for many thyroid conditions, and understanding its utilisation trends and morbidity are central to improving patient care. Accepted ArticleThis article is protected by copyright. All rights reserved. Results: Mean age at surgery was 49±30 and a female predominance (82%) was observed.Most patients underwent hemithyroidectomy (51%) or total thyroidectomy (32%). Patients underwent surgery for benign (52.5%), benign inflammatory (21%), and malignant (17%) thyroid diseases. Thyroid surgery grew by 2.9% a year and increased in specialization.Increased surgeon volume significantly reduced lengths of stay: the proportion of length of stay outliers fell from 11.8% for patients of occasional thyroidectomists (<5 per year) to 2.8% for patients of high-volume surgeons (>50 thyroidectomies a year). Post-discharge vocal palsy and hypocalcaemia occurred in 1.87% and 1.58% of cases respectively. High-volume surgeons had a reduced incidence of vocal palsy and volumes >30 were consistently protective.Conclusions: Thyroid surgery is increasingly specialised. High-volume surgeons achieve lower complications rates, including lower vocal palsy rates, and length of stay.

Vocal palsy increases the risk of lower respiratory tract infection in low‐risk, low‐morbidity patients undergoing thyroidectomy for benign disease: A big data analysis

“…There are also limitations to our study that relate to the influence of clinical coding subjectivity, variability and error on the accuracy of the English administrative big data. In order to reduce this influence, we eliminated all patients with unclear‐type thyroidectomies and aggregated codes into a small number of clinical entities to increase specificity . Conversely, using temporally linked data did allow index thyroidectomy to be linked to late complications regardless of which hospital they occurred in, and under whose care the patients were subsequently admitted.…”

“…Post‐operative disorders of calcium homeostasis and vocal palsy were defined as post‐operative if they were coded in the index thyroidectomy and as late if they were identified during a subsequent admission, as previously defined. Annual surgeon volume was dichotomised at 30 based on our earlier findings . Follow‐up was calculated as the most recent attendance at outpatients or a hospital admission, and time from index procedure to the occurrence of specific events such as placement of gastrostomy tube, emergency admission to hospital, hospital admission with acute lower respiratory tract infection were used as actuarial outcome variables.…”

“…In order to reduce this influence, we eliminated all patients with unclear-type thyroidectomies and aggregated codes into a small number of clinical entities to increase specificity. 17 Conversely, using temporally linked data did allow index thyroidectomy to be linked to late complications regardless of which hospital they occurred in, and under whose care the patients were subsequently admitted. This is particularly beneficial in this context as this association is not at this time widely recognised by the surgical or medical communities and the complication may be going unnoticed between the two disciplines.…”

Training in endocrine surgery

“…Considering the usually inadequate endocrine surgical training during residency, surgery residents wishing to practice endocrine surgery may benefit from additional training in their final year or dedicated fellowship training [14]. Many studies published in recent years showed a relationship between hospital/surgeon volume and patient outcomes which highlights the importance of advanced postgraduate training in endocrine surgery [78][79][80][81][82][83]. Two years of additional fellowship training in thyroid and endocrine surgery is now being advocated by an increasing number of national endocrine surgical associations as the best way to prepare surgeons for society's needs for highly skilled, competent thyroid surgeons of the future [1].…”

Ensuring Quality in Thyroid Cancer Surgery

“…Recent studies demonstrate lower complication rates (hypocalcemia, nerve injuries, bleeding, and surgical site infections) as well as shorter lengths of stay for surgeons performing a high volume of thyroid operations in comparison to low volume surgeons. [17][18][19][20] Adam and colleagues looked at almost 17,000 patients from the National Inpatient Sample and determined that a surgeon volume threshold of >25 total thyroidectomies per year was associated with decreased complications and shorter hospital stays. 21 Another group compared financial costs of high versus low volume surgeons considering both cost of complications and cost of hospital stay.…”