Racial Disparities in Clinical and Economic Outcomes From Thyroidectomy

Racial and insurance disparities in the utilization of supportive care after inpatient admission for proximal humerus fracture

BACKGROUND

Post-discharge supportive services such as home health assistance and rehabilitation or skilled nursing facilities are often utilized after inpatient care for fracture of the proximal humerus. It is unclear whether sociodemographic disparities exist in the utilization of post-hospital supportive care. The present study aimed to evaluate the individual and combined effects of race and insurance status on the utilization of supportive services after hospital admission for fracture of the proximal humerus.

METHODS

Among the more than 40,000 patients with a proximal humerus fracture identified in the Nationwide Inpatient Sample (2008 to 2011), 85% were white, 7.7% were Hispanic and 7.0% were black. More black patients (19%) and Hispanic patients (15%) were uninsured compared to white patients (8.7%). Multivariable logistic regression was performed to determine the effect of race/ethnicity and insurance status on the utilization of post-hospital supportive care.

RESULTS

Sixty-nine percent of patients were discharged home, 13% went to home health care and 15% went to rehabilitation or skilled nursing facilities. Compared to white patients, Hispanic patients [odds ratio (OR) = 0.71; 95% confidence interval (CI) = 0.64 to 0.79] and black patients (OR = 0.79; 95% CI = 0.71 to 0.88) exhibited lower odds for the utilization of specialized post-hospital supportive services. Uninsured patients were significantly less likely to use post-discharge supportive services (OR = 0.38; 95% CI = 0.33 to 0.42) compared to privately insured patients. Even when insured at levels comparable to whites, Hispanic and black patients tended to experience decreased rates of discharge to post-acute supportive care.

CONCLUSIONS

The utilization of post-hospital supportive services varies by race, ethnicity and insurance status after an inpatient admission for proximal humerus fracture.

Annual financial impact of thyroidectomies for nodular thyroid disease in China

A large proportion of patients with thyroid nodules in China undergo thyroidectomy in order to get confirmatory histology diagnosis. The financial impact of this modality remains to be investigated. To evaluate rationality of performing thyroidectomy without a routine FNA preoperatively from the economic perspective, we conducted a retrospective, observational study of all archival thyroidectomies with records of cost per stay (CPS), cost per day (CPD) and length of stay (LOS) from 2008 to 2013 in the First Affiliated Hospital of Nanjing Medical University. We compared all the parameters between cancer and non-cancer thyroidectomies. We recruited 6, 140 thyroidectomies with valid records of CPS, CPD and LOS in this period. The CPS of cancer thyroidectomy was significantly higher than non-cancer thyroidectomy. The percentage of cancer thyroidectomy increased from 26.5% to 41.6%. The percentage of annual cost of cancer thyroidectomies rose from 30.2% to 45.2%. The LOS for cancer and non-cancer thyroidectomy decreased while the CPD increased in the past six years. The estimated national cost in 2012 for all thyroidectomies would be USD 1.86 billion with USD 1.09 billion for non-cancer thyroidectomies. We have witnessed great improvement in the healthcare for patients with thyroid nodules in China. However, given limited healthcare resources, currently thyroid FNA for more precise preoperative diagnosis may help to curb the rapidly increasing demand in healthcare costs in the future for nodular thyroid disease in China.

The impact of surgical volume on racial disparity in thyroid and parathyroid surgery

PURPOSE

The aim of this study was to evaluate the association between surgeon volume and patient outcomes among different race ethnicities undergoing thyroid or parathyroid surgery.

METHODS

The nationwide inpatient sample was used to identify all thyroidectomy and parathyroidectomy admissions from 2003 to 2009, using International Classification of Diseases, 9th Clinical Modification (ICD-9-CM) procedure codes. Race, demographic, and clinical characteristics of patients were collected, along with surgeon volume, to predict the length of stay (LOS), complication rates, mortality, and total charges by racial group, using univariate and multivariate analyses.

RESULTS

A total of 106,314 thyroid and parathyroid surgeries were included in the current analysis. Of these patients, 54 % were Caucasian, 11 % African American, 7 % Hispanic, and 3 % Asian. Mean LOS was longer for African American patients (4 ± 8.7 days) than for Caucasians (2.3 ± 5.5 days) [p < 0.001]. African Americans had higher overall complications (16.8 %) compared with Caucasians (11 %), Hispanics (13.5 %), and Asians (12 %) [p < 0.001]. In-hospital mortality was higher for African Americans (0.8 %) compared with that from other race groups (0.3 %) [p < 0.001]. Mean total charges were significantly higher for African Americans ($33,292 ± $67,387) compared with those for Caucasians ($22,855 ± $40,167) (p < 0.001). African Americans had less access to intermediate- (10-99 cases) and high- (>100 cases) volume surgeons compared with Caucasians-45 versus 49 %, and 16 versus 19 %, respectively (p < 0.001). Higher surgeon volume was associated with improved outcomes (p < 0.001). Racial disparity in all investigated outcomes was still significantly evident even after stratification by surgeon volume.

CONCLUSION

Higher surgeon volume is associated with improved patient outcomes. However, our data suggests that the observed racial disparities in thyroid and parathyroid surgery go beyond access to quality healthcare providers.

Racial disparities in readmissions and site of care for major surgery

BACKGROUND

Racial disparities have been described in many surgical outcomes. We sought to examine whether these disparities extend to postoperative readmission rates and whether the disparities are associated with differences in patient mix and/or hospital-level differences.

STUDY DESIGN

National Medicare beneficiaries undergoing operations in 3 different specialties from 2006 to 2008 were examined: colectomy, hip replacement, and coronary artery bypass grafting (CABG) (n = 798,279). Our outcome measure was risk-adjusted 30-day readmission. We first used logistic regression to adjust for patient factors. We then stratified hospitals into quintiles according to the proportion of black patients treated and examined the differences in readmission rates between blacks and whites. Finally, we used fixed effects regression models that further adjust for the hospital to explore whether the disparity was attenuated after accounting for hospital differences.

RESULTS

Black patients were readmitted more often after all 3 operations compared with white patients. The unadjusted odds ratio (OR) for readmission for all 3 operations combined was 1.25 (95% CI 1.22 to 1.28) (colectomy OR 1.17, 95% CI 1.13 to 1.22; hip replacement OR 1.20, 95% CI 1.14 to 1.27; CABG OR 1.25, 95% CI 1.19 to 1.30). Adjusting for patient factors explained 36% of the disparity for all 3 operations (35% for colectomy, 0% for hip replacement, and 32% for CABG), but in analysis that adjusts for hospital differences, we found that the hospitals where care was received also explained 28% of the disparity (35% for colectomy, 70% for hip replacement and 20% for CABG).

CONCLUSIONS

Black patients are significantly more likely to be readmitted to the hospital after major surgery compared with white patients. This disparity was attenuated after adjusting for patient factors as well as hospital differences.

Variations in postoperative complications according to race, ethnicity, and sex in older adults

OBJECTIVES

To explore differences in the incidence of postoperative complications between three racial and ethnic groups (white, black, Hispanic) before and after taking into account potentially confounding patient and hospital characteristics.

DESIGN

Cross-sectional study using 2006 to 2007 administrative discharge data from hospitals in four states (CA, PA, NJ, FL) linked to American Hospital Association Annual Survey data and data from the U.S. Census. Risk-adjusted logistic regression models were used in the analyses.

SETTING

Six hundred U.S. adult nonfederal acute care hospitals.

PARTICIPANTS

Individuals aged 65 and older undergoing general, orthopedic, or vascular surgery (N = 587,314; 86% white, 6% black, 8% Hispanic).

MEASUREMENTS

Thirteen frequent postoperative complications.

RESULTS

When considered without controls, black patients had significantly greater odds than white patients of developing 12 of the 13 complications, by factors (ORs) ranging from 1.09 to 2.69. Hispanic patients had significantly greater odds than white patients in nine of the 13 complications (ORs = 1.11-1.82) and significantly lower odds than white patients on two of the other four (ORs both = 0.84). The fully adjusted models that accounted for hospital and especially patient characteristics substantially diminished the number of complications for which black and Hispanic patients had significantly greater odds than white patients. Many of the significant differences between black, Hispanic, and white patients that persisted after controls were different for men and women.

CONCLUSION

Older black and Hispanic individuals have greater odds than white individuals of developing a vast majority of postoperative complications. Procedure type and health status largely explained differences in postoperative complication risk, which are frequently conditional on sex.

Central lymph node dissection in patients with papillary thyroid cancer: a population level analysis of 14,257 cases

BACKGROUND

This study analyzes the impact of demographics and tumor size on the use of central compartment lymph node dissection (CLND) for papillary thyroid cancer (PTC) in the United States.

METHODS

Adult patients with PTC and the follicular variant of PTC who underwent thyroidectomy with or without CLND and were reported in the Surveillance Epidemiology and End Results (SEER) database from 2004 to 2008 were included. Bivariate and multivariate analyses were performed to determine the effects of demographic and clinical characteristics on the likelihood of a patient undergoing CLND.

RESULTS

Of 14,257 patients included, 80.3% were women, 84.3% were white, average age was 50.1 years, and 37.1% had CLND. Over 5 years, there was an 18.3% increase in CLND, with the greatest increase seen in patients with T1 tumors (23.2%). Patients who were older, men, black, and from the South were less likely to undergo CLND; however, there were no differences in the total number of lymph nodes examined based on patient demographics or the year of their thyroid cancer diagnoses.

CONCLUSIONS

Being older, black, and from the South are negatively associated with CLND. This practice variation suggests potential disparity in access and quality of surgical care for PTC in the United States.

Disease severity and radioactive iodine use for thyroid cancer

CONTEXT

Although variation in radioactive iodine (RAI) use for thyroid cancer has been demonstrated, the role of region and nonclinical correlates of use within risk groups has not been investigated.

OBJECTIVE

The objective of the study was to determine the correlates of RAI use within risk groups.

DESIGN/SETTING/PATIENTS

Use of RAI was evaluated across 9 US regions in 85 948 patients with well-differentiated thyroid cancer diagnosed between 2004 and 2008 at 986 hospitals associated with the US National Cancer Database. Cancers were then categorized as low risk (tumor size ≤ 1 cm and American Joint Committee on Cancer stage I disease), medium risk (neither low nor high-risk), and high risk (American Joint Committee on Cancer stage III or IV). Within each risk stratum, the role of region and nonclinical correlates of RAI use were evaluated using hierarchical logistic regression.

MAIN OUTCOME MEASURE

Use of RAI was measured.

RESULTS

Rates of RAI use varied across geographic regions from 49% to 66%. Regional differences persisted after controlling for patient and hospital characteristics and evaluating less vs more intensive regions within low-risk [odds ratio (OR) 0.36 (95% confidence interval [CI] 0.25-0.53)], medium-risk [OR 0.23 (95% CI 0.16-0.34)], and high-risk cancers [OR 0.30 (95% CI 0.19-0.49)]. Patterns of RAI use were similar in medium- and high-risk patients. The most nonclinical correlates of use were in low-risk patients.

CONCLUSION

Similar treatment patterns for the heterogeneous medium-risk thyroid cancer patients compared with the high-risk patients suggest more intensive management in patients with medium-risk disease. The large number of nonclinical correlates of RAI use, including region, imply controversy over indications for RAI.

Health disparities in endocrine disorders: biological, clinical, and nonclinical factors--an Endocrine Society scientific statement

OBJECTIVE

The aim was to provide a scholarly review of the published literature on biological, clinical, and nonclinical contributors to race/ethnic and sex disparities in endocrine disorders and to identify current gaps in knowledge as a focus for future research needs. PARTICIPANTS IN DEVELOPMENT OF SCIENTIFIC STATEMENT: The Endocrine Society's Scientific Statement Task Force (SSTF) selected the leader of the statement development group (S.H.G.). She selected an eight-member writing group with expertise in endocrinology and health disparities, which was approved by the Society. All discussions regarding the scientific statement content occurred via teleconference or written correspondence. No funding was provided to any expert or peer reviewer, and all participants volunteered their time to prepare this Scientific Statement.

EVIDENCE

The primary sources of data on global disease prevalence are from the World Health Organization. A comprehensive literature search of PubMed identified U.S. population-based studies. Search strategies combining Medical Subject Headings terms and keyword terms and phrases defined two concepts: 1) racial, ethnic, and sex differences including specific populations; and 2) the specific endocrine disorder or condition. The search identified systematic reviews, meta-analyses, large cohort and population-based studies, and original studies focusing on the prevalence and determinants of disparities in endocrine disorders. consensus process: The writing group focused on population differences in the highly prevalent endocrine diseases of type 2 diabetes mellitus and related conditions (prediabetes and diabetic complications), gestational diabetes, metabolic syndrome with a focus on obesity and dyslipidemia, thyroid disorders, osteoporosis, and vitamin D deficiency. Authors reviewed and synthesized evidence in their areas of expertise. The final statement incorporated responses to several levels of review: 1) comments of the SSTF and the Advocacy and Public Outreach Core Committee; and 2) suggestions offered by the Council and members of The Endocrine Society.

CONCLUSIONS

Several themes emerged in the statement, including a need for basic science, population-based, translational and health services studies to explore underlying mechanisms contributing to endocrine health disparities. Compared to non-Hispanic whites, non-Hispanic blacks have worse outcomes and higher mortality from certain disorders despite having a lower (e.g. macrovascular complications of diabetes mellitus and osteoporotic fractures) or similar (e.g. thyroid cancer) incidence of these disorders. Obesity is an important contributor to diabetes risk in minority populations and to sex disparities in thyroid cancer, suggesting that population interventions targeting weight loss may favorably impact a number of endocrine disorders. There are important implications regarding the definition of obesity in different race/ethnic groups, including potential underestimation of disease risk in Asian-Americans and overestimation in non-Hispanic black women. Ethnic-specific cut-points for central obesity should be determined so that clinicians can adequately assess metabolic risk. There is little evidence that genetic differences contribute significantly to race/ethnic disparities in the endocrine disorders examined. Multilevel interventions have reduced disparities in diabetes care, and these successes can be modeled to design similar interventions for other endocrine diseases.

Racial disparities in voice outcomes after thyroid and parathyroid surgery

BACKGROUND

There is evidence that the outcomes of head and neck surgery may differ across racial and ethnic groups. Vocal changes related to the operation are an anticipated risk of thyroidectomy and parathyroidectomy. Race-specific voice outcomes after thyroid and parathyroid operations have not been reported. Therefore, our aim was to examine the potential disparity in voice outcomes between white and black patients after thyroid or parathyroid operations.

PATIENTS AND METHODS

Eighty-seven patients (59 white and 28 black) were included in a prospective observational trial. Subjects were evaluated before operation, and 2 weeks, 3 months, and 6 months postoperatively using a comprehensive battery of functional voice assessments of voice characteristics. The association of race with voice outcomes over time was evaluated with generalized linear models.

RESULTS

Aside from volume of pathologic specimen (black, 117.5 cm3 vs. white, 43.2 cm3; P = .004), presence of multinodular goiter (black, 32.1% vs. white, 6.8%; P = .004) or Hashimoto's thyroiditis (black, 3.6% vs. white, 28.8%; P = .009), there were no differences between racial groups. Blacks were more likely than whites to have negative voice outcomes (odds ratio, 2.6; 95% confidence interval, 1.1-6.2; P = .034] throughout the postoperative period, especially at 6 months (black, 25% vs. white, 4%; P = .018). This finding was related principally to divergent scores on the voice-related quality-of-life scale, the voice handicap index.

CONCLUSION

We observed greater rates of self-reported, negative voice outcomes among blacks than whites after thyroid or parathyroid operations. The precise mechanism for this disparity has not been described. The observed racial disparity in self-perceived voice impairment in this study merits further investigation.

Predictors of hypocalcemia after thyroidectomy: results from the nationwide inpatient sample

Hypocalcemia is a common complication following thyroidectomy. However, the incidence of postoperative hypocalcemia varies widely in the literature, and factors associated with hypocalcemia after thyroid surgery are not well established. We aimed to identify incidence trends and independent risk factors of postoperative hypocalcemia using the nationwide inpatient sample (NIS) database from 1998 to 2008. Overall, 6,605 (5.5%) of 119,567 patients who underwent thyroidectomy developed hypocalcemia. Total thyroidectomy resulted in a significantly higher increased incidence (9.0%) of hypocalcemia when compared with unilateral thyroid lobectomy (1.9%; P < .001). Thyroidectomy with bilateral neck dissection, the strongest independent risk factor of postoperative hypocalcemia (odds ratio, 9.42; P < .001), resulted in an incidence of 23.4%. Patients aged 45 years to 84 years were less likely to have postoperative hypocalcemia compared with their younger and older counterparts (P < .001). Hispanic (P = .003) and Asian (P = .027) patients were more likely, and black patients were less likely (P = .003) than white patients to develop hypocalcemia. Additional factors independently associated with postoperative hypocalcemia included female gender, nonteaching hospitals, and malignant neoplasms of thyroid gland. Hypocalcemia following thyroidectomy resulted in 1.47 days of extended hospital stay (3.33 versus 1.85 days P < .001).

Disparities in the initial presentation of differentiated thyroid cancer in a large public hospital and adjoining university teaching hospital

BACKGROUND

Healthcare disparities associated with insurance and socioeconomic status have been well characterized for several malignancies, such as lung cancer. To assess whether there are healthcare disparities in thyroid cancer, this study evaluated the stage on initial presentation of patients with differentiated thyroid cancer (DTC) in a public versus university teaching hospital.

METHODS

A retrospective chart review was performed to identify patients with a new diagnosis of DTC from January 1, 2007, to January 1, 2010, in a large public and adjoining university teaching hospital at a single academic medical center. Medical records were reviewed for demographics, pathology, and American Joint Committee on Cancer tumor-node-metastasis stage at initial presentation.

RESULTS

There were 49 cases of well-DTC (96% papillary and 4% Hürthle) in the public hospital and 370 cases (95% papillary, 2% Hürthle, and 3% follicular) in the university teaching hospital. Median age (years) at presentation was 50 in the public versus 48 in the university teaching hospital (p=0.39). Ninety-six percent of public hospital patients were from ethnic minorities compared with 16% of university teaching hospital patients (p<0.0001). Only 1 (2%) public hospital patient had private insurance compared with 85% of university teaching hospital patients. Tumor status (p=0.002) and stage (p=0.03) were more advanced and extrathyroidal extension (p=0.02) was more prevalent among public hospital patients compared with university teaching hospital patients. In a multivariable analysis, public hospital, male gender, increasing age, advanced tumor status, and the presence of lymphovascular invasion were the best predictors of more advanced disease stage. Public hospital patients were 3.4 times more likely to present with advanced DTC than university teaching hospital patients of the same age, gender, tumor status, and lymphovascular invasion status (95% confidence interval 1.29-8.95).

CONCLUSIONS

In a public hospital, where the patient population is defined primarily by insurance status, patients were more likely to present with advanced-stage DTC than patients presenting to an adjacent university teaching hospital. These results suggest a disparity in the stage on initial presentation of DTC, possibly resulting in a delayed diagnosis of cancer.

Impact of comorbidities on hospitalization costs following hip fracture

BACKGROUND

Hip fractures are common in the elderly, and patients with hip fractures frequently have comorbid illnesses. Little is known about the relationship between comorbid illness and hospital costs or length of stay following the treatment of hip fracture in the United States. We hypothesized that specific individual comorbid illnesses and multiple comorbid illnesses would be directly related to the hospitalization costs and the length of stay for older patients following hip fracture.

METHODS

With use of discharge data from the 2007 Nationwide Inpatient Sample, 32,440 patients who were fifty-five years or older with an isolated, closed hip fracture were identified. Using generalized linear models, we estimated the impact of comorbidities on hospitalization costs and length of stay, controlling for patient, hospital, and procedure characteristics.

RESULTS

Hypertension, deficiency anemias, and fluid and electrolyte disorders were the most common comorbidities. The patients had a mean of three comorbidities. Only 4.9% of patients presented without comorbidities. The average estimated cost in our reference patient was $13,805. The comorbidity with the largest increased hospitalization cost was weight loss or malnutrition, followed by pulmonary circulation disorders. Most other comorbidities significantly increased the cost of hospitalization. Compared with internal fixation of the hip fracture, hip arthroplasty increased hospitalization costs significantly.

CONCLUSIONS

Comorbidities significantly affect the cost of hospitalization and length of stay following hip fracture in older Americans, even while controlling for other variables.

Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists

OBJECTIVE

Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This article describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspeciality physicians and others providing care for patients with this condition.

METHODS

The development of these guidelines was commissioned by the American Thyroid Association in association with the American Association of Clinical Endocrinologists. The American Thyroid Association and American Association of Clinical Endocrinologists assembled a task force of expert clinicians who authored this report. The task force examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to develop the text and a series of specific recommendations. The strength of the recommendations and the quality of evidence supporting each was rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group.

RESULTS

Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves' hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves' disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves' ophthalmopathy; and management of other miscellaneous causes of thyrotoxicosis.

CONCLUSIONS

One hundred evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.

Characteristics of Inpatient Thyroid Surgery at US Academic and Affiliated Medical Centers

Objective. Describe data from patients undergoing thyroid surgeries for benign and malignant disease at US academic medical centers.

Study Design. Retrospective, database search.

Setting. The University Health System (UHC) Consortium (Oak Brook, Illinois) data compiled from discharge summaries.

Subjects and Methods. Discharge data were collected from the first quarter of 2002 through the fourth quarter of 2009. Searching strategy was based on diagnosis of thyroid disease and patients undergoing thyroid surgery across all UHC facilities. Demographic information was collected as well as length of stay (LOS) and costs. Complications were evaluated in this analysis.

Results. During the study period, 68,014 thyroidectomies were performed, with 27,200 for thyroid cancer. During the same period 6365 neck dissections were performed, with 1539 as stand-alone procedures. Total thyroidectomy was the procedure of choice for malignant disease. More total thyroidectomies and fewer hemithyroidectomies were being performed for benign thyroid disease in the inpatient setting. Almost all postoperative complications were more frequent after surgery for cancer except myocardial infarction and aspiration pneumonia. On average, LOS was longer for benign disease, but costs were higher for malignant disease.

Conclusion. This is the largest series reporting inpatient LOS and mortality for thyroid surgery. The limitation of this study is that it reports patients whose stays were more than 23 hours, leaving out a significant number of thyroid surgeries that are performed as outpatients. Although the results contribute greatly to characterizing inpatient surgery, the results may not reflect current US trends for thyroid surgery.

Racial disparities in changing to a high-volume urologist among men with localized prostate cancer

BACKGROUND

Patients who receive surgery from high-volume surgeons tend to have better outcomes. Black patients, however, are less likely to receive surgery from high-volume surgeons.

OBJECTIVE

Among men with localized prostate cancer, we examined whether disparities in use of high-volume urologists resulted from racial differences in patients being diagnosed by high-volume urologists and/or changing to high-volume urologists for surgery.

RESEARCH DESIGN

Retrospective cohort study from Surveillance, Epidemiology, and End Results-Medicare data.

SUBJECTS

A total of 26,058 black and white men in Surveillance, Epidemiology, and End Results-Medicare diagnosed with localized prostate cancer from 1995 to 2005 that underwent prostatectomy. Patients were linked to their diagnosing urologist and a treating urologist (who performed the surgery).

MEASURES

Diagnosis and receipt of prostatectomy by a high-volume urologist, and changing between diagnosing and treating urologist

RESULTS

After adjustment for confounders, black men were as likely as white men to be diagnosed by a high-volume urologist; however, they were significantly less likely than white men to be treated by a high-volume urologist [odds ratio 0.76; 95% confidence interval (CI), 0.67-0.87]. For men diagnosed by a low-volume urologist, 46.0% changed urologists for their surgery. Black men were significantly less likely to change to a high-volume urologist (relative risk ratio 0.61; 95% CI, 0.47-0.79). Racial differences appeared to reflect black and white patients being diagnosed by different urologists and having different rates of changing after being diagnosed by the same urologists.

CONCLUSIONS

Lower rates of changing to high-volume urologists for surgery among black men contribute to racial disparities in treatment by high-volume surgeons.

Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists

BACKGROUND

Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This article describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspeciality physicians and others providing care for patients with this condition.

METHODS

The development of these guidelines was commissioned by the American Thyroid Association in association with the American Association of Clinical Endocrinologists. The American Thyroid Association and American Association of Clinical Endocrinologists assembled a task force of expert clinicians who authored this report. The task force examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to develop the text and a series of specific recommendations. The strength of the recommendations and the quality of evidence supporting each was rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group.

RESULTS

Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves' hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves' disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves' ophthalmopathy; and management of other miscellaneous causes of thyrotoxicosis.

CONCLUSIONS

One hundred evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.

Pediatric thyroidectomy: a collaborative surgical approach

INTRODUCTION

We have developed a collaborative approach to pediatric thyroid surgery, with operations performed at a children's hospital by a pediatric surgeon and an endocrine surgeon. We hypothesize that this strategy minimizes specialist-specific limitations and optimizes care of children with surgical thyroid disease.

METHODS

Data from all partial and total thyroidectomies performed by the pediatric-endocrine surgery team at a tertiary children's hospital between 1995 and 2009 were collected and analyzed retrospectively. Statistical analyses were performed with IBM SPSS software (SPSS, Chicago, IL).

RESULTS

Thirty-five children met the inclusion criteria (69% female; median age, 13 years; median follow-up, 1119 days). The indications for operation were thyroid nodule (71%), genetic abnormality with predisposition to thyroid malignancy (17%), multinodular goiter (5.7%), Grave disease (2.9%), and Hashimoto thyroiditis (2.9%). Sixteen children (46%) underwent thyroid lobectomy, and 19 children (54%) underwent total thyroidectomy. Median length of stay was 1 day (1 day after lobectomy vs 2 days after total thyroidectomy, P < .0001). There were 4 cases of transient hypocalcemia after total thyroidectomy, but there were no nerve injuries or other in-hospital complications in either group (overall complication rate, 11%).

CONCLUSIONS

For pediatric thyroidectomy and thyroid lobectomy, collaboration of high-volume endocrine and pediatric surgeons as well as pediatric endocrinologists at a dedicated pediatric medical center provides optimal surgical outcomes.

Medullary thyroid cancer: are practice patterns in the United States discordant from American Thyroid Association guidelines?

BACKGROUND

Surgery is the mainstay of treatment for medullary thyroid cancer (MTC), with long-term patient outcomes associated with adequacy of resection. This study benchmarked national practice patterns against 2009 American Thyroid Association (ATA) guidelines for MTC regarding use of thyroidectomy, lymphadenectomy, radioactive iodine (RAI), and external-beam radiotherapy (EBRT).

METHODS

This is a cross-sectional, retrospective cohort study of MTC patients in the Surveillance, Epidemiology, and End Results Program database, 1973 to 2006. ATA recommendations 61 to 66 (extent of surgery), 85 (RAI), and 93 (EBRT) were analyzed. Outcome of interest was practice accordance with these recommendations. Predictors of accordance were determined and Kaplan-Meier survival analyses were performed.

RESULTS

A total of 2033 patients with MTC were identified. Fifty-nine percent were women; 78% were white. Forty-one percent of patients did not receive appropriate surgical therapy (recommendations 61 to 63). Most patients with distant metastatic disease had less aggressive surgery and more EBRT (P < 0.001) (recommendations 64 to 66). Four percent of patients received inappropriate RAI (recommendation 85). Two hundred nine patients had gross incomplete resections, with 33% receiving postoperative EBRT (recommendation 93). Statistically significant predictors of receiving surgery discordant with ATA recommendations in multivariate analysis were patient age >65, female sex, earlier year of diagnosis (1988 to 1997), geographic region, intrathyroidal tumor extent, and tumor size of </=1 cm. Patients receiving surgery discordant with recommendations had shorter survival than those receiving surgery according to recommendations (P < 0.05).

CONCLUSIONS

Variation in practice patterns exist in the United States with regard to extent of surgery and lymphadenectomy for MTC. Dissemination of standardized guidelines is important to ensure optimal treatment with less variation in quality of care.

ATA practice guidelines for the treatment of differentiated thyroid cancer: were they followed in the United States?

BACKGROUND

The aim of this study was to benchmark national practice patterns against American Thyroid Association guidelines for thyroidectomy, lymphadenectomy, and radioactive iodine (RAI) for differentiated thyroid cancer (DTC).

METHODS

A cross-sectional analysis of patients with DTC in Surveillance, Epidemiology, and End Results was performed. Outcomes were practice accordance with guidelines for extent of surgery and RAI treatment. Predictors of accordance were identified.

RESULTS

A total of 52,964 patients with DTC were included. Seventy-six percent were women, and 83% white. There was 71% accordance with surgery recommendations; among these, 15% underwent central lymphadenectomy, 31% had RAI but no lymphadenectomy, and 25% had RAI and lymphadenectomy. The highest accordance with guidelines was for patients aged <45 years with stage II disease (80%); the lowest accordance was for patients aged > or = 45 years with stage II disease (52%). Patients aged >65 years and of black race had the lowest accordance (P < .001).

CONCLUSIONS

Variation in practice suggests variation in the quality of care for DTC. Greater dissemination of evidence-based recommendations is needed for elderly and minority patients.

Insurance status, geography, race, and ethnicity as predictors of anterior cervical spine surgery rates and in-hospital mortality: an examination of United States trends from 1992 to 2005

STUDY DESIGN

Retrospective cross-sectional study.

OBJECTIVE

To determine the role of race, insurance status, and geographic location on US anterior cervical spine surgery rates and in-hospital mortality between 1992 and 2005.

SUMMARY OF BACKGROUND DATA

Previous investigation indicates that anterior cervical spine surgery has been increasingly used in the management of degenerative cervical spine disease throughout the 1990s. Significant predictors of health outcomes, including race, ethnicity, geography, and insurance coverage have yet to be investigated in detail for these procedures.

METHODS

Cases of anterior cervical spine surgery were identified from the Nationwide Inpatient Sample. The US population counts were taken from the Current Population Survey. Multivariate regression models were employed to describe national rates of anterior cervical spine surgery and model the odds of death among admissions for anterior cervical spine surgery. All models incorporated adjustment for hospital sample clustering, age, and comorbidity status.

RESULTS

Based on an analysis of a total 100,286,482 hospital discharge records, an estimated 965,600 anterior cervical spine procedures were performed between 1992 and 2005 in the United States. During this period, rates of surgery increased by 289%. Though adjusted rates of surgery were lowest among minority populations, disparities decreased with time. The mean age of patients, as well as the average preoperative comorbidity status, increased with time. The odds of mortality did not significantly increase between 1992 and 2005. Odds of in-hospital death were greatest in among black patients (P < 0.001) and lowest in Southern states (P < 0.001) and patients with private insurance (P < 0.001).

CONCLUSION

With the recent rise of anterior cervical spine procedures in the United States, substantial variation in the delivery of surgical care exists along a number of demographic factors. A detailed investigation of variation in surgical decision-making algorithms among spine specialists, as well as a determination of differences among patient populations in attitudes toward surgery, may help elucidate the trends observed in this study.

Does ethnicity influence in vitro fertilization (IVF) birth outcomes?

OBJECTIVE

To determine if ethnicity influences IVF birth outcome.

DESIGN

Retrospective cohort study.

SETTING

University-based IVF program.

PATIENT(S)

All African American women (n = 71) and Caucasian women (n = 180) who underwent initial fresh, nondonor IVF/embryo transfer (ET) cycles between January 1, 2004 and December 31, 2005.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Gonadotropin dose, duration of stimulation, peak estradiol levels, oocyte yield, implantation, clinical pregnancy, and live birth rates.

RESULT(S)

African American women generated significantly fewer embryos than Caucasian women (5.3 +/- 3.7 vs. 6.6 +/- 4.8) despite having similar ages, day 3 FSH, peak estradiol levels, length of stimulation, and number of oocytes retrieved. In addition, compared with Caucasian women, African American had significantly greater body mass indices (26.5 +/- 5.2 vs. 23.7 +/- 4.8) and required significantly more total gonadotropin (IU) (4,791 +/- 2,161 vs. 3,725 +/- 2,005) for ovarian stimulation. African American women were more likely to have uterine fibroids (21% vs. 3%) and tubal factor infertility (23% vs. 9%). Caucasian women were more likely to have unexplained infertility (53% vs. 32%). Differences in embryo yield between patient groups persisted after accounting for differences in infertility diagnosis and prevalence of fibroids. Biochemical, clinical pregnancy, and live birth rates as well as implantation rates (number of sacs visualized/number of embryos transferred) did not significantly differ between groups.

CONCLUSION(S)

Although African Americans yield fewer embryos than Caucasian women with IVF, these ethnic groups do not seem to differ with regard to IVF pregnancy outcomes.

Pediatric endocrine surgery: who is operating on our children?

BACKGROUND

High surgeon volume is associated with improved outcomes in adult endocrine surgery. This is the first population-based outcomes study for thyroidectomy/parathyroidectomy in children.

METHODS

Cross-sectional analyses were performed using 1999 to 2005 Healthcare Cost and Utilization Project Nationwide Inpatient Sample data. Outcomes included complications, length of stay (LOS), and costs. High-volume surgeons performed >30 cervical endocrine procedures per year in adults and children; pediatric surgeons restricted >90% of their practices to patients </=17 years old. Other surgeons fell into neither category. Bivariate and multivariate regression analyses were performed.

RESULTS

We included 607 patients, representing 20% of the pediatric endocrine operations done between 1999 and 2005 in the United States. Seventy-six percent of patients were female. Among the procedures performed, 92% were thyroidectomies and 8% were parathyroidectomies. Surgeons were classified as follows: 18% High-volume, 21% Pediatric, and 61% Other. High-volume surgeons had the lowest LOS (1.5 days vs 2.3 Pediatric, 2.0 Other; P = .01), costs ($12,474 vs $19,594 Pediatric, $13,614 Other; P < .01), and complications (6% vs 11% Pediatric, 10% Other; P = NS). In multivariate analyses, case volume of the endocrine surgeons was an independent predictor of LOS and costs.

CONCLUSION

High-volume surgeons have better outcomes after thyroidectomy/parathyroidectomy in children compared with Pediatric and Other surgeons. Surgeon experience was an independent predictor of LOS and costs. High-volume endocrine and pediatric surgeons could combine expertise to improve outcomes in children.

AAA Repair: Sociodemographic Disparities in Management and Outcomes

Objective: To evaluate sociodemographic influences on utilization and outcomes of endovascular abdominal aortic repair (EVAR) for the treatment of abdominal aortic aneurysm (AAA).

Methods: Secondary data analysis of the State Inpatient Databases for New Jersey.

Results: Between 2001 and 2006, a total of 6227 adult subjects (mean [SD] age, 73.3 [8.3] years; 77.6% male) underwent AAA repair (3167 EVAR and 3060 open surgery [OS]). Patients receiving EVAR were older than those undergoing OS (mean [SD] age, 74.2 [8.0] vs 72.4 [8.6] years) ( P < .001). Men were 1.60 (95% confidence interval [CI], 1.39-1.77) times more likely to receive EVAR than women. White subjects had the same odds of undergoing EVAR as black subjects, and white subjects had 1.60 (95% CI, 1.29-2.06) times higher odds of receiving EVAR than Hispanics. Subjects with Medicare coverage were 3.90 (96% CI, 2.28-6.59) times more likely to receive EVAR than uninsured subjects. Logistic regression analysis demonstrated that older age, male sex, and Medicare coverage were significantly associated with increased utilization of EVAR and that uninsured subjects and Hispanics are less likely to receive EVAR. Octogenarians and black subjects (odds ratios: 3.69 CI: 2.31-5.91, and 2.59 CI: 1.47-4.54 respectively) had significantly greater likelihood of death after elective AAA repair.

Conclusions: For AAA repair, significant sociodemographic disparities exist in the use of endovascular technology and in mortality. The risk of death after elective AAA repair was significantly greater for black subjects. Further analysis is warranted to delineate inequalities of vascular care for AAA and to assist in formulating policy to address these disparities.

Clinical and economic outcomes of thyroid and parathyroid surgery in children

CONTEXT

Clinical and economic outcomes after thyroidectomy/parathyroidectomy in adults have demonstrated disparities based on patient age and race/ethnicity; there is a paucity of literature on pediatric endocrine outcomes.

OBJECTIVE

The objective was to examine the clinical and demographic predictors of outcomes after pediatric thyroidectomy/parathyroidectomy.

DESIGN

This study is a cross-sectional analysis of Healthcare Cost and Utilization Project-National Inpatient Sample hospital discharge information from 1999-2005. All patients who underwent thyroidectomy/parathyroidectomy were included. Bivariate and multivariate analyses were performed to identify independent predictors of patient outcomes.

SUBJECTS

Subjects included 1199 patients 17 yr old or younger undergoing thyroidectomy/parathyroidectomy.

MAIN OUTCOME MEASURES

Outcome measures included in-hospital patient complications, length of stay (LOS), and inpatient hospital costs.

RESULTS

The majority of patients were female (76%), aged 13-17 yr (71%), and White (69%). Whites were more often in the highest income group (80% vs. 8% for Hispanic and 6% for Black; P < 0.01) and had private/HMO insurance (76% vs. 10% for Hispanic and 5% for Black; P < 0.001) rather than Medicaid (13% vs. 32% for Hispanic and 41% for Black; P < 0.001). Ninety-one percent of procedures were thyroidectomies and 9% parathyroidectomies. Children aged 0-6 yr had higher complication rates (22% vs. 15% for 7-12 yr and 11% for 13-17 yr; P < 0.01), LOS (3.3 d vs. 2.3 for 7-12 yr and 1.8 for 13-17 yr; P < 0.01), and higher costs. Compared with children from higher-income families, those from lower-income families had higher complication rates (11.5 vs. 7.7%; P < 0.05), longer LOS (2.7 vs. 1.7 d; P < 0.01), and higher costs. Children had higher endocrine-specific complication rates than adults after parathyroidectomy (15.2 vs. 6.2%; P < 0.01) and thyroidectomy (9.1 vs. 6.3%; P < 0.01).

CONCLUSIONS

Children undergoing thyroidectomy/parathyroidectomy have higher complication rates than adult patients. Outcomes were optimized when surgeries were performed by high-volume surgeons. There appears to be disparity in access to high-volume surgeons for children from low-income families, Blacks, and Hispanics.