Improving the adoption of thyroid cancer clinical practice guidelines

Impact of point-of-care clinical decision support on referrer behavior, imaging volume, patient radiation dose exposure, and sustainability

OBJECTIVES

When referring patients to radiology, it is important that the most appropriate test is chosen to avoid inappropriate imaging that may lead to delayed diagnosis, unnecessary radiation dose, worse patient outcome, and poor patient experience. The current radiology appropriateness guidance standard at our institution is via access to a standalone web-based clinical decision support tool (CDST). A point-of-care (POC) CDST that incorporates guidance directly into the physician workflow was implemented within a subset of head and neck cancer specialist referrers. The purpose of this audit was to evaluate the imaging pathway, pre- and post-implementation to assess changes in referral behavior.

METHODS

CT and MRI neck data were collected retrospectively to examine the relationship between imaging referrals pre- and post-POC CDST implementation. Effective radiation dose and estimated carbon emissions were also compared.

RESULTS

There was an overall reduction in absolute advanced imaging volume by 8.2%, and a reduction in duplicate CT and MRI imaging by 61%, p < 0.0001. There was also a shift in ordering behavior in favor of MRI (OR [95% CI] = 1.50 [1.02-2.22], p = 0.049). These changes resulted in an effective radiation dose reduction of 0.27 mSv per patient, or 13 equivalent chest x-rays saved per patient, p < 0.0001. Additionally, the reduction in unnecessary duplicate imaging led to a 13.5% reduction in carbon emissions, p = 0.0002.

CONCLUSIONS

Implementation of the POC CDST resulted in a significant impact on advanced imaging volume, saved effective dose, and reduction in carbon emissions.

CRITICAL RELEVANCE STATEMENT

The implementation of a point-of-care clinical decision support tool may reduce multimodality ordering and advanced imaging volume, manifesting in reduced effective dose per patient and reduced estimated carbon emissions. Widespread utilization of the point-of-care clinical decision support tool has the potential to reduce imaging wait times.

KEY POINTS

• Implementation of the point-of-care clinical decision support tool reduced the number of patients who simultaneously had a CT and MRI ordered for the same clinical indication compared to a standalone web-based clinical decision support tool. • The point-of-care clinical decision support tool reduced the absolute number of CT/MRI scans requested compared to the standalone web-based clinical decision support tool. • Utilization of the point-of-care clinical decision support tool led to a significant reduction in the effective dose per patient compared to the standalone web-based clinical decision support tool.

Adoption of Active Surveillance for Very Low-Risk Differentiated Thyroid Cancer in the United States: A National Survey

CONTEXT

Active surveillance (AS) of thyroid cancer with serial ultrasounds is a newer management option in the United States.

OBJECTIVE

This work aimed to understand factors associated with the adoption of AS.

METHODS

We surveyed endocrinologists and surgeons in the American Medical Association Masterfile. To estimate adoption, respondents recommended treatment for 2 hypothetical cases appropriate for AS. Established models of guideline implementation guided questionnaire development. Outcome measures included adoption of AS (nonadopters vs adopters, who respectively did not recommend or recommended AS at least once; and partial vs full adopters, who respectively recommended AS for one or both cases).

RESULTS

The 464 respondents (33.3% response) demographically represented specialties that treat thyroid cancer. Nonadopters (45.7%) were significantly (P < .001) less likely than adopters to practice in academic settings, see more than 25 thyroid cancer patients/year, be aware of AS, use applicable guidelines (P = .04), know how to determine whether a patient is appropriate for AS, have resources to perform AS, or be motivated to use AS. Nonadopters were also significantly more likely to be anxious or have reservations about AS, be concerned about poor outcomes, or believe AS places a psychological burden on patients. Among adopters, partial and full adopters were similar except partial adopters were less likely to discuss AS with patients (P = .03) and more likely to be anxious (P = .04), have reservations (P = .03), and have concerns about the psychological burden (P = .009) of AS. Few respondents (3.2%) believed patients were aware of AS.

CONCLUSION

Widespread adoption of AS will require increased patient and physician awareness, interest, and evaluation of outcomes.

Changes in Population-Level and Institutional-Level Prescribing Habits of Radioiodine Therapy for Papillary Thyroid Cancer

Background: In the past two decades, new evidence and guidelines have emerged to refine recommendations for the use of radioactive iodine (RAI) therapy after thyroidectomy for cancer. We aim to describe national trends in RAI utilization, assess the impact of individual hospitals on RAI utilization, and examine whether variation in prescribing habits has declined over time. Methods: The National Cancer Database (NCDB) was queried from 2004 to 2016 for patients with papillary thyroid cancer (PTC) who received total thyroidectomy. Trends were analyzed using Joinpoint analysis. Hospital-specific effects and variation in prescribing habits were assessed through a hierarchical, mixed regression model. Results: RAI utilization declined from 61.0% in 2004 to 43.9% in 2016. RAI use declined most profoundly in patients with T1a, N0/X, M0 PTC without extrathyroidal extension (34.8% in 2004 to 9.5% in 2015), but continues to be used commonly in patients with advanced disease for whom it is routinely recommended (73.4% in 2004 to 72.0% in 2015). Furthermore, ∼80% of hospitals in 2016 utilized at or below the median utilization rate in 2006. Variation in RAI utilization across hospitals decreased by ∼50% from 2004 to 2016 (Levene's test p < 0.001), with a significant decline (p = 0.002) in the variation after 2012 (confidence interval: 2010 to 2014). Conclusions: Recommendations for whom to prescribe RAI appear to have impacted both the number of patients receiving RAI and the variation in prescribing habits across hospitals. Hospital selection has contributed less to the probability of receiving RAI over time.

Effectiveness of guideline dissemination and implementation strategies on health care professionals' behaviour and patient outcomes in the cancer care context: a systematic review

BACKGROUND

Health care professionals (HCPs) use clinical practice guidelines (CPGs) to make evidence-informed decisions regarding patient care. Although a large number of cancer-related CPGs exist, it is unknown which CPG dissemination and implementation strategies are effective for improving HCP behaviour and patient outcomes in a cancer care context. This review aimed to determine the effectiveness of CPG dissemination and/or implementation strategies among HCPs in a cancer care context.

METHODS

A comprehensive search of five electronic databases was conducted. Studies were limited to the dissemination and/or implementation of a CPG targeting both medical and/or allied HCPs in cancer care. Two reviewers independently coded strategies using the Mazza taxonomy, extracted study findings, and assessed study quality.

RESULTS

The search strategy identified 33 studies targeting medical and/or allied HCPs. Across the 33 studies, 23 of a possible 49 strategies in the Mazza taxonomy were used, with a mean number of 3.25 (SD = 1.45) strategies per intervention. The number of strategies used per intervention was not associated with positive outcomes. Educational strategies (n = 24), feedback on guideline compliance (n = 11), and providing reminders (n = 10) were the most utilized strategies. When used independently, providing reminders and feedback on CPG compliance corresponded with positive significant changes in outcomes. Further, when used as part of multi-strategy interventions, group education and organizational strategies (e.g. creation of an implementation team) corresponded with positive significant changes in outcomes.

CONCLUSIONS

Future CPG dissemination and implementation interventions for cancer care HCPs may benefit from utilizing the identified strategies. Research in this area should aim for better alignment between study objectives, intervention design, and evaluation measures, and should seek to incorporate theory in intervention design, so that behavioural antecedents are considered and measured; doing so would enhance the field's understanding of the causal mechanisms by which interventions lead, or do not lead, to changes in outcomes at all levels.

Evaluation of implementation strategies of the Best Practices Spotlight Organisations (BPSO) Project in Spain

OBJECTIVE

To identify favourable elements and barriers to implementation in the Program of Best Practice Spotlight Organization® that establish clinical practice guidelines of the Registered Nurse' Association of Ontario, so that future experiences could benefit from the assessments presented here.

METHOD

Evaluation research study of the process of implementing guidelines in institutions that make up the first two cohorts of the programme in Spain, through analysis of contents of implantation reports and inductive process, reading, interpretation, coding and categorized according to SWOT structure: Strengths, weaknesses, opportunities and threats.

RESULTS

Reports from 18 centres in 12 Autonomous Communities have been analyzed, including 22 different guidelines. As weaknesses, problems related to information systems and their exploitation stand out for frequency and intensity. Other elements related to dissemination of results, to professionals, care and factors related to the institution are presented. Standing out as threats are the instability of staff and continued changes in Senior Management or corporate policies. Among the strengths, the exclusive dedication of personnel to the project and its link to institutional objectives are distinguished. As opportunities, the possibility of standardized comparison of own results with others, as well as the dissemination of results are highlighted.

CONCLUSION

A useful pattern is set up to approach implementation in other scenarios, where changes in professional culture, training, communication and leadership, as well as aligning interests of managers and politicians, facilitate ideal conditions for Evidence-Based Practice.

Use of mind maps and iterative decision trees to develop a guideline-based clinical decision support system for routine surgical practice: case study in thyroid nodules

OBJECTIVE

The study sought to develop a clinical decision support system (CDSS) for the treatment of thyroid nodules, using a mind map and iterative decision tree (IDT) approach to the integration of clinical practice guidelines (CPGs).

MATERIALS AND METHODS

Thyroid nodule CPGs of the American Thyroid Association and Korean Thyroid Association were analyzed by endocrine surgeons (domain experts) and computer scientists. Clinical knowledge from the CPGs was expressed using mind maps. The mind maps were analyzed and converted into IDTs. The final IDT was implemented as a set of candidate rules (3700) for a knowledge-based CDSS. The system was evaluated via a retrospective review of the medical records of 483 patients who had undergone thyroidectomy between January and December 2015 at a single tertiary center (Seoul National University Hospital Bundang, Korea).

RESULTS

Concordance between CDSS recommendations and treatment in routine clinical practice was 78.9%. In the 21.1% discordant cases, deviation from the CDSS treatment recommendation was mainly attributable to (1) refusal of the patient to undergo total thyroidectomy and (2) conversion from lobectomy to total thyroidectomy following an unexpected histological finding during intraoperative frozen biopsy lymph node analysis.

CONCLUSIONS

The present study demonstrated that a knowledge-based CDSS is feasible in the treatment of thyroid nodules. A high-quality knowledge-based CDSS was developed, and medical domain and computer scientists collaborated effectively in an integrated development environment. The mind map and IDT approach represents a pioneering method of integrating knowledge from CPGs.

Implementing Key Changes in the American Thyroid Association 2015 Thyroid Nodules/Differentiated Thyroid Cancer Guidelines Across Practice Types

OBJECTIVE

This article provides suggestions to help clinicians implement important changes in the 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Carcinoma ("ATA 2015") across diverse settings.

METHODS

Key ATA 2015 changes are summarized regarding: ( 1) thyroid nodule management; ( 2) lobectomy versus thyroidectomy for differentiated thyroid carcinoma (DTC); and ( 3) surveillance following primary treatment of DTC. Advice to facilitate implementation is based on clinical experience and selected literature.

RESULTS

Strategies are described to enhance acquisition of high-quality information that helps identify patients who may possibly avoid fine-needle aspiration (FNA) of thyroid nodules or total thyroidectomy for DTC, or undergo less intense postoperative surveillance. Sonographic imaging of nodules may improve if sonograms are obtained by clinicians ordering or performing FNA or trusted high-volume sonographers. Cytopathologic assessment and reporting can be improved by working with regional or national experts. Pre-operative evaluation by endocrinologists is important so that patients are referred to experienced, proficient surgeons and assisted with well-informed decision-making regarding surgical radicality. Endocrinologists and surgeons should ensure performance of pre-operative neck ultrasonography, voice/laryngeal evaluation, and contrast-enhanced cross-sectional imaging when appropriate. Findings should be disseminated to all healthcare team members, ideally through a comprehensive medical record accessible to the entire team.

CONCLUSION

Optimization of the sequence of specialist visits and assembly of interactive multidisciplinary teams coupled with intensified interdisciplinary and patient communication may enable clinicians to more effectively implement ATA 2015, which calls for more individualized, and often, less "invasive" management of thyroid nodules and DTC.

ABBREVIATIONS

ATA 2009 = 2009 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Carcinoma; ATA 2015 = 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Carcinoma; DTC = differentiated thyroid carcinoma; FNA = fine-needle aspiration; PET/CT = positron emission tomography/computed tomography.

Fine-Needle Aspiration Utilization for Malignant Thyroid Neoplasms in the Community Hospital Setting: A Quality Improvement Study

Background

Thyroid nodules are increasingly common. Although guidelines have been published, it is unclear whether recommendations for the use of fine-needle aspiration (FNA) and ultrasonography are followed.

Objective

To evaluate the impact of a quality improvement initiative regarding utilization of FNA and ultrasonography before resection of malignant thyroid neoplasms at a community-based hospital.

Methods

A retrospective medical record review of patients who received thyroidectomy with histologically proven malignant thyroid neoplasms at a community-based teaching center in the Midwest in 2014 revealed inconsistent use of FNA and ultrasonography per national guidelines. Thus, a quality improvement initiative was conducted using the PDSA (Plan, Do, Study, Act) method and included both an intradepartmental outreach effort and an interdisciplinary hospital cancer committee presentation. To determine the success of the initiative, medical records were reviewed from January 1, 2015, through July 1, 2016 (after the initiative) and compared with findings from 2014 (before the initiative).

Results

The medical records of 366 patients were reviewed over a 2.5-year period, and 23 records (12 in 2014 and 11 in 2015-2016) met the inclusion criteria. In 2014, FNA was performed on 58% of patients before operative management of thyroid malignancy. After the quality improvement initiative, FNA was performed on 100% of patients before operative management of thyroid malignancy (P=.0155). Before the quality improvement initiative, 75% of patients undergoing an operation for malignant thyroid neoplasms underwent preoperative ultrasonography, compared with 100% after the initiative (P=.0753).

Conclusion

A performance improvement initiative that used the PDSA framework effectively influenced physician adherence to national guidelines for thyroid neoplasms.

Enhanced interdisciplinary communication: development of an interactive thyroid nodule/cancer disease map

OBJECTIVES

Deficits related to inadequate clinical communication can result in incorrect diagnoses, inappropriate surgery, incorrect disease stratification, pathologic reporting, and/or interpretation. There are currently no validated or defined solutions to disease-specific communication with regard to thyroid care.

METHODS

We propose a solution that could ameliorate problems arising from inadequate disease-specific communications between physicians through the development of a thyroid disease-specific database, the Thyroid Care Collaborative.

RESULTS

To improve the quality of thyroid nodule and cancer care, we have developed an imaging module for enhanced reporting of ultrasound, cytologic, surgical, and pathologic details that are obtained during the workup and treatment of a patient.

CONCLUSION

The main advantages of this disease-specific, dynamic, three-dimensional, anatomic disease map are: 1) portability across institutions and disciplines, 2) disease specificity to thyroid nodule and cancer care, and 3) ability to trigger more detailed evaluation or reconciliation of any change in a patient's status regarding the nature or the extent of a patient's disease. The first and second advantages above have been identified as areas representing opportunities for quality improvement in health informatics research. Laryngoscope, 129:269-274, 2019.

p21 participates in the regulation of anaplastic thyroid cancer cell proliferation by miR-146b

Anaplastic thyroid carcinoma (ATC) originates from completely undifferentiated cells, and is the most lethal type of thyroid-derived tumor. Numerous microRNAs have significant roles in tumorigenesis by targeting relevant genes. The role of microRNA 146b (miR-146b) in ATC remains to be elucidated. In order to characterize the role of miR-146b in ATC, overexpression or interference of miR-146b was induced in ATC cell lines, and cell proliferation and migration were evaluated. The potential targets of miR-146b were searched in the Gene Expression Omnibus database for ATC and matched non-tumor control samples. The expression level of potential targets was detected following overexpression or interference of miR-146b in ATC cell lines. In the present study, cell proliferation was promoted when overexpression of miR-146b was induced in ATC, and inhibited when interference of miR-146b was induced, which indicated that miR-146b affects the proliferation of ATC cells in vitro. In addition, cell migration of ATC was also affected by miR-146b. During the search for potential targets of miR-146b in ATC, p21 (also known as p21^Waf1/Cip1 or CDKN1A) was noted for its role in cell cycle progression and tumor pathogenesis. The expression level of p21 was influenced by the level of miR-146b, and the results of the present study demonstrated that the level of p21 was increased when FRO cells were transformed with miR-146b mimic, and p21 was downregulated when FRO cells transformed with anti-miR-146b. In conclusion, p21 may participate in the regulation of ATC cell proliferation by miR-146b.