1
|
Jensen CB, Mead M, Underwood HJ, Ibrahim A, Pitt SC. Sometimes Less Is More: A Cross-Sectional Analysis of Commercially-Negotiated Price Variation for Thyroidectomy. ANNALS OF SURGERY OPEN 2025; 6:e564. [PMID: 40134502 PMCID: PMC11932599 DOI: 10.1097/as9.0000000000000564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2025] [Accepted: 02/17/2025] [Indexed: 03/27/2025] Open
Abstract
Introduction The Hospital Price Transparency Rule requires hospitals to publicly report prices for healthcare services to enhance transparency. Among the most common thyroidectomy procedures are thyroid lobectomy (TL) and total thyroidectomy alone (TT) or with central neck dissection (TT+CND). This study aimed to examine factors associated with variations in commercially-negotiated prices for thyroidectomy. Methods This cross-sectional analysis examined commercial price data obtained from Turquoise Health and linked to the American Hospital Association Annual Survey. Thyroidectomy procedures were categorized using Current Procedural Terminology codes (60220 TL, 60240 TT, and 60252 TT+CND, listed in increasing extent of surgery). The main outcome included intrahospital variation in commercially-negotiated prices and hospital-level factors associated with price differences. Results Overall, 1299 hospitals (30.4%) reported commercial prices for TL and TT. In increasing order of surgical complexity, the median price (interquartile range) was $6483 ($2217-$11,443) for TL, $6732 ($2566-$11,321) for TT, and $6232 ($3118-$10,916) for TT+CND. Only 28% (n = 303) reported median negotiated prices concordant with increasing extent of thyroidectomy. Risk-adjusted mean negotiated prices found that not-for-profit hospitals had significantly lower adjusted mean prices compared with for-profit ($8266 vs $10,625, P = 0.022). Procedure type significantly impacted adjusted mean prices, with TT+CND having lower prices compared with TT ($8295 vs $9446, P = 0.001). Conclusions The complexity of thyroidectomy is not reflected in the price-negotiated rates paid by insurers to hospitals. Most hospitals are paid less when taking on more complex procedures. These findings underscore concerns about fair reimbursement to hospitals and the potential of the Price Transparency Rule to illuminate unwarranted differences in negotiated rates.
Collapse
Affiliation(s)
- Catherine B. Jensen
- From the Department of Surgery, University of Wisconsin, Madison, WI
- Department of Surgery, University of Michigan, Ann Arbor, MI
- National Clinician Scholars Program, University of Michigan, Ann Arbor, MI
| | - Mitchell Mead
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Taubman College of Architecture and Urban Planning, University of Michigan, Ann Arbor, MI
| | | | - Andrew Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Taubman College of Architecture and Urban Planning, University of Michigan, Ann Arbor, MI
| | - Susan C. Pitt
- Department of Surgery, University of Michigan, Ann Arbor, MI
| |
Collapse
|
2
|
Chen DH, Hurtado CR, Chang P, Zakher M, Angell TE. Clinical Features and Outcomes of Myxedema Coma in Patients Hospitalized for Hypothyroidism: Analysis of the United States National Inpatient Sample. Thyroid 2024; 34:419-428. [PMID: 38279788 DOI: 10.1089/thy.2023.0559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Background: Hypothyroidism is a common endocrine condition and chronic thyroid hormone deficiency is associated with adverse effects across multiple organ systems. In compensated hypothyroidism, however, patients remain clinically stable due to gradual physiological adaptation. In contrast, the clinical syndrome of decompensated hypothyroidism referred to as myxedema coma (MC) is an endocrine emergency with high risk of mortality. Because of its rarity, there are currently limited data regarding MC. This study analyzes the clinical features and hospital outcomes of MC compared with hypothyroid patients without MC (nonMChypo) in national United States hospital data. Methods: A retrospective analysis of the National Inpatient Sample, a public database of inpatient admissions to nonfederal hospitals in the United States, 2016-2018, including adult patients with primary diagnosis of MC (International Classification of Diseases 10th Revision [ICD-10]: E03.5) or nonMChypo (E03.0-E03.9, E89.0). Patient demographics, relevant clinical features, mortality, length of stay (LOS), and hospital costs were compared. Results: Of 18,635 patients hospitalized for hypothyroidism, 2495 (13.4%) had a diagnosis of MC. Sex distribution and race/ethnicity were similar between patients with MC and nonMChypo, whereas MC was associated with older patient age (p = 0.02), public insurance (p = 0.01), and unhoused status (p = 0.04). More admissions with MC occurred in winter compared with other seasons (p = 0.01). The overall mortality rate for MC was 6.8% versus 0.7% for nonMChypo (p < 0.001), and MC was independently associated with in-hospital mortality after adjusted regression analysis (adjusted odds ratio = 9.92 [CI 5.69-17.28], p < 0.001). Mean LOS ± standard error was 9.64 ± 0.73 days for MC versus 4.62 ± 0.12 days for nonMChypo (p < 0.001), and total hospital cost for MC was $21,768 ± $1759 versus $8941 ± $276 for nonMChypo (p = 0.07). In linear regression analyses, MC was an independent predictor of both increased LOS and total hospital cost. Conclusions: In summary, MC remains a clinically significant diagnosis in the modern era, independently associated with high mortality and health care costs. This continued burden demonstrates a need for further efforts to prevent, identify, and optimize treatment for patients with MC.
Collapse
Affiliation(s)
- Dennis H Chen
- Department of Internal Medicine, University of Southern California, Los Angeles, California, USA
| | - Carolina R Hurtado
- Division of Endocrinology, Diabetes and Metabolism, Los Angeles General Medicine Center, Los Angeles, California, USA
| | - Patrick Chang
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Mariam Zakher
- Division of Endocrinology and Diabetes; Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Trevor E Angell
- Division of Endocrinology and Diabetes; Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| |
Collapse
|
3
|
Finn CB, Sharpe JE, Krumeich LN, Ginzberg SP, Soegaard Ballester JM, Tong JK, Wachtel H, Fraker DL, Kelz RR. The use and costs of same-day surgery versus overnight admission for total thyroidectomy: A multi-state, all-payer analysis. Surgery 2024; 175:207-214. [PMID: 37989635 PMCID: PMC10870294 DOI: 10.1016/j.surg.2023.06.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 05/29/2023] [Accepted: 06/09/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Outpatient thyroidectomy is increasingly favored, given evidence of safety and convenience for selected patients. However, the prevalence of same-day discharge is unclear. We aimed to evaluate temporal trends, hospital characteristics, and costs associated with same-day discharge after total thyroidectomy in an all-payer, multi-state cohort. METHODS We included patients aged ≥18 years who underwent a total thyroidectomy (2013-2019) using Healthcare Cost and Utilization Project data. Admission type was defined as same-day, overnight, or inpatient based on length of stay. Same-day patients were propensity-score matched 1:1 with overnight patients. Hospital characteristics and costs were compared in the matched cohort. RESULTS Among 86,187 patients who underwent total thyroidectomy, 16,743 (19.4%) cases were same-day, 59,778 (69.4%) were overnight, and 9,666 (11.2%) were inpatient. The proportion of patients who underwent same-day thyroidectomy increased from 14.8% to 20.8% over the study period (P < .001), whereas overnight admissions decreased from 72.9% to 68.8% (P < .001). In total, 9,571 same-day patients were matched to 9,571 overnight patients. Same-day patients had higher odds of treatment at a certified cancer center (odds ratio 1.77; 95% confidence interval 1.65-1.90), Accreditation Council for Graduate Medical Education-accredited teaching hospital (odds ratio 1.72; 95% confidence interval 1.61-1.85), and high-volume hospital (odds ratio 1.53; 95% confidence interval 1.42-1.65). Pairwise cost differences showed median savings of $974 (interquartile range -1,610 to 3,491) for same-day relative to overnight admission (P < .001). CONCLUSION Although over two-thirds of patients are admitted overnight, same-day total thyroidectomy is increasingly performed. Same-day thyroidectomy may be a lower-cost option for selected patients, particularly in specialty centers with experience in thyroidectomy.
Collapse
Affiliation(s)
- Caitlin B Finn
- Department of Surgery, Weill Cornell Medicine, New York, NY; Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA; Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - James E Sharpe
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Lauren N Krumeich
- Massachusetts General Hospital, Department of Surgery, Boston, MA; Brigham and Women's Hospital, Department of Surgery, Boston, MA. https://twitter.com/LaurenNorell
| | - Sara P Ginzberg
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA. https://twitter.com/SaraGinzbergMD
| | - Jacqueline M Soegaard Ballester
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA. https://twitter.com/JMSoegaard
| | - Jason K Tong
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA. https://twitter.com/JasonTong_MD
| | - Heather Wachtel
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Douglas L Fraker
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Rachel R Kelz
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA; Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA. https://twitter.com/surgeryspice
| |
Collapse
|
4
|
Melot C, Deniziaut G, Menegaux F, Chereau N. Incidental parathyroidectomy during total thyroidectomy and functional parathyroid preservation: a retrospective cohort study. BMC Surg 2023; 23:269. [PMID: 37674156 PMCID: PMC10481605 DOI: 10.1186/s12893-023-02176-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/30/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND The published rate of incidental parathyroidectomy (IP) during thyroid surgery varies between 5.8% and 29%. The risk factors and clinical significance of postoperative transient hypocalcemia and permanent hypoparathyroidism are still debated. The aims of this study were to assess the clinical relevance of avoidable IP for transient hypocalcemia and permanent hypoparathyroidism, and to describe the risk factors for IP. METHODS This retrospective cohort study included 1,537 patients who had a one-step total thyroidectomy in a high-volume endocrine surgery center between 2018 and 2019. Pathology reports were reviewed for incidentally removed parathyroid glands. Intrathyroidal parathyroid glands were excluded from the study. Demographic characteristics, potential risk factors, and postoperative calcium and PTH levels were compared between IP and control groups. RESULTS Avoidable IP occurred in 234 (15.2%) patients. Patients with IP had a higher risk of transient hypocalcemia (17.9% vs. 11.5%, p = 0.006; odds ratio [OR] 1.68, 95% confidence interval [95% CI]1.16-2.45) and permanent hypoparathyroidism (4.7% vs. 1.6%, p = 0.002; OR 3.01, 95% CI 1.29-6.63) than patients without IP. Multivariate analysis showed that central lymph node dissection (CLND) and incidental removal of thymus tissue were independent risk factors for IP (OR 4.83, 95% CI 2.71-8.86, p < 0.001 and OR 1.72, 95% CI 1.02-2.82, p = 0.038). CONCLUSIONS Patients with IP were more likely to develop transient hypocalcemia and permanent hypoparathyroidism, indicating the clinical significance of avoidable IP for patients and the need for raising awareness among surgeons. Patients undergoing CLND are at a higher risk for IP, and should be adequately informed and treated. Any removal of thymus tissue should be avoided during CLND.
Collapse
Affiliation(s)
- Charlotte Melot
- Department of General and Endocrine Surgery, Pitié Salpêtrière Hospital, APHP, Sorbonne University, 47-83 Boulevard de L'Hôpital, Paris, 75013, France.
| | - Gabrielle Deniziaut
- Department of Pathology, Pitié Salpêtrière Hospital, APHP, Sorbonne University, Paris, France
- Groupe de Recherche Clinique N°16 Thyroid Tumors, Sorbonne University, Paris, France
| | - Fabrice Menegaux
- Department of General and Endocrine Surgery, Pitié Salpêtrière Hospital, APHP, Sorbonne University, 47-83 Boulevard de L'Hôpital, Paris, 75013, France
- Groupe de Recherche Clinique N°16 Thyroid Tumors, Sorbonne University, Paris, France
| | - Nathalie Chereau
- Department of General and Endocrine Surgery, Pitié Salpêtrière Hospital, APHP, Sorbonne University, 47-83 Boulevard de L'Hôpital, Paris, 75013, France
- Groupe de Recherche Clinique N°16 Thyroid Tumors, Sorbonne University, Paris, France
| |
Collapse
|
5
|
Kuo EJ, Oh A, Hu Y, McManus CM, Lee JA, Kuo JH. If the price is right: Cost-effectiveness of radiofrequency ablation versus thyroidectomy in the treatment of benign thyroid nodules. Surgery 2023; 173:201-206. [PMID: 36334980 DOI: 10.1016/j.surg.2022.08.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/21/2022] [Accepted: 08/24/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Radiofrequency ablation is an emerging technology in the United States to treat benign thyroid nodules. The cost-effectiveness of radiofrequency ablation in comparison with traditional thyroidectomy is unknown. METHODS A patient-level state transition microsimulation decision model was constructed comparing radiofrequency ablation with lobectomy in the management of benign thyroid nodules. Our base case was a 45-year-old woman with a solitary 30-cm3 nodule. Estimates of health utilities, complications, and mortality were obtained from the literature, and costs were estimated using Medicare reimbursement data. The primary outcomes of interest included total cost, quality-adjusted life years, and incremental cost-effectiveness ratios. All model estimates were subjected to 1-way sensitivity analyses to identify factors that strongly influence cost-effectiveness. A probabilistic sensitivity analysis was run across 1 million simulations to gauge outcome confidence with a willingness-to-pay threshold set at $100,000/quality-adjusted life year. RESULTS Radiofrequency ablation was assumed to cost $5,000, with an initial success rate of 78%. Patients with volume reduction ratio <50% underwent a second treatment of radiofrequency ablation. Radiofrequency ablation represented the dominant strategy, yielding 21.31 quality-adjusted life years for a total cost of $16,563 in comparison to lobectomy, which yielded 21.13 quality-adjusted life years for a total cost of $19,262. In a 1-way sensitivity analysis varying the cost of radiofrequency ablation across of range of values, the radiofrequency ablation strategy remained cost-effective until the cost of radiofrequency ablation exceeded $12,330 at willingness-to-pay $50,000 or $17,950 at willingness-to-pay $100,000. CONCLUSION Radiofrequency ablation is a cost-effective strategy in the treatment of benign thyroid nodules but is most sensitive to the cost of radiofrequency ablation.
Collapse
Affiliation(s)
- Eric J Kuo
- Section of Endocrine Surgery, Columbia University, New York, NY.
| | - Aaron Oh
- Albert Einstein College of Medicine, New York, NY
| | - Yinin Hu
- Division of General and Oncologic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | | | - James A Lee
- Section of Endocrine Surgery, Columbia University, New York, NY
| | - Jennifer H Kuo
- Section of Endocrine Surgery, Columbia University, New York, NY
| |
Collapse
|
6
|
Urban MJ, Shimomura A, Shah S, Losenegger T, Westrick J, Jagasia AA. Rural Otolaryngology Care Disparities: A Scoping Review. Otolaryngol Head Neck Surg 2022; 166:1219-1227. [PMID: 35015580 DOI: 10.1177/01945998211068822] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/04/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To broadly synthesize the literature regarding rural health disparities in otolaryngology, categorize findings, and identify research gaps to stimulate future work. STUDY DESIGN Scoping review. DATA SOURCES A comprehensive literature search was performed in the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, and CINAHL. REVIEW METHODS The methods were developed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Peer-reviewed, English-language, US-based studies examining a rural disparity in otolaryngology-related disease incidence, prevalence, diagnosis, treatment, or outcome were included. Descriptive studies, commentaries, reviews, and letters to the editor were excluded. Studies published prior to 1980 were excluded. RESULTS The literature search resulted in 1536 unique abstracts and yielded 79 studies that met final criteria for inclusion. Seventy-five percent were published after 2010. The distribution of literature was as follows: otology (34.2%), head and neck cancer (20.3%), endocrine surgery (13.9%), rhinology and allergy (8.9%), trauma (5.1%), laryngology (3.8%), other pediatrics (2.5%), and adult sleep (1.3%). Studies on otolaryngology health care systems also accounted for 10.1%. The most common topics studied were practice patterns (41%) and epidemiology (27%), while the Southeast (47%) was the most common US region represented, and database study (42%) was the most common study design. CONCLUSION Overall, there was low-quality evidence with large gaps in the literature in all subspecialties, most notably facial plastic surgery, laryngology, adult sleep, and pediatrics. Importantly, there were few studies on intervention and zero studies on resident exposure to rural populations, which will be critical to making rural otolaryngology care more equitable in the future.
Collapse
Affiliation(s)
- Matthew J Urban
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Aoi Shimomura
- Loyola University of Chicago, Stritch School of Medicine, Maywood, Illinois, USA
| | - Swapnil Shah
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Tasher Losenegger
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Ashok A Jagasia
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| |
Collapse
|
7
|
Abstract
PURPOSE OF REVIEW Although traditionally an inpatient procedure, outpatient thyroidectomy has gained traction as a viable and well tolerated alternative for selected patients, with an added benefit of cost savings. RECENT FINDINGS Research on outpatient thyroidectomy has focused on establishing its noninferiority in outcomes compared to the standard inpatient or overnight observation. Numerous studies have found comparable low rates of postoperative complications and no increase in readmission. Selection criteria have been well established by professional societies and research studies support the selection bias benefitting appropriately selected patients. The primary benefit of outpatient thyroidectomy reported is a decrease in cost, though additional theoretical benefits such as decreased exposure to nosocomial infections. SUMMARY Outpatient thyroidectomy is a well tolerated approach in appropriately selected candidates, with cost reduction benefits. Adherence to societal guidelines for patient selection is paramount.
Collapse
|
8
|
Van Den Heede K, Tolley NS, Di Marco AN, Palazzo FF. Differentiated Thyroid Cancer: A Health Economic Review. Cancers (Basel) 2021; 13:cancers13092253. [PMID: 34067214 PMCID: PMC8125846 DOI: 10.3390/cancers13092253] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 12/22/2022] Open
Abstract
Simple Summary This review reflects on health economic considerations associated with the increasing diagnosis and treatment of differentiated thyroid cancer. Analysis of different relevant health economic topics, such as overdiagnosis, overtreatment, surgical costs, and costs of follow-up are being addressed. Several unanswered research questions such as optimising molecular markers for diagnosis, active surveillance of primary tumours, and improved risk stratification and survivorship care all influence future healthcare expenditures. Abstract The incidence of differentiated thyroid cancer (DTC) is rising, mainly because of an increased detection of asymptomatic thyroid nodularity revealed by the liberal use of thyroid ultrasound. This review aims to reflect on the health economic considerations associated with the increasing diagnosis and treatment of DTC. Overdiagnosis and the resulting overtreatment have led to more surgical procedures, increasing health care and patients’ costs, and a large pool of community-dwelling thyroid cancer follow-up patients. Additionally, the cost of thyroid surgery seems to increase year on year even when inflation is taken into account. The increased healthcare costs and spending have placed significant pressure to identify potential factors associated with these increased costs. Some truly ground-breaking work in health economics has been undertaken, but more cost-effectiveness studies and micro-cost analyses are required to evaluate expenses and guide future solutions.
Collapse
Affiliation(s)
- Klaas Van Den Heede
- Department of Endocrine & Thyroid Surgery, Hammersmith Hospital, London W12 0HS, UK; (N.S.T.); (A.N.D.M.); (F.F.P.)
- Department of General and Endocrine Surgery, OLV Hospital, 9300 Aalst, Belgium
- Correspondence:
| | - Neil S. Tolley
- Department of Endocrine & Thyroid Surgery, Hammersmith Hospital, London W12 0HS, UK; (N.S.T.); (A.N.D.M.); (F.F.P.)
- Department of Surgery and Cancer, Imperial College, London SW7 2AZ, UK
| | - Aimee N. Di Marco
- Department of Endocrine & Thyroid Surgery, Hammersmith Hospital, London W12 0HS, UK; (N.S.T.); (A.N.D.M.); (F.F.P.)
- Department of Surgery and Cancer, Imperial College, London SW7 2AZ, UK
| | - Fausto F. Palazzo
- Department of Endocrine & Thyroid Surgery, Hammersmith Hospital, London W12 0HS, UK; (N.S.T.); (A.N.D.M.); (F.F.P.)
- Department of Surgery and Cancer, Imperial College, London SW7 2AZ, UK
| |
Collapse
|
9
|
Sahli ZT, Zhou S, Sharma AK, Segev DL, Massie A, Zeiger MA, Mathur A. Rising Cost of Thyroid Surgery in Adult Patients. J Surg Res 2020; 260:28-37. [PMID: 33316757 DOI: 10.1016/j.jss.2020.11.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/28/2020] [Accepted: 11/01/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of this study is to describe the economic trends in adults who underwent elective thyroidectomy. METHODS We performed a population-based study utilizing the Premier Healthcare Database to examine adult patients who underwent elective thyroidectomy between January 2006 and December 2014. Time was divided into three equal time periods (2006-2008, 2009-2011, and 2012-2014). To examine trend in patient charges, we modeled patient charges using generalized linear regressions adjusting for key covariates with standard errors clustered at the hospital level. RESULTS Our study cohort consisted of 52,012 adult patients who underwent a thyroid operation. During the study period, the most common procedure changed from a thyroid lobectomy to bilateral thyroidectomy. Over the study period, there was an increase in the proportion of completion thyroidectomies from 1.1% to 1.6% (P < 0.001), malignant diagnoses from 21.7% to 26.8% (P < 0.001), procedures performed at teaching hospitals from 27.7% to 32.9% (P < 0.001), and procedures performed on an outpatient basis from 93.85% to 97.55% (P < 0.001). The annual increase in median patient charge adjusted for inflation was $895 or 4.3% resulting in an increase of 38.8% over 9 y. Higher thyroidectomy charges were associated with male patients, malignant surgical pathology, patients undergoing limited or radical neck dissection, experiencing complications, those with managed health care insurance, and a prolonged length of stay. CONCLUSIONS Despite recent changes in thyroid surgery practices to decrease the economic burden of hospitals, costs continue to rise 4.3% annually. Additional prospective studies are needed to identify factors associated with this increasing cost.
Collapse
Affiliation(s)
- Zeyad T Sahli
- Department of Surgery, The University of Virginia Health System, Charlottesville, Virginia.
| | - Sheng Zhou
- Center for Outcomes Research & Evaluation (CORE), Yale School of Medicine, New Haven, Connecticut
| | - Ashwyn K Sharma
- Department of Surgery, University of California San Diego Health System, San Diego, California
| | - Dorry L Segev
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Allan Massie
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Martha A Zeiger
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Aarti Mathur
- Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
10
|
Wu SY, Terrell J, Park A, Perrier N. Understanding Thyroidectomy Cost Variations Among National Cancer Institute-Designated Cancer Centers. World J Surg 2020; 44:385-392. [PMID: 31576441 DOI: 10.1007/s00268-019-05176-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The cost of thyroidectomy varies across the USA, while the causes of this variation are poorly understood. We examined the cost of inpatient thyroidectomy among National Cancer Institute-designated cancer centers nationwide to determine why it differs. METHODS A retrospective study of inpatient thyroidectomies was performed using the Vizient Clinical Data Base. Fifty-two of 70 eligible hospitals were grouped into five geographic regions (Mid-Atlantic and New England, East Central, South Atlantic, West Central, and Mountain and Pacific). We identified drivers of cost variation in the five geographic regions and used risk adjustment model to evaluate the rationality of cost from each hospital. RESULTS Male sex, more extended hospital stays, and occurrence of complications were consistently associated with increased costs in all regions. Also, the cost was significantly lower in the Mid-Atlantic and New England region. The higher than expected costs did not correlate well with the case mix index among hospitals (p = 0.289), but the lower than expected costs were more common in high-volume hospitals. The average length of stay was the shortest in high-volume hospitals, which might account for the lower cost in the Mid-Atlantic and New England region; however, the overages of costs still varied widely among hospitals in all regions even if the length of stay was adjusted. CONCLUSIONS Cost variation may result from both patient-related factors and volume-related practice pattern differences among hospitals. A more standard of care and charge transparency is still needed for patients seeking affordable care at cancer centers.
Collapse
Affiliation(s)
- Si-Yuan Wu
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
- Division of General Surgery, Departments of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - John Terrell
- Office of Performance Improvement, Unit 466, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Anne Park
- Office of Performance Improvement, Unit 466, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Nancy Perrier
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
| |
Collapse
|
11
|
Smith A, Thimmappa V, Boughter JD, Vanison C, Shires CB, Sebelik M. The effect of intrathyroidal versus intraperitoneal bevacizumab on thyroid volume and vasculature flow in a rat model. Gland Surg 2019; 8:212-217. [PMID: 31328099 DOI: 10.21037/gs.2018.09.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Several clinical conditions increase thyroid gland vascularity, impacting surgical blood loss. Bevacizumab has been observed to reduce thyroid function, possibly through its effect on gland angiogenesis. This study aimed to determine if bevacizumab has any effect on thyroid vascularity as measured by gland volume and superior thyroid artery (STA) flow velocity in the normal rat thyroid. Methods Sixteen adult female Sprague-Dawley rats were placed under general anesthesia to measure baseline thyroid gland characteristics. A Vevo 2100 high-frequency ultrasound with 40 mHz transducer was used to obtain STA flow measurements and thyroid gland dimensions. Four rats served as controls. Six rats received intrathyroidal (IT) injections and 6 received intraperitoneal (IP) injections of bevacizumab (4-5 mg/kg). After two weeks ultrasound measurements were repeated. Results Pretreatment animals displayed similar thyroid volume and vascularity. Thyroid volume decreased (62.583 vs. 42.161, P=0.004) after IP administration of bevacizumab, and blood flow measurements did not change [peak velocity 75.896 vs. 76.7, P=0.96, average velocity 45.748 vs. 43.867, P=0.88, or resistivity index (RI) 30.345 vs. 25.32, P=0.60]. IT bevacizumab did not change thyroid volume (55.229 vs. 58.16, P=0.64). The average peak (73.191 vs. 100.589 cm/s, P=0.03) and mean (45.047 vs. 62.843 m/s, P=0.03) velocities were increased, but did not differ in the RI (0.619 vs. 0.632, P=0.82). No differences were noted on VEGF or CD 31 immunohistochemical analysis. Conclusions Single systemic administration of bevacizumab appears to decrease thyroid volume without an effect on STA flow, VEGF or CD31 staining. These preliminary findings support further study of pharmacologic intervention in thyroid conditions characterized by increased angiogenesis and vascularity, such as iodine deficiency, Graves disease, and hypothyroidism.
Collapse
Affiliation(s)
- Aaron Smith
- Department of Otolaryngology, Head & Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Vikrum Thimmappa
- Department of Otolaryngology, Head & Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - John D Boughter
- Department of Anatomy and Neurobiology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Christopher Vanison
- Department of Otolaryngology, Head & Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Courtney B Shires
- Department of Otolaryngology, Head & Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Merry Sebelik
- Department of Otolaryngology, Head & Neck Surgery, Emory University, Atlanta, GA, USA
| |
Collapse
|
12
|
Galindo RJ, Hurtado CR, Pasquel FJ, García Tome R, Peng L, Umpierrez GE. National Trends in Incidence, Mortality, and Clinical Outcomes of Patients Hospitalized for Thyrotoxicosis With and Without Thyroid Storm in the United States, 2004-2013. Thyroid 2019; 29:36-43. [PMID: 30382003 PMCID: PMC6916241 DOI: 10.1089/thy.2018.0275] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Current evidence on the incidence and outcomes of patients with thyroid storm in the United States is limited to single-center case series. This study determined the national incidence of thyrotoxicosis with and without thyroid storm and clinical outcomes among hospitalized patients during a 10-year period in the United States. METHODS Retrospective longitudinal analysis was conducted of clinical characteristics, mortality, hospital length of stay, and costs from 2004 to 2013. Adults (≥18 years of age) with a primary diagnosis of thyrotoxicosis with and without thyroid storm were included. To determine the incidence, outcomes, and cost of thyrotoxicosis with and without thyroid storm, the study used data from the National Inpatient Sample database, the largest public inpatient database, with a representative sample of all non-federal hospitals in the United States. RESULTS Among 121,384 discharges with thyrotoxicosis during the study period (Mage ± standard error = 48.7 ± 0.11 years; 51.9% Caucasian; 77.3% female), 19,723 (16.2%) were diagnosed with thyroid storm. During the past decade, the incidence of thyroid storm ranged between 0.57 and 0.76 cases/100,000 U.S. persons per year, and 4.8 and 5.6/100,000 hospitalized patients per year. Thyroid storm was associated with significantly higher hospital mortality (1.2-3.6% vs. 0.1-0.4%, p < 0.01) and longer length of stay (4.8-5.6 vs. 2.7-3.4 mean days, p < 0.001) compared to patients with thyrotoxicosis without storm. Inflation-adjusted hospitalization costs progressively increased in patients with thyroid storm from $9942 to $12,660 between 2004 and 2013 (p < 0.01). CONCLUSIONS One of every six discharges for thyrotoxicosis was diagnosed with thyroid storm. Thyroid storm is associated with a 12-fold higher mortality rate compared to thyrotoxicosis without storm. The incidence and mortality of thyroid storm has not substantially changed in the past decade. However, hospitalization costs have significantly increased.
Collapse
Affiliation(s)
- Rodolfo J. Galindo
- Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, Georgia
- Address correspondence to: Rodolfo J. Galindo, MD, Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, 69 Jesse Hill Jr. Dr., Glenn Bld #202, Atlanta, GA 30303
| | - Carolina R. Hurtado
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Francisco J. Pasquel
- Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, Georgia
| | - Rodrigo García Tome
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Limin Peng
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Guillermo E. Umpierrez
- Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, Georgia
| |
Collapse
|
13
|
Ziegler A, Lazzara G, Thorpe E. Safety and Efficacy of Outpatient Parotidectomy. J Oral Maxillofac Surg 2018; 76:2433-2436. [PMID: 29792835 DOI: 10.1016/j.joms.2018.04.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/24/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Given the increasing costs of medical care, there has been a shift to outpatient elective surgeries in certain patient populations among all surgical specialties. The goal of this study was to compare the safety and efficacy of outpatient parotidectomy with traditional inpatient parotidectomy. MATERIALS AND METHODS This is a retrospective chart review of all patients who underwent a parotidectomy at a single tertiary academic center from 2007 through 2017. RESULTS There were 568 patients who met the inclusion criteria. There was no difference in demographics or patient comorbidities between the inpatient and outpatient groups. There was no increased incidence of postoperative complications or extent of postoperative care in patients who underwent outpatient parotidectomy. On average at the authors' institution, the direct outpatient parotidectomy cost was $1,200 less than the inpatient equivalent. CONCLUSION Outpatient parotidectomy can be performed safely and cost effectively with no increased risk of complications.
Collapse
Affiliation(s)
- Andrea Ziegler
- Resident, Department of Otolaryngology, Loyola University Medical Center, Maywood, IL.
| | - Gina Lazzara
- Medical Student, Stritch School of Medicine, Maywood, IL
| | - Eric Thorpe
- Program Director, Department of Otolaryngology, Loyola University Medical Center, Maywood, IL
| |
Collapse
|
14
|
Smith A, Braden L, Wan J, Sebelik M. Association of Otolaryngology Resident Duty Hour Restrictions With Procedure-Specific Outcomes in Head and Neck Endocrine Surgery. JAMA Otolaryngol Head Neck Surg 2017; 143:549-554. [PMID: 28196195 DOI: 10.1001/jamaoto.2016.4182] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Graduate medical education has undergone a transformation from traditional long work hours to a restricted plan to allow adequate rest for residents. The initial goal of this restriction is to improve patient outcomes. Objective To determine whether duty hour restrictions had any impact on surgery-specific outcomes by analyzing complications following thyroid and parathyroid procedures performed before and after duty hour reform. Design, Setting, and Participants Retrospective cross-sectional analysis of the National Inpatient Sample (NIS).The NIS was queried for procedure codes associated with thyroid and parathyroid procedures for the years 2000 to 2002 and 2006 to 2008. Hospitals were divided based on teaching status into 3 groups: nonteaching hospitals (NTHs), teaching hospitals without otolaryngology programs (THs), and teaching hospitals with otolaryngology programs (THs-OTO). Main Outcomes and Measures Procedure-specific complication rates, length of stay, and mortality rates were collected. SAS statistical software (version 9.4) was used for analysis with adjustment using Charlson comorbidity index. Results Total numbers of head and neck endocrine procedures were 34 685 and 39 770 (a 14.7% increase), for 2000 to 2002 and 2006 to 2008, respectively. THs-OTO contributed a greater share of procedures in 2006 to 2008 (from 18% to 25%). With the earlier period serving as the reference, length of stay remained constant (2.1 days); however, total hospital charges increased (from $12 978 to $23 708; P < .001). Rates of postoperative hematoma (odds ratio [OR], 1.21; 95% CI, 1.06-1.38), hypoparathyroidism (OR, 1.27; 95% CI, 1.06-1.52), and unintentional vessel lacerations (OR, 1.36; 95% CI, 1.02-1.83) increased overall with NTHs (OR, 1.26; 95% CI, 1.04-1.52), THs (OR, 1.65; 95% CI, 1.15-2.37), and THs-OTO (OR, 1.98; 95% CI, 1.09-3.61) accounting for these differences, respectively. Overall mortality decreased (OR, 0.66; 95% CI, 0.47-0.94) following a decrease in the TH-OTO mortality rate (OR, 0.34; 95% CI, 0.12-0.93). Conclusions and Relevance While recurrent laryngeal nerve injury, hematoma formation, and hypoparathyroidism did not change, length of stay and mortality improved within THs-OTO following head and neck endocrine procedures after implementation of duty hour regulations. This finding refutes the concern that duty hour restrictions result in poorer overall outcomes. Less time available to develop technical competence may play a factor in some outcomes in lieu of recurrent laryngeal nerve injury increasing within THs and accidental injury to vessels, organs, or nerves and hypocalcemia increasing within THs-OTO. Furthermore, head and neck endocrine cases increased at THs with otolaryngology programs.
Collapse
Affiliation(s)
- Aaron Smith
- Department of Otolaryngology-Head & Neck Surgery, University of Tennessee Health Science Center, Memphis
| | - Lauren Braden
- Department of Otolaryngology-Head & Neck Surgery, University of Tennessee Health Science Center, Memphis
| | - Jim Wan
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis
| | - Merry Sebelik
- Department of Otolaryngology-Head & Neck Surgery, University of Tennessee Health Science Center, Memphis
| |
Collapse
|
15
|
Greenleaf EK, Goyal N, Hollenbeak CS, Boltz MM. Resource utilization associated with cervical hematoma after thyroid and parathyroid surgery. J Surg Res 2017; 218:67-77. [PMID: 28985879 DOI: 10.1016/j.jss.2017.04.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 03/06/2017] [Accepted: 04/29/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Postoperative cervical hematoma (PCH) after thyroid and parathyroid surgery is a well-known complication. This study used data from the Nationwide Inpatient Sample to identify risk factors, estimate mortality, length of stay (LOS), and total costs attributable to PCH in patients undergoing procedures for thyroid and parathyroid diseases. METHODS Patients aged >18 y who underwent thyroid or parathyroid surgery between 2001 and 2011 were identified and stratified by the occurrence of PCH. Univariate analyses of patient demographics, clinical and hospital characteristics were performed. Multivariable logistic regression was used to determine risk factors for hematoma formation. LOS and costs were fit to linear regression models to determine the effect of PCH after adjusting for patient and hospital characteristics. RESULTS Of patients who underwent thyroid or parathyroid surgery, 619 patients (0.8%) had a PCH. Predisposing factors included nonelective admission (emergent: OR = 2.01, P < 0.0001; urgent: OR = 1.47, P = 0.003), diagnosis of Graves' disease (OR = 1.90, P < 0.0001), or other benign pathology (OR = 1.43, P = 0.011) and having ≥2 comorbidities (2-3 comorbidities, OR = 1.24; P = 0.036 and ≥ 4 comorbidities, OR = 2.28; P < 0.0001). After adjusting for those characteristics, the total excess LOS and costs attributable to PCH were 2.1 d (P < 0.0001) and $7316 (P < 0.0001), respectively. In addition, after risk adjustment, odds of mortality more than tripled (P < 0.0001) in the setting of PCH. CONCLUSIONS Because risk for PCH is largely driven by preoperative patient risk factors, five clinicians have an opportunity to stratify patients accordingly and thereby minimize the resource utilization and health care spending among those with lowest risk.
Collapse
Affiliation(s)
- Erin K Greenleaf
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Neerav Goyal
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Christopher S Hollenbeak
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Melissa M Boltz
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania.
| |
Collapse
|
16
|
Abstract
PURPOSE OF REVIEW This article provides an update on the role of the essential trace element selenium and its interaction with the other trace elements iodine and iron that together contribute to adequate thyroid hormone status. Synthesis, secretion, metabolism and action of thyroid hormone in target tissues depend on a balanced nutritional availability or supplementation of these elements. Selenium status is altered in benign and malignant thyroid diseases and various selenium compounds have been used to prevent or treat widespread diseases such as goiter, autoimmune thyroid disease or thyroid cancer. RECENT FINDINGS Several studies, most with still too low numbers of cases, indicate that selenium administration in both autoimmune thyroiditis (Hashimoto thyroiditis) and mild Graves' disease improves clinical scores and well-being of patients and reduces thyroperoxidase antibody titers. However, published results are still conflicting depending on basal selenium status, dose, time and form of selenium used for intervention. Evidence for sex-specific selenium action, lack of beneficial effects in pregnancy and contribution of genetic polymorphisms (selenoprotein S) has been presented. SUMMARY Adequate nutritional supply of selenium that saturates expression of circulating selenoprotein P, together with optimal iodine and iron intake, is required for a healthy and functional thyroid during development, adolescence, adulthood and aging.
Collapse
Affiliation(s)
- Josef Köhrle
- Institute of Experimental Endocrinology, Charité University Medicine Berlin, Berlin, Germany
| |
Collapse
|