Thyroid cancer surgeries at very low-volume centers increase odds for complications
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Key takeaways:
- Adults living in lower socioeconomic areas were more likely to have thyroid cancer surgery at an ultra-low volume clinic.
- Ultra-low volume centers were linked to higher odds for complications and reoperation.
Adults who undergo thyroid cancer surgery at clinics performing five or fewer operations per year are more likely to have recurrence or persistent disease than those attending higher-volume centers, according to study data.
In an analysis of data from California, researchers examined outcomes for patients with thyroid cancer who underwent surgery from 1999 to 2017. The study found adults had worse outcomes if they had surgery at a hospital that performed few thyroid surgery procedures. Additionally, Hispanic, Asian and American Indian adults and those living in lower socioeconomic area were more likely to have procedures performed at ultra-low volume clinics.
“The inferior patient outcomes at ultra-low volume centers expands on our current understanding of the relationship between surgical volume and patient outcomes, specifically in thyroid cancer,” James X. Wu, MD, endocrine surgeon and assistant professor of surgery at the David Geffen School of Medicine at UCLA, and colleagues wrote in a study published in Thyroid.
Researchers obtained data from the California Office of Statewide Health and Planning Development of adults who underwent a thyroid lobectomy, thyroidectomy or lymph node dissection from 1999 to 2017. Patient characteristics, Charlson Comorbidity Index and insurance status were collected. Researchers obtained census tract characteristics, including median household income, average years of schooling, percentage of resident with blue-collar jobs, unemployment rate and percent of people living below the 200% federal poverty line. Surgery complications included endocrine, nerve, airway, wound and bleeding complications. Researchers also analyzed the use of guideline-concordant adjuvant radioactive iodine ablation, reoperation for cancer recurrence, 30-day mortality and in-hospital mortality. Facilities were classified as having an ultra-low volume of thyroid cancer surgeries if they treated five or fewer cases per year, low volume if they performed six to 25 surgeries per year, mid volume if they performed 26 to 50 surgeries per year and high volume if they performed more than 50 procedures annually.
There were 52,599 adults with thyroid cancer who had surgery at 505 centers during the study period. Of all procedures performed, 39% took place at low-volume centers, 34% at high-volume centers, 15% at mid-volume centers and 12% at ultra-low volume centers.
Disparities with access to thyroid cancer care
Hispanic adults, Asian/Pacific Islander adults and American Indian adults were more likely to have surgery at an ultra-low volume center than white adults (P < .01 for all), and women were more likely to attend an ultra-low volume center than men (P = .03). Ultra-low volume centers were accessed more by adults in the lowest three quintiles of socioeconomic status, those with no insurance and adults receiving Medicaid or Medicare (P < .01 for all). Adults attending low-volume centers were also more likely to come from areas with lower median incomes, fewer years of schooling, more blue-collar jobs, higher unemployment and more people living below the 200% poverty line (P < .01 for all). Ultra-low volume centers performed higher rates of thyroid lobectomies and the lowest rate of total thyroidectomies with lymph node dissection of all hospital volume categories.
Ultra-low volume centers increase odds for complications
After adjusting for high-risk tumor features, adults who underwent surgery at an ultra-low volume center were more likely to have reoperation for recurrent diseases than adults who attended a low-volume center (adjusted OR = 1.17; 95% CI, 1.02-1.35) mid-volume center (aOR = 1.25; 95% CI, 1.06-1.46) or high-volume center (aOR = 1.26; 95% CI, 1.03-1.56). Of adults who received hard indications for radioactive iodine ablation, those who attended an ultra-low volume center were less likely to receive it than adults treated at the three higher-volume centers (OR = 0.77; 95% CI, 0.72-0.82).
“Several reasons may underlie the lower rate of appropriate radioactive iodine use at ultra-low volume centers,” the researchers wrote. “Administration of radioactive iodine necessitates the availability of nuclear medicine, a highly specialized field involving specialty equipment, infrastructure and personnel to deliver care. These may not be available in lower-resourced settings. Many ultra-low volume centers, particularly in rural areas, do not have endocrinologists, the practitioners who typically prescribe and oversee radioactive iodine ablation. Encouraging more fellowship-trained endocrinologists to provide at least partial coverage in rural areas, particularly by telemedicine, may close the aperture on some of these disparities.”
Compared with adults treated at mid-volume centers, those attending ultra-low volume centers were more likely to have wound complications (OR = 1.44; 95% CI, 1.06-1.94; P = .02) or airway complications (OR = 1.21; 95% CI, 1.02-1.43; P = .03) stemming from surgery.
“Quality improvement initiatives at ultra-low volume centers may focus on these areas to improve delivery of high-quality thyroid cancer treatment,” the researchers wrote. “Partial coverage by fellowship-trained endocrinologists and endocrine surgeons at these centers may provide an opportunity to close the aperture on these disparities. Equally, higher-volume centers should interrogate their financial barriers to patients receiving thyroid cancer care.”
Perspective
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The study by Huston-Paterson and colleagues highlights an important issue and ongoing dilemma in thyroid cancer care. There are clear disparities in patient outcomes with vulnerable patients at greatest risk for poor care and subsequent adverse events. As surgeons operate within hospitals, it is expected that in addition to surgeon volume, the volume and experience of the hospital is relevant to patient outcome and patient receipt of guideline-concordant care.
The findings by Huston-Paterson and colleagues are extremely important, but perhaps not surprising. However, the work does shed light on an ongoing dilemma. If ultra-low hospital volume (and directly related to this, low-surgeon volume) correlates with worse patient outcomes, how is this issue best addressed? Is the solution to redirect patients to high-volume centers? If so, does this create new obstacles, such as transportation barriers? Is the solution to send trained surgeons to these ultra-low volume centers to operate? Or is the solution better training for surgeons at the ultra-low volume hospitals, potentially by nearby high-volume surgeons? If so, how does society incentivize this sharing of expertise? Physicians and policymakers should begin to consider how best to achieve equitable care for all patients diagnosed with thyroid cancer.
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