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AHNS Endocrine Surgery Section
Guidelines
https://endocrine.ahns.info
North American Quality Statements and
Evidence Based...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Care for patients with thyroid nodules is complex and
multi...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Consensus Author Panel
• National, multidisciplinary effort...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Rigorous method to achieve consensus
• Consensus achieved i...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule Preoperative Workup
Figure 1. THYROID NODULE P...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule Preoperative Workup
Figure 1. THYROID NODULE P...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
EUTHYROID
NODULE
Tracking
Metric 1
Obtain US ofthyroid
and al...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule Preoperative Workup
Figure 1. THYROID NODULE P...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Bethesda I
Nondiagnostic
RepeatFNA
biopsy in 3mos
(ATA A12/RE...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Consensus on Statements 1-6
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule
Perioperative Management
Figure 2. THYROID NOD...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule
Perioperative Management
Figure 2. THYROID NOD...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule
Perioperative Management
Figure 2. THYROID NOD...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule
Perioperative Management
Figure 2. THYROID NOD...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Pathology Results
If malignant, should include:
 Histologic ...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Consensus on Statements 7-8
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule
Postoperative Management
Figure 3. THYROID NOD...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule
Postoperative Management
Figure 3. THYROID NOD...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Empiric therapy
Calcium1000-1200 mgTID
+/- calcitriol 0.25-0....
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Thyroid Nodule
Postoperative Management
Figure 3. THYROID NOD...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Order post-op thyroid
hormonereplacement for
patients followi...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
Consensus on Statements 9-16
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
1. Clinic and OR Access
2. Risk Stratification
3. Monitoring ...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Monitoring access to specialist consultation and
elective s...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Risk stratification utilizing thyroid sonography with
surve...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
The institutional or system wide annual rate of
thyroidectomi...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Utilization of Bethesda classification is important for
con...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• To avoid the potential complications associated with
reoper...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Surgical volume is a positive indicator of more efficient
a...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Antibiotics are not usually recommended for clean
surgeries...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• To have an understanding of true post op voice status
follo...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Monitoring post-operative serum thyroglobulin levels
for pa...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• The AJCC Staging and Dynamic Risk Stratification
systems fo...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Patients should have their vocal cord function
evaluated be...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Mortality rates should be monitored after thyroid
surgery
M...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Readmission rates within the first 30 days following
thyroi...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• Reoperation rate during the first 30 days is an indicator
f...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• For patients who require high dose vitamin D
supplementatio...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• The average length of stay is a good proxy for
perioperativ...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
• These workflows and quality metric provide a
simplified app...
AHNS Endocrine Surgery Section - https://endocrine.ahns.info
North American Quality Statements and
Evidence Based Multidis...
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North American quality statements and evidence based multidisciplinary workflow algorithms for the evaluation and management of thyroid nodules

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Care for patients with thyroid nodules is complex and multidisciplinary. Has been shown to vary significantly between institutions and providers. Goal was to reduce unwarranted variation and improve quality of care

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North American quality statements and evidence based multidisciplinary workflow algorithms for the evaluation and management of thyroid nodules

  1. 1. AHNS Endocrine Surgery Section Guidelines https://endocrine.ahns.info North American Quality Statements and Evidence Based Multidisciplinary Workflow Algorithms for the Evaluation and Management of Thyroid Nodules Meltzer CJ, Irish J, Odell M, Wiseman SM, Haymart MR, Shin J, Monteiro E, Ferris RL, Wong RJ, Tuttle RM, Morris JC, Haugen BR, Morris LGT, McIver B, Busady NL, Mechanick JI, Harrell RM, Shonka DC, Scharpf J, Dwojak S, Urken M, Davies L, Thompson GB, Angelos P, Randolph GW
  2. 2. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
  3. 3. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • Care for patients with thyroid nodules is complex and multidisciplinary • Has been shown to vary significantly between institutions and providers • Goal was to reduce unwarranted variation and improve quality of care Background
  4. 4. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • Consensus Author Panel • National, multidisciplinary effort • Members of AHNS Endocrine Surgery Section, endocrine surgeons, head & neck surgeons, endocrinologists • Modified Delphi approach • Source Documents • Workflow algorithm from Kaiser Permanente Northern California • Workflow algorithm from Cancer Care of Ontario Consensus Development
  5. 5. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • Rigorous method to achieve consensus • Consensus achieved in 2 rounds • Likert scale ranging from 1 (strongly disagree) to 9 (strongly agree) used • RAND/UCLA Appropriateness method used to quantify findings • Consensus criteria required a median of > 7.0 to agree • Disagreement index (DI) calculated at >1.0 indicated disagreement Consensus Process
  6. 6. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Thyroid Nodule Preoperative Workup Figure 1. THYROID NODULE PREOPERATIVE WORKUP EUTHYROID NODULE Tracking Metric 1 Obtain US ofthyroid and all anterior and lateral neck structures (ATA A8/REC 6)* Risk stratification of US using ATA or ACR TIRADS Tracking Metric 2 No nodule or nodules smaller than FNA sizecut-off ATA Benign or TIRADS **1 TIRADS 2 ATA Very low suspicion TIRADS 3 ATA Intermediate Suspicion Observe (ATA A8/REC 8E) Tracking Metric 3 FNA 2 cm (ATA A9/REC 8D) FNA 2.5 cm FNA 1.5 cm (ATA A9/REC 8C) FNA 1 cm (ATA A9/REC 8B) FNA 1 cm (ATA A9 /REC 8A) Utilization of Bethesda System for Reporting Thyroid Cytopathology (ATA A11/REC 9) Bethesda I Nondiagnostic Repeat FNA biopsy in 3 mos (ATA A12/REC 10A) US very low risk nodules, consider US in 2 yrs (ATA A24/REC 23C) Bethesda V-VI Suspicious for malignancy or malignant Bethesda III AUS/FLUS If Bethesda I again, consider observation vs. diagnostic lobectomy (ATA 12/REC 10B/C) IfBethesda II-VI, follow the appropriate path Bethesda II Benign If FNA is repeated and again found to bebenign, no further surveillance is indicated (ATA A25/REC 23D) US low to intermediate risk nodules or TIRADS 3, consider repeat US in 12-24 mos (ATA A24/REC 23 B) If evidence of growth 2 mmin 2 dimensions or 50% change in volume or suspicious US findings, repeat FNA (ATA A24/REC 23B) Bethesda IV Follicular neoplasm or suspicious for a follicular neoplasm US high risk nodules or TIRADS 4-5, consider repeat US or FNAin 6-12 mos (ATA A24/REC 23A) If repeat FNA is benign, no further surveillance is indicated (ATA A25/REC 23D) If repeat US still appears high risk, consider repeat US at 2-3 yrs and less often if stable Repeat FNAbiopsy in 3 mos or surveillance or surgery Consider molecular testing or surveillance or surgery (ATA A17/REC 15) Order perioperative serum calcium test for alland serum calcitonin for known or suspected medullary CA RoutineTSH suppression NOT recommended (ATA A27/REC 25) Repeat FNA yields AUS/ FLUS Tracking Metric 5 If initial US did not include lateral neck, then repeat US of central and lateral neck with FNA of any suspicious nodes > 8-10 mmin smallest diameter (ATA B4/REC 32) Obtain cross-sectional imaging with contrast or MRI if there are abnormal nodes at the limits ofthe sonogram, extensive nodaldisease or the primary tumor is very large or invasive (ATA 85/REC 33) Surgery consult with high volume surgeon (ATA A14/REC 12) Tracking Metric 6 PATHOLOGY MEDICAL IMAGING SURGERY ENDOCRINOLOGY STRONG RECOMMENDATION – High quality evidence STRONG RECOMMENDATION – Moderate quality evidence STRONG RECOMMENDATION – Low quality evidence WEAK RECOMMENDATION – Moderate quality evidence WEAK RECOMMENDATION– Low quality evidence  AUS – Atypia of unknown significance  FLUS – Follicular lesion of undetermined significance  CT – Computed tomography  MRI – Magnetic resonance imaging  US – Ultrasound  FNA – Fine-needle aspiration NOTE: There are slightly different management recommendations from the ATA and ACR: *2015 ATA Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Cancer **ACR Thyroid Imaging, Reporting, and Data System (TIRADS): White Paper of the ACR TIRADS Committee Tracking Metric 4 IMAGING/ ENDOCRINOLOGY ATA Low suspicion or TIRADS 4 ATA High suspicion or TIRADS 5
  7. 7. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Thyroid Nodule Preoperative Workup Figure 1. THYROID NODULE PREOPERATIVE WORKUP EUTHYROID NODULE Tracking Metric 1 Obtain US ofthyroid and all anterior and lateral neck structures (ATA A8/REC 6)* Risk stratification of US using ATA or ACR TIRADS Tracking Metric 2 No nodule or nodules smaller than FNA sizecut-off ATA Benign or TIRADS **1 TIRADS 2 ATA Very low suspicion TIRADS 3 ATA Intermediate Suspicion Observe (ATA A8/REC 8E) Tracking Metric 3 FNA 2 cm (ATA A9/REC 8D) FNA 2.5 cm FNA 1.5 cm (ATA A9/REC 8C) FNA 1 cm (ATA A9/REC 8B) FNA 1 cm (ATA A9 /REC 8A) Utilization of Bethesda System for Reporting Thyroid Cytopathology (ATA A11/REC 9) Bethesda I Nondiagnostic Repeat FNA biopsy in 3 mos (ATA A12/REC 10A) US very low risk nodules, consider US in 2 yrs (ATA A24/REC 23C) Bethesda V-VI Suspicious for malignancy or malignant Bethesda III AUS/FLUS If Bethesda I again, consider observation vs. diagnostic lobectomy (ATA 12/REC 10B/C) IfBethesda II-VI, follow the appropriate path Bethesda II Benign If FNA is repeated and again found to bebenign, no further surveillance is indicated (ATA A25/REC 23D) US low to intermediate risk nodules or TIRADS 3, consider repeat US in 12-24 mos (ATA A24/REC 23 B) If evidence of growth 2 mmin 2 dimensions or 50% change in volume or suspicious US findings, repeat FNA (ATA A24/REC 23B) Bethesda IV Follicular neoplasm or suspicious for a follicular neoplasm US high risk nodules or TIRADS 4-5, consider repeat US or FNAin 6-12 mos (ATA A24/REC 23A) If repeat FNA is benign, no further surveillance is indicated (ATA A25/REC 23D) If repeat US still appears high risk, consider repeat US at 2-3 yrs and less often if stable Repeat FNAbiopsy in 3 mos or surveillance or surgery Consider molecular testing or surveillance or surgery (ATA A17/REC 15) Order perioperative serum calcium test for alland serum calcitonin for known or suspected medullary CA RoutineTSH suppression NOT recommended (ATA A27/REC 25) Repeat FNA yields AUS/ FLUS Tracking Metric 5 If initial US did not include lateral neck, then repeat US of central and lateral neck with FNA of any suspicious nodes > 8-10 mmin smallest diameter (ATA B4/REC 32) Obtain cross-sectional imaging with contrast or MRI if there are abnormal nodes at the limits ofthe sonogram, extensive nodaldisease or the primary tumor is very large or invasive (ATA 85/REC 33) Surgery consult with high volume surgeon (ATA A14/REC 12) Tracking Metric 6 PATHOLOGY MEDICAL IMAGING SURGERY ENDOCRINOLOGY STRONG RECOMMENDATION – High quality evidence STRONG RECOMMENDATION – Moderate quality evidence STRONG RECOMMENDATION – Low quality evidence WEAK RECOMMENDATION – Moderate quality evidence WEAK RECOMMENDATION– Low quality evidence  AUS – Atypia of unknown significance  FLUS – Follicular lesion of undetermined significance  CT – Computed tomography  MRI – Magnetic resonance imaging  US – Ultrasound  FNA – Fine-needle aspiration NOTE: There are slightly different management recommendations from the ATA and ACR: *2015 ATA Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Cancer **ACR Thyroid Imaging, Reporting, and Data System (TIRADS): White Paper of the ACR TIRADS Committee Tracking Metric 4 IMAGING/ ENDOCRINOLOGY ATA Low suspicion or TIRADS 4 ATA High suspicion or TIRADS 5
  8. 8. AHNS Endocrine Surgery Section - https://endocrine.ahns.info EUTHYROID NODULE Tracking Metric 1 Obtain US ofthyroid and all anterior and lateral neck structures (ATA A8/REC 6)* Risk stratification of US usingATA or ACR TIRADS Tracking Metric 2 No nodule or nodules smaller than FNA sizecut-off ATA Benign or TIRADS **1 TIRADS 2 ATA Very low suspicion TIRADS 3 ATA Intermediate Suspicion Observe (ATA A8/REC 8E) Tracking Metric 3 FNA 2 cm (ATA A9/REC 8D) FNA 2.5 cm FNA 1.5 cm (ATA A9/REC 8C) FNA 1 cm (ATA A9/REC 8B) FNA 1 cm (ATA A9 /REC 8A) Utilization of Bethesda System for Reporting Thyroid Cytopathology (ATA A11/REC 9) PATHOLOGY MEDICAL IMAGING SURGERY ENDOCRINOLOGY STRONG RECOMMENDATION – High quality evidence STRONG RECOMMENDATION – Moderate quality evidence STRONG RECOMMENDATION – Low quality evidence WEAK RECOMMENDATION– Moderate quality evidence WEAK RECOMMENDATION– Low quality evidence Tracking Metric 4 IMAGING/ ENDOCRINOLOGY ATA Low suspicion or TIRADS 4 ATA High suspicion or TIRADS 5
  9. 9. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Thyroid Nodule Preoperative Workup Figure 1. THYROID NODULE PREOPERATIVE WORKUP EUTHYROID NODULE Tracking Metric 1 Obtain US ofthyroid and all anterior and lateral neck structures (ATA A8/REC 6)* Risk stratification of US using ATA or ACR TIRADS Tracking Metric 2 No nodule or nodules smaller than FNA sizecut-off ATA Benign or TIRADS **1 TIRADS 2 ATA Very low suspicion TIRADS 3 ATA Intermediate Suspicion Observe (ATA A8/REC 8E) Tracking Metric 3 FNA 2 cm (ATA A9/REC 8D) FNA 2.5 cm FNA 1.5 cm (ATA A9/REC 8C) FNA 1 cm (ATA A9/REC 8B) FNA 1 cm (ATA A9 /REC 8A) Utilization of Bethesda System for Reporting Thyroid Cytopathology (ATA A11/REC 9) Bethesda I Nondiagnostic Repeat FNA biopsy in 3 mos (ATA A12/REC 10A) US very low risk nodules, consider US in 2 yrs (ATA A24/REC 23C) Bethesda V-VI Suspicious for malignancy or malignant Bethesda III AUS/FLUS If Bethesda I again, consider observation vs. diagnostic lobectomy (ATA 12/REC 10B/C) IfBethesda II-VI, follow the appropriate path Bethesda II Benign If FNA is repeated and again found to bebenign, no further surveillance is indicated (ATA A25/REC 23D) US low to intermediate risk nodules or TIRADS 3, consider repeat US in 12-24 mos (ATA A24/REC 23 B) If evidence of growth 2 mmin 2 dimensions or 50% change in volume or suspicious US findings, repeat FNA (ATA A24/REC 23B) Bethesda IV Follicular neoplasm or suspicious for a follicular neoplasm US high risk nodules or TIRADS 4-5, consider repeat US or FNAin 6-12 mos (ATA A24/REC 23A) If repeat FNA is benign, no further surveillance is indicated (ATA A25/REC 23D) If repeat US still appears high risk, consider repeat US at 2-3 yrs and less often if stable Repeat FNAbiopsy in 3 mos or surveillance or surgery Consider molecular testing or surveillance or surgery (ATA A17/REC 15) Order perioperative serum calcium test for alland serum calcitonin for known or suspected medullary CA RoutineTSH suppression NOT recommended (ATA A27/REC 25) Repeat FNA yields AUS/ FLUS Tracking Metric 5 If initial US did not include lateral neck, then repeat US of central and lateral neck with FNA of any suspicious nodes > 8-10 mmin smallest diameter (ATA B4/REC 32) Obtain cross-sectional imaging with contrast or MRI if there are abnormal nodes at the limits ofthe sonogram, extensive nodaldisease or the primary tumor is very large or invasive (ATA 85/REC 33) Surgery consult with high volume surgeon (ATA A14/REC 12) Tracking Metric 6 PATHOLOGY MEDICAL IMAGING SURGERY ENDOCRINOLOGY STRONG RECOMMENDATION – High quality evidence STRONG RECOMMENDATION – Moderate quality evidence STRONG RECOMMENDATION – Low quality evidence WEAK RECOMMENDATION – Moderate quality evidence WEAK RECOMMENDATION– Low quality evidence  AUS – Atypia of unknown significance  FLUS – Follicular lesion of undetermined significance  CT – Computed tomography  MRI – Magnetic resonance imaging  US – Ultrasound  FNA – Fine-needle aspiration NOTE: There are slightly different management recommendations from the ATA and ACR: *2015 ATA Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Cancer **ACR Thyroid Imaging, Reporting, and Data System (TIRADS): White Paper of the ACR TIRADS Committee Tracking Metric 4 IMAGING/ ENDOCRINOLOGY ATA Low suspicion or TIRADS 4 ATA High suspicion or TIRADS 5
  10. 10. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Bethesda I Nondiagnostic RepeatFNA biopsy in 3mos (ATA A12/REC10A) USverylowrisk nodules,consider USin 2yrs (ATA A24/REC23C) Bethesda V-VI Suspiciousfor malignancy or malignant Bethesda III AUS/FLUS IfBethesdaIagain, consider observationvs. diagnostic lobectomy (ATA 12/REC10B/C) IfBethesdaII-VI, followthe appropriatepath Bethesda II Benign IfFNA is repeated andagainfoundto bebenign,no furthersurveillance is indicated (ATA A25/REC23D) USlowtointermediate risk nodulesorTIRADS 3,considerrepeatUS in 12-24 mos (ATA A24/REC23 B) Ifevidenceof growth 2mmin2 dimensions or 50% changeinvolumeor suspicious USfindings, repeatFNA (ATA A24/REC23B) Bethesda IV Follicularneoplasm orsuspicious for a follicularneoplasm UShighrisknodules or TIRADS 4-5,consider repeatUSorFNAin 6-12 mos (ATA A24/REC23A) IfrepeatFNA is benign, nofurthersurveillance is indicated (ATA A25/REC23D) IfrepeatUS still appears highrisk, considerrepeatUS at 2-3yrsandlessoftenif stable RepeatFNAbiopsy in 3mos or surveillanceor surgery Consider molecular testingor surveillanceor surgery (ATA A17/REC15) Orderperioperative serumcalciumtest forallandserum calcitoninforknown orsuspected medullaryCA RoutineTSH suppressionNOT recommended (ATA A27/REC25) RepeatFNA yieldsAUS/ FLUS Tracking Metric 5 IfinitialUSdidnot includelateralneck,then repeatUSofcentraland lateralneckwithFNA of anysuspicious nodes >8-10 mminsmallest diameter (ATA B4/REC32) Obtaincross-sectional imaging withcontrastor MRIif thereare abnormalnodes atthe limits ofthesonogram, extensivenodaldisease ortheprimarytumoris verylargeorinvasive (ATA85/REC33) Surgery consultwith highvolumesurgeon (ATA A14/REC12) Tracking Metric 6
  11. 11. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Consensus on Statements 1-6
  12. 12. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Thyroid Nodule Perioperative Management Figure 2. THYROID NODULE PERIOPERATIVE MANAGEMENT Consider total thyroidectomy (ATA A21/REC 20) Surgeon:  Provides informed consent (ATA B11/REC 39)  Confirms plan with/or notifies endocrinologist ifpatient opts for a different procedure other than theoriginal recommendation  Performs pre-op voice or vocalfold assessment Document quality of voice or laryngeal examination (ATA B12/REC 40) Laryngeal examination (ATA B12/REC 41) Tracking Metric 7 General considerations at time of surgery Visualize all important anatomy including: NOT recommended unless specific indications:  Drains or perioperative antibiotics  Frozen section is generally NOT indicated Large substernal goiters should be doneat centers with thoracic backup Notify pathologist of evidence of gross extrathyroidal extension into strap muscles Prophylactic central compartment neck dissection (ATA B8/REC 36B) Pathology Results If malignant, should include:  Histologic type  Margins  Vascular invasion  Number ofnodes examined and involved  Extrathyroidal spread  Extranodal spread (ATA B15/REC 46) Central compartment neck dissection (ATA B8/REC 36A, 37) Lateral neck dissection (ATA B8/REC 37) CNo CN+ N+ Identification of recurrent laryngeal nerve(s) (ATA B13/REC 42A) Preservation of parathyroid glands (ATA B13/REC 43)No previous neck surgery or normal voice Previous neck or chest surgery or any voice issue Well-differentiated thyroid carcinoma Microscopic papillary thyroid Benign High risk tumors Surveillance Refer to tumor board Pathology results sent to endocrinologist (ATA B14/REC 45) Neck dissection options to consider for confirmed cancer undergoing total thyroidectomy Thyroid lobectomy may be sufficient initial treatment for low risk papillary and follicular carcinomas without central compartment dissection (ATA B7/REC35B, 35C) (ATA B8/REC 36C) Totalthyroidectomy already completed or proceed with totalor completion or near total thyroidectomy based on pathology, RAI planning, or patient preferenceand consider neck dissection options (ATA 21/REC 20) (ATA B7/REC 35A) (ATA B8/REC 36C) (ATA B9/REC 38A)) < 4 cm. and based on clinical, US, and patient preference 4 cm. or presence of contralateral nodules or AUS/FN with possible molecular results Surgical consult for patient with Bethesda III-VI thyroid nodule Consider lobectomy (ATA A21/REC 19) Go to Postoperative Management (Figure 3) PATHOLOGY SURGERY STRONG RECOMMENDATION– High quality evidence STRONG RECOMMENDATION – Moderate quality evidence STRONG RECOMMENDATION – Low quality evidence WEAK RECOMMENDATION – Low quality evidence T1 or T2/ CNo T3 or T4 ENDOCRINOLOGY Tracking Metric 8
  13. 13. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Thyroid Nodule Perioperative Management Figure 2. THYROID NODULE PERIOPERATIVE MANAGEMENT Consider total thyroidectomy (ATA A21/REC 20) Surgeon:  Provides informed consent (ATA B11/REC 39)  Confirms plan with/or notifies endocrinologist ifpatient opts for a different procedure other than theoriginal recommendation  Performs pre-op voice or vocalfold assessment Document quality of voice or laryngeal examination (ATA B12/REC 40) Laryngeal examination (ATA B12/REC 41) Tracking Metric 7 General considerations at time of surgery Visualize all important anatomy including: NOT recommended unless specific indications:  Drains or perioperative antibiotics  Frozen section is generally NOT indicated Large substernal goiters should be doneat centers with thoracic backup Notify pathologist of evidence of gross extrathyroidal extension into strap muscles Prophylactic central compartment neck dissection (ATA B8/REC 36B) Pathology Results If malignant, should include:  Histologic type  Margins  Vascular invasion  Number ofnodes examined and involved  Extrathyroidal spread  Extranodal spread (ATA B15/REC 46) Central compartment neck dissection (ATA B8/REC 36A, 37) Lateral neck dissection (ATA B8/REC 37) CNo CN+ N+ Identification of recurrent laryngeal nerve(s) (ATA B13/REC 42A) Preservation of parathyroid glands (ATA B13/REC 43)No previous neck surgery or normal voice Previous neck or chest surgery or any voice issue Well-differentiated thyroid carcinoma Microscopic papillary thyroid Benign High risk tumors Surveillance Refer to tumor board Pathology results sent to endocrinologist (ATA B14/REC 45) Neck dissection options to consider for confirmed cancer undergoing total thyroidectomy Thyroid lobectomy may be sufficient initial treatment for low risk papillary and follicular carcinomas without central compartment dissection (ATA B7/REC35B, 35C) (ATA B8/REC 36C) Totalthyroidectomy already completed or proceed with totalor completion or near total thyroidectomy based on pathology, RAI planning, or patient preferenceand consider neck dissection options (ATA 21/REC 20) (ATA B7/REC 35A) (ATA B8/REC 36C) (ATA B9/REC 38A)) < 4 cm. and based on clinical, US, and patient preference 4 cm. or presence of contralateral nodules or AUS/FN with possible molecular results Surgical consult for patient with Bethesda III-VI thyroid nodule Consider lobectomy (ATA A21/REC 19) Go to Postoperative Management (Figure 3) PATHOLOGY SURGERY STRONG RECOMMENDATION– High quality evidence STRONG RECOMMENDATION – Moderate quality evidence STRONG RECOMMENDATION – Low quality evidence WEAK RECOMMENDATION – Low quality evidence T1 or T2/ CNo T3 or T4 ENDOCRINOLOGY Tracking Metric 8
  14. 14. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
  15. 15. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Thyroid Nodule Perioperative Management Figure 2. THYROID NODULE PERIOPERATIVE MANAGEMENT Consider total thyroidectomy (ATA A21/REC 20) Surgeon:  Provides informed consent (ATA B11/REC 39)  Confirms plan with/or notifies endocrinologist ifpatient opts for a different procedure other than theoriginal recommendation  Performs pre-op voice or vocalfold assessment Document quality of voice or laryngeal examination (ATA B12/REC 40) Laryngeal examination (ATA B12/REC 41) Tracking Metric 7 General considerations at time of surgery Visualize all important anatomy including: NOT recommended unless specific indications:  Drains or perioperative antibiotics  Frozen section is generally NOT indicated Large substernal goiters should be doneat centers with thoracic backup Notify pathologist of evidence of gross extrathyroidal extension into strap muscles Prophylactic central compartment neck dissection (ATA B8/REC 36B) Pathology Results If malignant, should include:  Histologic type  Margins  Vascular invasion  Number ofnodes examined and involved  Extrathyroidal spread  Extranodal spread (ATA B15/REC 46) Central compartment neck dissection (ATA B8/REC 36A, 37) Lateral neck dissection (ATA B8/REC 37) CNo CN+ N+ Identification of recurrent laryngeal nerve(s) (ATA B13/REC 42A) Preservation of parathyroid glands (ATA B13/REC 43)No previous neck surgery or normal voice Previous neck or chest surgery or any voice issue Well-differentiated thyroid carcinoma Microscopic papillary thyroid Benign High risk tumors Surveillance Refer to tumor board Pathology results sent to endocrinologist (ATA B14/REC 45) Neck dissection options to consider for confirmed cancer undergoing total thyroidectomy Thyroid lobectomy may be sufficient initial treatment for low risk papillary and follicular carcinomas without central compartment dissection (ATA B7/REC35B, 35C) (ATA B8/REC 36C) Totalthyroidectomy already completed or proceed with totalor completion or near total thyroidectomy based on pathology, RAI planning, or patient preferenceand consider neck dissection options (ATA 21/REC 20) (ATA B7/REC 35A) (ATA B8/REC 36C) (ATA B9/REC 38A)) < 4 cm. and based on clinical, US, and patient preference 4 cm. or presence of contralateral nodules or AUS/FN with possible molecular results Surgical consult for patient with Bethesda III-VI thyroid nodule Consider lobectomy (ATA A21/REC 19) Go to Postoperative Management (Figure 3) PATHOLOGY SURGERY STRONG RECOMMENDATION– High quality evidence STRONG RECOMMENDATION – Moderate quality evidence STRONG RECOMMENDATION – Low quality evidence WEAK RECOMMENDATION – Low quality evidence T1 or T2/ CNo T3 or T4 ENDOCRINOLOGY Tracking Metric 8
  16. 16. AHNS Endocrine Surgery Section - https://endocrine.ahns.info
  17. 17. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Thyroid Nodule Perioperative Management Figure 2. THYROID NODULE PERIOPERATIVE MANAGEMENT Consider total thyroidectomy (ATA A21/REC 20) Surgeon:  Provides informed consent (ATA B11/REC 39)  Confirms plan with/or notifies endocrinologist ifpatient opts for a different procedure other than theoriginal recommendation  Performs pre-op voice or vocalfold assessment Document quality of voice or laryngeal examination (ATA B12/REC 40) Laryngeal examination (ATA B12/REC 41) Tracking Metric 7 General considerations at time of surgery Visualize all important anatomy including: NOT recommended unless specific indications:  Drains or perioperative antibiotics  Frozen section is generally NOT indicated Large substernal goiters should be doneat centers with thoracic backup Notify pathologist of evidence of gross extrathyroidal extension into strap muscles Prophylactic central compartment neck dissection (ATA B8/REC 36B) Pathology Results If malignant, should include:  Histologic type  Margins  Vascular invasion  Number ofnodes examined and involved  Extrathyroidal spread  Extranodal spread (ATA B15/REC 46) Central compartment neck dissection (ATA B8/REC 36A, 37) Lateral neck dissection (ATA B8/REC 37) CNo CN+ N+ Identification of recurrent laryngeal nerve(s) (ATA B13/REC 42A) Preservation of parathyroid glands (ATA B13/REC 43)No previous neck surgery or normal voice Previous neck or chest surgery or any voice issue Well-differentiated thyroid carcinoma Microscopic papillary thyroid Benign High risk tumors Surveillance Refer to tumor board Pathology results sent to endocrinologist (ATA B14/REC 45) Neck dissection options to consider for confirmed cancer undergoing total thyroidectomy Thyroid lobectomy may be sufficient initial treatment for low risk papillary and follicular carcinomas without central compartment dissection (ATA B7/REC35B, 35C) (ATA B8/REC 36C) Totalthyroidectomy already completed or proceed with totalor completion or near total thyroidectomy based on pathology, RAI planning, or patient preferenceand consider neck dissection options (ATA 21/REC 20) (ATA B7/REC 35A) (ATA B8/REC 36C) (ATA B9/REC 38A)) < 4 cm. and based on clinical, US, and patient preference 4 cm. or presence of contralateral nodules or AUS/FN with possible molecular results Surgical consult for patient with Bethesda III-VI thyroid nodule Consider lobectomy (ATA A21/REC 19) Go to Postoperative Management (Figure 3) PATHOLOGY SURGERY STRONG RECOMMENDATION– High quality evidence STRONG RECOMMENDATION – Moderate quality evidence STRONG RECOMMENDATION – Low quality evidence WEAK RECOMMENDATION – Low quality evidence T1 or T2/ CNo T3 or T4 ENDOCRINOLOGY Tracking Metric 8
  18. 18. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Pathology Results If malignant, should include:  Histologic type  Margins  Vascular invasion  Number of nodes examined and involved  Extrathyroidal spread  Extranodal spread (ATA B15/REC 46) Well-differentiated thyroid carcinoma Microscopic papillary thyroid Benign High risk tumors Surveillance Refer to tumor board Pathology results sent to endocrinologist (ATA B14/REC 45) Thyroid lobectomy may be sufficient initial treatment for low risk papillary and follicular carcinomas without central compartment dissection (ATA B7/REC35B, 35C) (ATA B8/REC 36C) Total thyroidectomy already completed or proceed with total or completion or near total thyroidectomy based on pathology, RAI planning, or patient preference and consider neck dissection options (ATA 21/REC 20) (ATA B7/REC 35A) (ATA B8/REC 36C) (ATA B9/REC 38A)) T1 or T2/ CNo T3 or T4
  19. 19. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Consensus on Statements 7-8
  20. 20. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Thyroid Nodule Postoperative Management Figure 3. THYROID NODULE POSTOPERATIVE MANAGEMENT SURGERY ENDOCRINOLOGY STRONG RECOMMENDATION – Moderate quality evidence  TID – three times a day  Tg – thyroglobulin  PTH – parathyroid hormone  TSH – thyroid-stimulating hormone  BID – two times a day Post-op thyroidectomy Tracking Metric 16 Order post-op thyroid hormonereplacement for patients following total or completion thyroidectomy Order post-op TSH/Tg levels (ATA C5/REC 62) Updatestaging (ATA B17/REC 47) Empiric therapy Calcium 1000-1200 mg TID +/- calcitriol 0.25-0.5 µg BID PTH-guided management PTH > 20 No supplementation or low dosecalcium PTH 10-20 Give calcium 1000-1200 mg TID at discharge PTH < 10 Add calcitriol 0.25-0.5 µg BID to calcium at discharge Management options for immediate postoperative potential transient hypoparathyroidism Documents quality of voiceand/or vocal fold status within 2-8 weeks post-op (ATA B14/REC 44) Tracking Metric 11 Consider serum calcium check on postoperative day 2 or 3** Consider endocrinologist if having difficulty with immediatepostoperative hypocalcemia management and/or if ongoing beyond 4 weeks Tracking Metric 15 **NOTE: If ordering a postoperative calcium test in EMR for symptomatic patients, use the diagnosis postoperative or history of parathyroidectomy or thyroidectomy Do NOT use hypocalcemia without previous laboratory-validated diagnosis Following completion or total thyroidectomy Following completion or totalthyroidectomy ALL patients Tracking Metric 9 Tracking Metric 10 Pathology results Surveillance Tracking Metric 12, 13, 14
  21. 21. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Thyroid Nodule Postoperative Management Figure 3. THYROID NODULE POSTOPERATIVE MANAGEMENT SURGERY ENDOCRINOLOGY STRONG RECOMMENDATION – Moderate quality evidence  TID – three times a day  Tg – thyroglobulin  PTH – parathyroid hormone  TSH – thyroid-stimulating hormone  BID – two times a day Post-op thyroidectomy Tracking Metric 16 Order post-op thyroid hormonereplacement for patients following total or completion thyroidectomy Order post-op TSH/Tg levels (ATA C5/REC 62) Updatestaging (ATA B17/REC 47) Empiric therapy Calcium 1000-1200 mg TID +/- calcitriol 0.25-0.5 µg BID PTH-guided management PTH > 20 No supplementation or low dosecalcium PTH 10-20 Give calcium 1000-1200 mg TID at discharge PTH < 10 Add calcitriol 0.25-0.5 µg BID to calcium at discharge Management options for immediate postoperative potential transient hypoparathyroidism Documents quality of voiceand/or vocal fold status within 2-8 weeks post-op (ATA B14/REC 44) Tracking Metric 11 Consider serum calcium check on postoperative day 2 or 3** Consider endocrinologist if having difficulty with immediatepostoperative hypocalcemia management and/or if ongoing beyond 4 weeks Tracking Metric 15 **NOTE: If ordering a postoperative calcium test in EMR for symptomatic patients, use the diagnosis postoperative or history of parathyroidectomy or thyroidectomy Do NOT use hypocalcemia without previous laboratory-validated diagnosis Following completion or total thyroidectomy Following completion or totalthyroidectomy ALL patients Tracking Metric 9 Tracking Metric 10 Pathology results Surveillance Tracking Metric 12, 13, 14
  22. 22. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Empiric therapy Calcium1000-1200 mgTID +/- calcitriol 0.25-0.5 µgBID PTH-guided management PTH> 20 No supplementation or low dosecalcium PTH10-20 Give calcium 1000-1200 mgTID at discharge PTH< 10 Add calcitriol 0.25-0.5 µgBID to calcium at discharge Management options for immediate postoperative potential transient hypoparathyroidism Consider serum calcium check on postoperative day2 or3** Consider endocrinologist if havingdifficultywith immediatepostoperative hypocalcemiamanagement and/or if ongoing beyond 4 weeks Tracking Metric 15
  23. 23. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Thyroid Nodule Postoperative Management Figure 3. THYROID NODULE POSTOPERATIVE MANAGEMENT SURGERY ENDOCRINOLOGY STRONG RECOMMENDATION – Moderate quality evidence  TID – three times a day  Tg – thyroglobulin  PTH – parathyroid hormone  TSH – thyroid-stimulating hormone  BID – two times a day Post-op thyroidectomy Tracking Metric 16 Order post-op thyroid hormonereplacement for patients following total or completion thyroidectomy Order post-op TSH/Tg levels (ATA C5/REC 62) Updatestaging (ATA B17/REC 47) Empiric therapy Calcium 1000-1200 mg TID +/- calcitriol 0.25-0.5 µg BID PTH-guided management PTH > 20 No supplementation or low dosecalcium PTH 10-20 Give calcium 1000-1200 mg TID at discharge PTH < 10 Add calcitriol 0.25-0.5 µg BID to calcium at discharge Management options for immediate postoperative potential transient hypoparathyroidism Documents quality of voiceand/or vocal fold status within 2-8 weeks post-op (ATA B14/REC 44) Tracking Metric 11 Consider serum calcium check on postoperative day 2 or 3** Consider endocrinologist if having difficulty with immediatepostoperative hypocalcemia management and/or if ongoing beyond 4 weeks Tracking Metric 15 **NOTE: If ordering a postoperative calcium test in EMR for symptomatic patients, use the diagnosis postoperative or history of parathyroidectomy or thyroidectomy Do NOT use hypocalcemia without previous laboratory-validated diagnosis Following completion or total thyroidectomy Following completion or totalthyroidectomy ALL patients Tracking Metric 9 Tracking Metric 10 Pathology results Surveillance Tracking Metric 12, 13, 14
  24. 24. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Order post-op thyroid hormonereplacement for patients followingtotal or completion thyroidectomy Order post-op TSH/Tg levels (ATA C5/REC 62) Updatestaging (ATA B17/REC 47) Followingcompletion or total thyroidectomy Followingcompletion or totalthyroidectomy ALL patients Tracking Metric 9 Tracking Metric 10 Pathology results
  25. 25. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Consensus on Statements 9-16
  26. 26. AHNS Endocrine Surgery Section - https://endocrine.ahns.info 1. Clinic and OR Access 2. Risk Stratification 3. Monitoring DTC Rates 4. Bethesda Classification 5. Pre-op calcium 6. Surgeon case volume 7. Antibiotic utilization 8. Pre-op voice check Quality Metrics 9. Post-op serum TSH and Tg 10. Staging of all DTC 11. Post-op voice check 12. Mortality rates 13. Readmission rates 14. Reoperation rates 15. Permanent hypoparathyroidism rates 16. Length of stay
  27. 27. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • Monitoring access to specialist consultation and elective surgery may help determine whether clinical care is readily available to patients Metric 1: Clinic and OR Access EUTHYROID NODULE Tracking Metric 1
  28. 28. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • Risk stratification utilizing thyroid sonography with survey of the cervical lymph nodes should be performed in all patients with known or suspected thyroid nodules Metric 2: Sonographic Risk Stratification Risk stratification of US using ATA or ACR TIRADS Tracking Metric 2
  29. 29. AHNS Endocrine Surgery Section - https://endocrine.ahns.info The institutional or system wide annual rate of thyroidectomies performed for WDTC in a nodule with a maximum diameter less than 1 cm should be monitored Metric 3: Incidence of WDTC No nodule or nodules smaller than FNA sizecut-off ATA Benign or TIRADS **1 TIRADS 2 Observe (ATA A8/REC 8E) Tracking Metric 3
  30. 30. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • Utilization of Bethesda classification is important for consistent reporting of thyroid cytopathology Metric 4: Bethesda Classification FNA 2 cm (ATA A9/REC 8D) FNA 2.5 cm FNA 1.5 cm (ATA A9/REC 8C) FNA 1 cm (ATA A9/REC 8B) FNA 1 cm (ATA A9 /REC 8A) Utilization of Bethesda System for Reporting Thyroid Cytopathology (ATA A11/REC 9) Tracking Metric 4
  31. 31. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • To avoid the potential complications associated with reoperations, it is suggested to obtain a PTH or serum calcium level prior to thyroid surgery Metric 5: Pre-op Calcium and Calcitonin* Order perioperative serum calcium test for all and serum calcitonin for known or suspected medullary CA Tracking Metric 5 * For known medullary thyroid carcinoma
  32. 32. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • Surgical volume is a positive indicator of more efficient and effective care. Thyroid surgeons should perform a minimum of at least 10 cases per year Metric 6: Surgeon Case Volume Surgery consult with high volume surgeon (ATA A14/REC 12) Tracking Metric 6
  33. 33. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • Antibiotics are not usually recommended for clean surgeries including thyroidectomy. Monitoring for antibiotic usage is a way to evaluate quality of care and appropriate utilization Metric 7: Perioperative Antibiotic Use Tracking Metric 7 General considerations at time of surgery Visualize all important anatomy including: NOT recommended unless specific indications:  Drains or perioperative antibiotics  Frozen section is generally NOT indicated Large substernal goiters should be done at centers with thoracic backup Notify pathologist of evidence of gross extrathyroidal extension into strap muscles Identification of recurrent laryngeal nerve(s) (ATA B13/REC 42A) Preservation of parathyroid glands (ATA B13/REC 43)
  34. 34. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • To have an understanding of true post op voice status following thyroid surgery, a preop assessment of the voice and possible laryngeal exam if there a voice issue or previous neck or chest surgery is recommended Metric 8: Preoperative Voice Assessment Document quality of voice or laryngeal examination (ATA B12/REC 40) Laryngeal examination (ATA B12/REC 41) Tracking Metric 8 No previous neck surgery or normal voice Previous neck or chest surgery or any voice issue
  35. 35. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • Monitoring post-operative serum thyroglobulin levels for patients on thyroid hormone therapy or after TSH stimulation is helpful in assessing the persistence of disease or thyroid remnant and predicting future disease recurrence Metric 9: Serum TSH and Tg/TgAb Order post-op TSH/Tg levels (ATA C5/REC 62) Following completion or totalthyroidectomy Tracking Metric 9
  36. 36. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • The AJCC Staging and Dynamic Risk Stratification systems for DTC bring value when predicting disease mortality or recurrence, as well as for guiding decisions about treatment and surveillance Metric 10: Staging Updatestaging (ATA B17/REC 47) ALL patients Tracking Metric 10 Pathology results
  37. 37. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • Patients should have their vocal cord function evaluated between 2 weeks and 2 months after thyroid surgery Metric 11: Postoperative Voice Assessment Post-op thyroidectomy Documents quality of voice and/or vocal fold status within 2-8 weeks post-op (ATA B14/REC 44) Tracking Metric 11
  38. 38. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • Mortality rates should be monitored after thyroid surgery Metric 12: Mortality Rates
  39. 39. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • Readmission rates within the first 30 days following thyroid surgery is a potential proxy for some complications after surgery Metric 13: Readmission Rates
  40. 40. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • Reoperation rate during the first 30 days is an indicator for some postoperative surgical complications after thyroid surgery (e.g. hematoma, vocal cord medialization due to aspiration) Metric 14: Reoperation Rates
  41. 41. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • For patients who require high dose vitamin D supplementation at 12 months or longer following total or completion thyroidectomy, a calcium and or PTH level should be checked Metric 15: Permanent Hypoparathyroidism Rates Consider endocrinologist if having difficulty with immediatepostoperative hypocalcemia management and/or if ongoing beyond 4 weeks Tracking Metric 15
  42. 42. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • The average length of stay is a good proxy for perioperative resource management, and allows comparisons to be made to other surgical and medical patients Metric 16: Length of Stay Post-op thyroidectomy Tracking Metric 16
  43. 43. AHNS Endocrine Surgery Section - https://endocrine.ahns.info • These workflows and quality metric provide a simplified approach to incorporating the 2015 ATA guidelines into the everyday management of thyroid nodules and DTC and have the potential to improve quality and decrease unwarranted variations in care • For implementation, users should create multidisciplinary teams in their local settings to review, refine, implement, and sustain these practices Conclusions
  44. 44. AHNS Endocrine Surgery Section - https://endocrine.ahns.info North American Quality Statements and Evidence Based Multidisciplinary Workflow Algorithms for the Evaluation and Management of Thyroid Nodules Meltzer CJ, Irish J, Odell M, Wiseman SM, Haymart MR, Shin J, Monteiro E, Ferris RL, Wong RJ, Tuttle RM, Morris JC, Haugen BR, Morris LGT, McIver B, Busady NL, Mechanick JI, Harrell RM, Shonka DC, Scharpf J, Dwojak S, Urken M, Davies L, Thompson GB, Angelos P, Randolph GW

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