1. Thyroid Surgery Prioritization among Canadian Otolaryngology-Head and Neck Surgeons Uthman Alamoudi, Blair Williams, Martin Bullock, Matthew Rigby, S. Mark Taylor, Jonathan RB Trites, Robert Hart Otolaryngology, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
Introduction:
Thyroid nodules are a common health issue and constitute large proportion of Otolaryngology – Head & Neck Surgery consultations. The prevalence of thyroid nodules is up to 7% when determined by palpation, 67%-70% by ultrasound and 30–60% at autopsy [1,2].
Fine-needle aspiration (FNA) biopsy and cytologic interpretation plays an essential role in the diagnosis and evaluation of thyroid nodules [3]. Despite widespread use and clinical utility of FNAs, cytological indeterminate thyroid nodules continue to present a diagnostic dilemma for clinicians. This results in 10–30 % of patients with a thyroid nodule undergoing thyroidectomy to obtain a definitive histologic diagnosis [4]. The increased proportion of patients undergoing surgery for indeterminate lesions may simply be a result of an increased number of patients with benign FNA results avoiding thyroidectomy. Another explanation for the increased proportion of patients undergoing thyroidectomy with indeterminate FNA results is the addition of the cytology category AUS/ FLUS [3]. Non-diagnostic aspirate can result in a delay in diagnosis and definitive management, which has prognostic significance, since patients with a non-diagnostic FNA have a significantly higher rate  of all types of thyroid cancer [5]. The overall risk of malignancy in non-diagnostic thyroid FNA is also high, ranging from 2-14% [6,7].
Wait times for specialist services like Otolaryngology is a recurring issue in publicly funded healthcare systems. The reduction of wait times remains an ongoing priority in the Canadian government’s healthcare agenda [8]. Pothier et al, studied the general practitioner (GP) Otolaryngology consultation letters marked ‘urgent and found on that only 47%. Brake et al, found that the actual wait times were significantly longer than most physicians felt were appropriate; when they studied thyroid surgery wait times among Canadian Otolaryngologists, which included time to initial consult for workup of thyroid nodules, time to book surgery and time to completion thyroidectomy for surgically confirmed malignancies [12].
Purpose:
1. To depict the current wait times in Canada for thyroid nodule consults and surgeries given various pathologies.
2. To determine what Canadian otolaryngologists feel are appropriate wait times for these procedures.
3. To assess the factors which Canadian otolaryngologists use to prioritize patients for thyroid surgery.
Method:
This study is based on cross-sectional survey. addresses of all active members of the Canadian Society of Otolaryngology-Head and Neck Surgery (CSOHNS) were obtained from the members directory.
Opinio online survey software was used to develop a questionnaire incorporating questions regarding physician demographics and thyroid wait time data. Prior to conducting the study, the survey was used individually by all authors to ensure internal validity. was sent to all members inviting them to participate in our study, with a link to an online survey (Figure 1). A reminder was sent out two week after the initial invitation. The responses were anonymous. Information was gathered on practice demographics and individual practices regarding the method by which they prioritize the date of surgery for thyroid
Analysis:
The survey consisted of mostly of closed-ended and likert scale elements. The responses were tabulated and reported using descriptive statistics.
Results:
73 of 483 members responded (15.11%). 67 perform thyroid surgery (91.78%). 49 surgeons had been in practice > 5 years, and 85.07% perform > 10 thyroid surgeries/year, whereas 19 (28.36%) perform > 50. Factors that would alter prioritization of indeterminate thyroid FNAs, 92.54%, 80.6%, 76.12%, 55.22%, 53.73% and 43.28% ranked the following as much higher priority: FNA result showing suspicious for malignancy, infiltrative margins, radiation exposure, family history of thyroid cancer, microcalcification and compressive symptoms, respectively %, 58.21%, 55.22%, 49.25%, 46.26% and 40.3% chose higher priority for: nuclear atypia, male /size larger than 4 cm/increase vascularity/ FNA result showing AUS/FLUS, age above 45 years, FNA suspicious for follicular neoplasm, hypoechoic and taller than wide, respectively.
89.55% of surgeons have less than 6 months waiting time for diagnostic surgery, and 75% of them think less than 4 months would be appropriate.
Looking at the chart, visual analysis of respondent prioritization showed universal agreement regardless to the practice location, setting, the level of experience and/or duration of practice which is a reassurance sign that the training quality across the nation is somehow equivalent.
One of the possible explanations for inappropriately long wait times is because of the excellent prognosis associated with most types of thyroid cancer. Also, many patients with thyroid nodules do not have a diagnosis of cancer prior to surgery due to nondiagnostic FNAs. These factors contribute to a decreased sense of urgency when treating thyroid nodules and cancers.
Conclusion:
The majority of respondents prioritize referrals based on patient’s history, US features and on FNA result if available. Further study on developing evidence-based prioritization methods may be useful in assisting surgeons and their patients in outcome-based decisions.
References:
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Laryngoscope, 123:541–547, DOI: /lary.23503
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