Evaluation of Palpable Thyroid Nodules: Are Endocrinologists Assessing Patients Efficiently?

Abstract

One of the most common clinical problems for endocrinologists is the evaluation of thyroid nodules. Radionuclide scans and thyroid ultrasonography, traditionally used to distinguish malignant from benign nodules, are costly and provide nonspecific results. Currently, authors of clinical practice guidelines recommend fine-needle aspiration (FNA) cytology as the best initial test for evaluating thyroid nodules. This paper reviews the practice patterns of thyroid specialists and primary care providers at the Gundersen Lutheran Medical Center and summarizes the pattern of thyroid nodule evaluation published by other endocrinologists. The results indicate that FNA cytology was widely used at our institution by both thyroid specialists and primary care providers. Since the introduction of FNA cytology, the use of radionuclide scanning has decreased from 90% to 12% and the use of thyroid ultrasonography from 30% to 10%. Although the frequency of thyroid surgery fell, the detection of thyroid cancer in operative specimens increased from 16% to 43%, whereas the cost of removing a thyroid carcinoma decreased from $64,000 to $25,000. Primary care physicians used imaging studies modestly and generated $106 per patient in unnecessary costs. Thyroid specialists occasionally used radionuclide scanning but did not use thyroid ultrasonography; they generated $41 per patient in unnecessary costs. Review of the practice patterns of U.S. endocrinologists indicate that they have widely accepted FNA cytology and used fewer thyroid tests than primary care providers and European endocrinologists for evaluating thyroid nodules. However, they may be increasing the use of thyroid ultrasonography and order radioiodine uptake tests and in vitro studies unnecessarily. Avoiding unnecessary costs incurred in the evaluation of 275,000 thyroid nodules detected annually could save millions of dollars.