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. 2013 Dec 6;110(49):827-34.
doi: 10.3238/arztebl.2013.0827.

The management of thyroid nodules: a retrospective analysis of health insurance data

Romy Wienhold  1 , Markus Scholz, J Rgen-Bernhard Adler, Christian G Nster, Ralf Paschke
Affiliations

The management of thyroid nodules: a retrospective analysis of health insurance data

Romy Wienhold et al. Dtsch Arztebl Int. .

Abstract

Background: In Germany, about 59 000 thyroid operations are performed each year for uni- or multinodular goiter, most of them for diagnostic purposes. The rate of detection of thyroid cancer in such operations is relatively low, at 1:15. Evidence suggests that the preoperative tests recommended in guidelines for estimating the risk of cancer are not being performed as often as they should. In the present study, we determined the measures that were actually taken to diagnose and treat thyroid nodules and compared the findings with the guideline recommendations.

Method: We retrospectively analyzed data from a single, large statutory healthinsurance carrier in Germany (AOK), determining the diagnostic and therapeutic measures that were reimbursed for 25 600 patients in whom a uni- or multinodular goiter was newly diagnosed in the second quarter of 2006 (none of these patients had carried such a diagnosis 1 year previously). We recorded the diagnostic measures performed in the preceding 9 months and all other tests and treatments, including surgery and radioactive iodine treatment, in the 2 years thereafter.

Results: Among patients who underwent surgery for uninodular goiter, the preoperative diagnostic studies included ultrasonography (in 100% of patients), scintigraphy (94%), measurement of thyroid-stimulating hormone (95%), measurement of calcitonin (9%), and fine-needle aspiration cytology (FNAC)(21%). An ultrasonographic examination was billed for only 28% of patients with uninodular goiter in the two years after the diagnosis was made. 13% of patients with uninodular goiter who were not operated on were given L-thyroxine, even though this is against guideline recommendations.

Conclusion: Inadequate preoperative risk stratification of thyroid nodules may explain the large number of thyroid operations that are performed for diagnostic purposes, resulting in a low percentage of malignancies detected. Preoperative FNAC and calcitonin measurement should be used in the diagnostic evaluation of thyroid nodules far more often than this is now done. As a rule, follow-up ultrasonography should be performed for all thyroid nodules that are not operated on. Patients with non-operated thyroid nodules should not be given thyroxine. A limitation of this study is that diagnostic measures were only recorded if they were performed in the 9 months before surgery, with earlier diagnostic measures (if any) being missed.

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Figures

Figure 1
Figure 1
Patient selection *1ICD classification (International Statistical Classification of Diseases and Related Health Problems) E041; *2 ICD classification E042 or E011
Figure 2
Figure 2
Diagnosis of thyroid nodules according to guideline*1 and billing data*2 *1AACE/AME/ETA guidelines; a 100% target can be assumed for sonography, TSH, and calcitonin. Twenty-seven to 52% (26, 27) of thyroid nodules are benign on sonographic criteria and can be excluded from FNAC. For special constellations, e.g., elevated TSH levels during investigation of a thyroid nodule or the procedure in hot nodules, see the AACE/AME/ETA guidelines. *2According to AOK billing data for surgically managed patients with uninodular goiter (Table 2a) TSH, thyroid-stimulating hormone; ft3, free triiodothyronine; ft4, free tetraiodothyronine; FNAC, fine-needle aspiration cytology
See this image and copyright information in PMC

Comment in

  • Too much diagnostic evaluation and therapy.
    Braun B. Braun B. Dtsch Arztebl Int. 2014 Apr 18;111(16):287. doi: 10.3238/arztebl.2014.0287a. Dtsch Arztebl Int. 2014. PMID: 24791756 Free PMC article. No abstract available.
  • Benefit of follow-up not confirmed.
    Chenot JF. Chenot JF. Dtsch Arztebl Int. 2014 Apr 18;111(16):287. doi: 10.3238/arztebl.2014.0287b. Dtsch Arztebl Int. 2014. PMID: 24791757 Free PMC article. No abstract available.
  • Inconsistencies.
    Kreißl MC, Bockisch A, Dietleinl M, Grünwald F, Luster M. Kreißl MC, et al. Dtsch Arztebl Int. 2014 Apr 18;111(16):288. doi: 10.3238/arztebl.2014.0288a. Dtsch Arztebl Int. 2014. PMID: 24791758 Free PMC article. No abstract available.
  • Better diagnostics and treatment.
    Palmedo H, Tüürler A. Palmedo H, et al. Dtsch Arztebl Int. 2014 Apr 18;111(16):288-9. doi: 10.3238/arztebl.2014.0288b. Dtsch Arztebl Int. 2014. PMID: 24791759 Free PMC article. No abstract available.
  • Discrepancy between clinical reality and guidelines.
    Popert U. Popert U. Dtsch Arztebl Int. 2014 Apr 18;111(16):289. doi: 10.3238/arztebl.2014.0289a. Dtsch Arztebl Int. 2014. PMID: 24791760 Free PMC article. No abstract available.
  • In reply.
    Paschke R. Paschke R. Dtsch Arztebl Int. 2014 Apr 18;111(16):289-90. doi: 10.3238/arztebl.2014.0289b. Dtsch Arztebl Int. 2014. PMID: 24791761 Free PMC article. No abstract available.

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