Patient-Reported Outcomes Following Total Thyroidectomy for Graves' Disease

Abstract

Background: Graves' disease accounts for ∼80% of all cases of hyperthyroidism and is associated with significant morbidity and decreased quality of life. Understanding the association of total thyroidectomy with patient-reported quality-of-life and thyroid-specific symptoms is critical to shared decision-making and high-quality care. We estimate the change in patient-reported outcomes (PROs) before and after surgery for patients with Graves' disease to inform the expectations of patients and their physicians. Methods: PROs using the MD Anderson Symptom Inventory (MDASI) validated questionnaire were collected prospectively from adult patients with Graves' disease from January 1, 2015, to November 20, 2020, on a longitudinal basis. Survey responses were categorized as before surgery (≤120 days), short term after surgery (<30 days; ST), and long term after surgery (≥30 days; LT). Negative binomial regression was used to estimate the association of select covariates with PROs. Results: Eighty-five patients with Graves' disease were included. The majority were female (83.5%); 47.1% were non-Hispanic white and 35.3% were non-Hispanic black. The median thyrotropin (TSH) value before surgery was 0.05, which increased to 0.82 in ST and 1.57 in LT. In bivariate analysis, the Total Symptom Burden Score, a composite of all patient-reported burden, significantly reduced shortly after surgery (before surgery mean of 56.88 vs. ST 39.60, p < 0.001), demonstrating improvement in PROs. Furthermore, both the Thyroid Symptoms Score, including patient-reported thermoregulation, palpitations, and dysphagia, and the Quality-of-Life Symptom Score improved in ST and LT (thyroid symptoms, before surgery 13.88 vs. ST 8.62 and LT 7.29; quality of life, before surgery 16.16 vs. ST 9.14 and LT 10.04, all p < 0.05). After multivariate adjustment, the patient-reported burden in the Thyroid Symptom Score and the Quality-of-Life Symptom Score exhibited reduction in ST (thyroid symptoms, rate ratio [RR] 0.55, confidence interval [CI]: 0.42-0.72; quality of life, RR 0.57, CI: 0.40-0.81) and LT (thyroid symptoms, RR 0.59, CI: 0.44-0.79; quality of Life, RR 0.43, CI: 0.28-0.65). Conclusions: Quality of life and thyroid-specific symptoms of Graves' patients improved significantly from their baseline before surgery to both shortly after and longer after surgery. This work can be used to guide clinicians and patients with Graves' disease on the expected outcomes following total thyroidectomy.

Keywords: Graves'; disease; patient-reported outcomes; quality of life; thyroidectomy.

FIG. 1.

Summary of patient cohort and data collection. LT, Long Term After Surgery; ST, Short Term After Surgery.

FIG. 2.

Summary of patient-reported outcomes with relation to surgery over time. Predicted means of the summary scores for the MDASI patient-reported outcomes at three time points: before surgery, ST, and LT. Higher scores indicate higher symptom burden and lower scores indicate lower symptom burden. MDASI, MD Anderson Symptom Inventory.

FIG. 3.

Selected patient-reported outcomes before and after surgery. Specific patient-reported outcomes displayed by the mean value from before surgery and in the ST time point. All changes in the figure were statistically significant, p < 0.05. Higher scores indicate higher symptom burden, and lower scores indicate lower symptom burden.

FIG. 4.

Multivariate negative binomial regression for MDASI Thyroid Symptom Burden Score. Reference levels are: before surgery (MDASI timing), female (sex), non-Hispanic white (race/ethnicity), not married and no life partner (marital status), private (insurance), obese (BMI), and no hypertension. Higher scores indicate higher symptom burden, and lower scores indicate lower symptom burden. BMI, body mass index.