Heeding Risks May Prevent Hospital Readmissions after Thyroid Surgery

There are several conditions that represent the majority of cases requiring a return to the hospital following post-thyroidectomy procedures. By assessing patients for these anticipatable concerns, clinicians have an opportunity to reduce the rate of readmissions in the first few days after discharge.

With Raymond Chai, MD

The number of thyroidectomy procedures increased from nearly 66,900 to nearly 93,000 between 1996 and 2006,1 and the number has continued to rise.  Currently, 30-day readmission rates are the metric most frequently used to evaluate health care costs and quality of care.

In the absence of any nationally representative data regarding readmission rates following thyroid surgery, a team of investigators from the University of Pennsylvania and Thomas Jefferson University Hospital undertook a study to assess the rate of readmission of patients who had had a thyroidectomy;the findings appear in the journal, Surgery.

Doctors can reduce risk of hospital readmission in patients having thyroid surgery.

Assessing Possible Causes of Post-Thyroidectomy Hospital Readmissions

The investigators evaluated data from the 2014 Nationwide Readmissions Database (NRD), which indicated a total of 22,654 cases of thyroid lobectomy, partial thyroidectomy, complete thyroidectomy, and substernal thyroidectomy procedures having occurred during the study period.2 This database included information on individuals of all ages as well as those who were insured and uninsured from 27 states.

Based on the data,2 a total of 990 patients, or 4.4% of the patients undergoing a thyroid surgical procedure, were readmitted within 30 days of their surgery. More than half of the readmissions (54.6%) occurred within the first week after discharge, with 24.6% occurring within the first two days of returning home.

The most frequent diagnoses identified on readmission were for:

  • Disorders of mineral metabolism
  • Hypocalcemia
  • Obesity and thyroid cancer

Calcium disorders— including hypo- and hypercalcemia, hypoparathyroidism, and hungry bone syndrome—accounted for 22% of all readmissions,2 according to the authors. In particular, based on the cases found in this large database study, disorders of mineral metabolism and hypocalcemia accounted for 36% and 26.6% of readmissions, respectively.

Interestingly, neither the initial indication of a need for thyroid surgery nor the type of thyroid surgery were predictive of the need for readmission, according to the senior author, lliric I. Willis, MD, FACS, associate professor of surgery at Thomas Jefferson University Medical Centers and colleague. However, clinically relevant comorbidities (ei., obesity) and longer hospitalizations were predictive.2

Commonly Occurring Risk Factors Provide Clues to Likely Readmission in Thyroid Patients

Raymond Chai, MD, assistant professor of otolaryngology at the Icahn School of Medicine at Mount Sinai, and a head and neck surgeon at Mount Sinai Union Square in New York City, who was not involved in the study, spoke with EndocrineWeb about the implications of the study findings.

“The rate of readmissions observed in this study (4.37%) was noticeably higher than the rates that have been reported in previous albeit it smaller studies,3-6which were predominantly < 2%.” These studies reflected readmission rates after thyroidectomy procedures ranging from 0.1% to 2.6%.

“This [discrepancy] is likely related to the inherent problems associated with large database studies, such as this one —many of the readmissions for ‘thyroid cancer’ may have actually been due to scheduled thyroid surgeries and not actual readmissions,” said Dr. Chai.

The most common risk factors for readmission identified in the earlier studies included decreased patient functional status, hypocalcemia, hypoalbuminemia, renal insufficiency, malignancy, abbreviated or prolonged duration of stay, and procedures performed by low-volume surgeons.3-6

In addition, past studies have demonstrated an association between low-volume surgeons and increased complication rates and readmissions whereas a more recent study by Adam et al established a threshold number of cases for a surgeon to be considered a “high volume” surgeon would be more than 25 total thyroidectomies.7

Willis and colleagues reported that while prior studies had reflected substantially lower readmission rates,3-6 their findings suggest that there is room for improvement in the current treatment of patients undergoing thyroid surgery.2

Post-Thyroidectomy Readmissions Follow Pattern of Predictable Causes

The investigators emphasized that clinicians need to consider hypocalcemia risk prior to performing thyroid surgeries, and must integrate both patient education and postoperative calcium management into their postoperative standard of care.2

Dr. Chai agreed, saying: “We need to develop global strategies to address the calcium issues before they become problematic – whether that means preoperative supplementation with calcium or vitamin D, or to integrate the strategies mentioned in this study, such as scheduling lab work before and within the week after discharge, meticulous patient education and follow-up, and appropriate post-operative calcium management.”

Dr. Willis and his team reported that there is a need to integrate preventive strategies into patient care plans for those with an elevated risk such as those with prolonged durations of hospitalization, those with multiple comorbidities, those who presented with hypocalcemia during the index admission, and those being discharged to a facility other than home.2

The American Cancer Society estimates that thyroid cancer is the most rapidly increasing cancer in the US, tripling in incidence in the last three decades.8 As increasing numbers of patients face prospective thyroid surgery, it is important for clinicians to integrate the insights uncovered by this study in order to optimize outcomes and minimize the risk of hospital readmissions,2 according to the authors.

There were no financial conflicts indicated for this report.

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