A Population-Based Study of Outcomes from Thyroidectomy in Aging Americans: At What Cost?

Department of Surgery, Yale University, New Haven, Connecticut, United States
Journal of the American College of Surgeons (Impact Factor: 5.12). 06/2008; 206(3):1097-105. DOI: 10.1016/j.jamcollsurg.2007.11.023
Source: PubMed


We wanted to evaluate clinical and economic outcomes after thyroidectomy in patients 65 years of age and older, with special analyses of those aged 80 years and older, in the US.
This was a population-based study using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, 2003-2004, a national administrative database of all patients undergoing thyroidectomy and their surgeon providers. Independent variables included patient demographic and clinical characteristics and surgeon descriptors, including case volume. Clinical and economic outcomes included mean total costs and length of stay (LOS), in-hospital mortality, discharge status, and complications.
There were 22,848 patients who underwent thyroidectomies, including 4,092 (18%) aged 65 to 79 years and 744 (3%) 80 years of age or older. On a population level, patient age is an independent predictor of clinical and economic outcomes. Average LOS for patients 80 years and older is 60% longer than for similar patients 65 to 79 years of age (2.9 versus 2.2 days; p < 0.001), complication rates are 34% higher (5.6% versus 2.1%; p < 0.001), and total costs are 28% greater ($7,084 versus $5,917; p < 0.001). High-volume surgeons have shorter LOS and fewer complications but perform fewer thyroidectomies for aging Americans; although they do nearly 29% of these procedures in patients younger than 65 years, they do just 15% of thyroidectomies in patients 80 years and older and 23% in patients 65 to 79 years.
On a population level, clinical and economic outcomes for patients 65 years and older undergoing thyroidectomies are considerably worse than for similar, younger patients. The majority of thyroidectomies in aging Americans is performed by low-volume surgeons. More data are needed about longterm outcomes, but increased referrals to high-volume surgeons for aging Americans are necessary.

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    • "undergo total thyroidectomy than younger patients as overall patients had more preoperative comorbidities as reflected by a higher ASA class [4, 6]. In addition, the older thyroidectomy patients appear to have more advanced benign disease as substernal thyroidectomies were required for elderly and superelderly patients as compared to younger group [6]. Thyroid cancers behave generally more aggressive with increasing age [18, 25]. Park et al. evaluated 8899 patients who undergoing thyroidectomy and radioactive iodine (RAI) from the Surveillance, Epidemiology, and End Results (SEER) database in United States and found that older patients aged ≥65 years were more likely to have multiple primary tumours, advanced-staged disease, larger tumour, extrathyroidal extension, and nonpapillary histology [26]. "
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    ABSTRACT: An increasing elderly population, a rising incidence of differentiated thyroid carcinoma (DTC), and a rising incidence of benign nodular disease with age are all contributing to a rise in thyroid operations for the elderly. Literature review on the outcome and safety of thyroid surgery in elderly patients has been filled with conflicting results and this subject remains controversial. Although most single-institution studies conducted by high-volume surgeons did not find significant differences of complication rates in elderly when compared with younger cohorts, they often lacked the power necessary to identify subtle differences and suffered from various selection and referral biases. Recent evidence from large population-based studies concluded that thyroid surgery in the elderly was associated with higher complication rates. One of the major contributing factors for the increased complication rate was because most elderly patients suffered from many preexisting comorbidities. Therefore, elderly patients who have abnormal thyroid findings should complete a thorough preoperative workup and better postoperative care after undergoing any thyroid surgery. Furthermore, these high-risk patients would benefit if they could be referred to high-volume, specialized surgical units early. In this systemic review, we aimed to evaluate different issues and controversies in thyroidectomy for elderly patients.
    Journal of Thyroid Research 08/2012; 2012(1):946276. DOI:10.1155/2012/946276
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    • "Although the inverse association between hypocalcaemia and advancing age corroborates the work of others [27, 28], there is some conflict found in the literature. A previous study that also assessed the NIS, though for a narrower time frame, from 2003-2004, showed that patients 65 years and older, after adjusting for other risk factors, experienced similar rates of hypocalcemia and recurrent laryngeal nerve injury compared with younger patients [29]. In fact, older patients in the study had higher rates of total complications, consistent with a recent series [30]. "
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    ABSTRACT: Hypocalcemia is a common complication following thyroidectomy. However, the incidence of postoperative hypocalcemia varies widely in the literature, and factors associated with hypocalcemia after thyroid surgery are not well established. We aimed to identify incidence trends and independent risk factors of postoperative hypocalcemia using the nationwide inpatient sample (NIS) database from 1998 to 2008. Overall, 6,605 (5.5%) of 119,567 patients who underwent thyroidectomy developed hypocalcemia. Total thyroidectomy resulted in a significantly higher increased incidence (9.0%) of hypocalcemia when compared with unilateral thyroid lobectomy (1.9%; P < .001). Thyroidectomy with bilateral neck dissection, the strongest independent risk factor of postoperative hypocalcemia (odds ratio, 9.42; P < .001), resulted in an incidence of 23.4%. Patients aged 45 years to 84 years were less likely to have postoperative hypocalcemia compared with their younger and older counterparts (P < .001). Hispanic (P = .003) and Asian (P = .027) patients were more likely, and black patients were less likely (P = .003) than white patients to develop hypocalcemia. Additional factors independently associated with postoperative hypocalcemia included female gender, nonteaching hospitals, and malignant neoplasms of thyroid gland. Hypocalcemia following thyroidectomy resulted in 1.47 days of extended hospital stay (3.33 versus 1.85 days P < .001).
    07/2012; 2012:838614. DOI:10.5402/2012/838614
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    • "It is not surprising that many of these small series have demonstrated superlative outcomes; previous population-level analyses have delineated a positive association between increased surgeon and hospital case volume and patient outcomes, including those performed on children [48], pregnant women [49, 50], and the elderly [51]. For thyroid surgery in an elderly population, the use of a representative national database supports this notion [44, 45]. Therefore, small published case series may underestimate the true risks of surgery for the average elderly patient with thyroid pathology, potentially limiting external validity. "
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    ABSTRACT: The U.S. population is undergoing a dramatic shift in demographics, with a rise in the proportion of elderly Americans. Given an increased prevalence of thyroid disease and malignancy with age, understanding the safety of thyroid surgery in this age group is increasingly pertinent. There remains disagreement regarding the clinical outcomes of elderly patients after thyroidectomy and the applicability of single-institution cohorts to the population at large. This paper reviews the epidemiology of thyroid disease in the elderly, current surgical indications and practice patterns, and the clinical and economic outcomes of elderly patients with thyroid disease after surgical intervention.
    Journal of Thyroid Research 06/2012; 2012(10):615846. DOI:10.1155/2012/615846
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