Maryland surgeons who perform the greatest number of thyroidectomies have the lowest complication rates, according to results of a statewide study by Johns Hopkins researchers published in the September 1998 issue of Annals of Surgery. The complication rate for experienced surgeons was more than a third lower than for those performing fewer operations. Greater surgical experience also resulted in lower total hospital charges for patients undergoing the operation for more serious thyroid conditions.
Disorders of the thyroid gland occur in 3 percent to 5 percent of the population and are the second most prevalent endocrine disease, behind diabetes mellitus. Thyroidectomy -- or removal of the thyroid gland, is done to treat cancer, goiter and in some cases, hyperthyroidism.
"While it may seem like common sense that surgical experience is associated with superior performance in endocrine surgery, until now, there has been little evidence supporting this view," says Robert Udelsman, M.D., director of endocrine and oncology surgery at Hopkins. "Surgeons need to apply outcomes research rigorously to advance clinical care based on something more objective than personal anecdotes."
For the study, the Hopkins research team examined "outcomes" or results for all 5,869 patients who underwent thyroid operations for benign or malignant thyroid disease in 52 Maryland acute care hospitals between 1991 and 1996. Using hospital discharge data, the investigators looked at in-hospital complications, average length of stay and average hospital charges. Death was not considered as an outcome because it is rare following thyroidectomy.
To assess the role of surgical experience in patient results, investigators grouped the surgeons into three categories according to the number of thyroidectomies performed over the six-year study period. The three categories were one to nine operations (group A), 10 to 29 operations (group B), 30 to 100 operations (group C), and more than 100 operations (group D).
After taking into consideration patient age, race, and other existing medical problems to produce a more accurate comparison, the researchers found significant differences in the four categories of surgeons. Patients whose surgeons did the most thyroid operations (group D) had the shortest length of hospital stay (1.4 days versus 1.7 days for groups B and C and 1.9 days for group A. These patients also had the lowest complication rate (5.1 percent for group D versus 6.1 for groups B and C and 8.6 for group A). In fact, the surgeon who performed the most thyroid operations among all the surgeons had the lowest complication rate (2.4 percent), shortest length of stay (1.1 days) and lowest average hospital charges ($2,990).
The superior clinical outcomes produced by greater surgical experience also translated into cost savings for thyroid cancer operations. For surgeons performing the greatest number of cancer surgeries, the average hospital charge was $3,553, versus $3,978 for group C surgeons; $4,046 for group B doctors, and $4,416 for those doctors in group A.
"In an era of ever increasing cost containment, we need to demonstrate outcome data to determine how to allocate limited resources," Udelsman says. Toby Gordon, Sc.D., a coauthor of the study and associate professor of surgery at Hopkins, says, "These kinds of outcomes studies underscore the importance of surgical experience in obtaining the best clinical results for patients and the best economic results for payers."
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