Setting and Problem
Thyroid nodules are the most common endocrine tumor, with population-based studies identifying palpable nodules in approximately 5% of adults. Ultrasound and autopsy studies have demonstrated that more than 50% of women and more than 20% of men over the age of 50 have a thyroid nodule. It also is estimated that more than 450 000 thyroid biopsies are performed each year in the United States. Given the expanded availability and subsequent use of imaging technologies to identify thyroid nodules, the frequency of thyroid biopsies is a patient care issue, and the cost associated with them is a significant health care expenditure. An efficient, cost-effective strategy for the evaluation of thyroid nodules is an important quality of care goal. Because ultrasound-guided fine needle aspiration (FNA) remains the procedure of choice in the evaluation of thyroid nodules, there is an important need to provide a comprehensive educational experience to endocrinology and cytopathology fellows that ultimately leads to a reduction in repeat FNA and unnecessary surgery.
Intervention
The University of Vermont College of Medicine's Division of Endocrinology and Diabetes and Department of Pathology and Laboratory Medicine collaborated to design a novel Multidisciplinary Thyroid Biopsy Clinic (MTBC). This clinic improves the educational experience of endocrinology and cytopathology fellows by providing immediate feedback through rapid on-site evaluation (ROSE) of FNA specimens. Prior to implementation of the MTBC, ultrasound-guided FNA of thyroid nodules was performed during endocrine fellows' continuity clinics, and specimens were sent to the pathology department for review. A key component of the MTBC was the formation of a separate thyroid biopsy clinic. Each MTBC is staffed by an endocrine fellow, an attending endocrinologist, a cytopathology fellow, and an attending cytopathologist, all of whom see multiple patients. The MTBC format provides an endocrine and cytopathology fellow the opportunity to perform multiple biopsies—a maximum of 3 initial passes for each patient—that are evaluated on-site immediately and assessed for quality of technique and adequacy of the specimens.
Outcomes to Date
We performed retrospective chart reviews 2 years before and 2 years after instituting the MTBC. Secondary analyses of surgical rates and cost were also completed. After implementation of the MTBC and ROSE, the rate of nondiagnostic thyroid FNA biopsies in endocrinology fell from 24% prior to MTBC to 5% after (P < .001), resulting in more definitive cytopathology reports and reduced repeat aspirations. There was a concordant increase in the diagnosis of benign nodules, from 48% to 78% (P < .001). The size of nodules biopsied in the MTBC was smaller when compared to the nodules biopsied at the endocrine clinic prior to the MTBC (mean size, 19.94 mm compared to 23.63 mm; P < .001), and there was a decrease in surgical referrals after nondiagnostic cytopathology (from n = 20 [21%] to n = 0).
Development of the MTBC was primarily driven by the desire to better educate both endocrine and cytopathology fellows in the technique of ultrasound-guided FNA, adequate preparation of FNA samples, and management of thyroid nodules. It has achieved that goal, as demonstrated by the decrease in nondiagnostic FNA biopsies and the increase in the fellows' ability to successfully biopsy smaller nodules. In addition, the MTBC has also resulted in a significant improvement in patient care and lower health care costs due to reduction in repeat FNA biopsies and surgical referrals.
While it is often not typical to train across specialties, we have seen tremendous educational and quality benefits in having endocrinologists train pathology fellows (and vice versa), with each discipline providing a unique perspective to patient care, specimen preparation, and triage. The MTBC model could be adopted in other multidisciplinary clinic settings or procedures, such as central line placement by critical care, surgery, and medicine residents, and in biopsy procedures involving interventional radiologists and pathologists. Expanding multidisciplinary education, as evidenced by the MTBC, enhances trainee education and improves patient care.