Evaluation of palpable thyroid nodules: Are endocrinologists assessing patients efficiently?

One of the most common clinical problems for endocrinologists is the evalua tion of thyroid nodules. Radionuclide scans and thyroid ultrasonography, tr aditionally used to distinguish malignant from benign nodules, are costly a nd provide nonspecific results. Currently, authors of clinical practice gui delines recommend fine-needle aspiration (FNA) cytology as the best initial test for evaluating thyroid nodules. This paper reviews the practice patte rns of thyroid specialists and primary care providers at the Gundersen Luth eran Medical Center and summarizes the pattern of thyroid nodule evaluation published by other endocrinologists. The results indicate that FNA cytolog y was widely used at our institution by both thyroid specialists and primar y care providers. Since the introduction of FNA cytology, the use of radio. nuclide scanning has decreased from 90% to 12% and the use of thyroid ultr asonography from 30% to 10%. Although the frequency of thyroid surgery fell , the detection of thyroid cancer in operative specimens increased from 16% to 43%, whereas the cost of removing, a thyroid carcinoma decreased from $ 64,000 to $25,000. Primary care physicians used imaging studies modestly an d generated $106 per patient in unnecessary costs. Thyroid specialists occa sionally used radionuclide scanning but did not use thyroid ultrasonography ; they generated $41 per patient in unnecessary costs. Review of the practi ce patterns of U.S. endocrinologists indicate that they have widely accepte d FNA cytology and used fewer thyroid tests than primary care providers and European endocrinologists for evaluating thyroid nodules. However, they ma y be increasing the use of thyroid ultrasonography and order radioiodine up take tests and in vitro studies unnecessarily. Avoiding unnecessary costs i ncurred in the evaluation of 275,000 thyroid nodules detected annually coul d save millions of dollars.