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Complete Thyroid Audit

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  • 1. Primary Care direct access to thyroid ultrasound: Audit of clinical efficiency & governance   Bravis V ¹ , Lingam R ² , Haroon M ² , Devendra D 1,3,4 Dept. of Endocrinology ¹ & Radiology ² , Central Middlesex Hospital, Brent tPCT 3 & Imperial College 4 , London.
  • 2. Introduction
    • Thyroid Ultrasound (TUS) is a useful tool in a spectrum of thyroid conditions
    • High sensitivity, non-invasive, safe
    • In some hospitals, primary care has direct access to requesting TUS, rather than via a speciality
  • 3. Introduction
    • NICE (2005)
      • Primary care not recommended as may delay referral if cancer suspected
      • No specific recommendations for the use of Thyroid US (TUS) in the initial evaluation of most common thyroid problems
    • British Thyroid Association
      • TUS can be used as extension to the clinical examination
  • 4. Prevalence of Goitres Hatton & Devendra, BMJ 2008 submitted 60.0 n/a n/a Belarus [w16] 50.5 n/a n/a Mayo, USA [w10] n/a 14.5 n/a France [w15] n/a 25.0 n/a Belgium [w14] n/a 23.4 n/a Germany [3] n/a 21.3 3.2 Finland [w20] n/a 67.0 21.0 North America [w9] n/a 14.8 8.9 Poland [w13] n/a n/a 4.2 Framingham, USA [w8] n/a n/a 3.2 Whickham, England [2] Prevalence of nodules on autopsy (%) Prevalence of nodules on ultrasound (%) Prevalence of nodules on palpation (%) Country of study conducted
  • 5. Caveats in Clinical History & Examination
    • Compressive symptoms (eg.dyspnoea,stridor, hoarseness)
    • Rapid enlargement over days/weeks
    • MEN syndrome type 2 (RET mutation)
    • Childhood neck irradiation
    • Age<20 or >65
    • Male gender
    • Familial Adenomatous Polyposis
    • Hashimoto’s thyroiditis
    • Cervical LN
    • Hard and fixed nodule/goitre
    • RCP 2007
  • 6. Caveats to Ultrasound 85.7-97.4 24.0-41.9 78.6-80.8 54.3-74.2 Central blood flow on colour Doppler 38.9-97.4 9.3-60.0 38.9-85.0 17.5-77.5 Irregular margins/no halo 73.5-93.8 11.4-68.4 43.4-94.3 26.5-87.1 Echogenicity 41.8-94.2 24.3-70.7 85.8-95.0 26.1-59.1 Microcalcifications Negative predictive value (%) Positive predictive value (%) Specificity (%) Sensitivity (%) US feature
  • 7. Caveats in Cytology reports Obtained in around 3-5% of cases. Malignant Follicular adenomas and carcinomas are indistinguishable on cytology and so often produce a ‘suspicious’ cytology result. These nodules are managed as carcinomas. Suspicious Obtained in around 70% cases. No evidence of malignancy Benign 20% cases, even if FNA is ultrasound guided.Contain too few epithelial cells for a diagnosis to be made. Particularly common when aspirating cystic nodules. The presence of too much cyst fluid or blood, or inadequate technique in performing FNA and preparing the slide for cytology can all produce a non diagnostic sample Non-diagnostic Explanation Cytology results
  • 8. Problems in Brent : Inefficiency & Delay : Governance issues
    • Route of referrals not consistent:
    • A: GP Community USS – nodule – no F/U
    • B: GP Community USS – nodule – refer to endocrine/surgery/ENT team – repeat USS
    • C: GP CMH U/S dept tell GP to refer to Endocrine team for review
    • D: GP Endocrine/surgery - request USS seen 3 months later in ECC at BeCAD
  • 9. Aim of the audit 1 (presented last year to dept.)
    • We were keen to assess the outcomes of TUS referred by primary care in our hospital
    Winner of the British Thyroid Association abstract award 2007
  • 10. Method
    • All primary care referrals for TUS
    • January to June 2006
    • Retrospectively
    • Analysed them according to the following 3 reasons for referral:
      • 1) suspicion of goitre/thyroid swelling
      • 2) abnormal thyroid function
      • 3) dysphagia
      • Performance indicators - audit criteria :
      • 1) Number of neoplasia detected
      • 2) FNAs lost to follow up
  • 11. Results
    • 77 primary care referrals
    • Male (19), female (58)
    • Mean age 42.9 (SD 15.96)
  • 12. TUS result according to reason for referral 77 44 1 2 12 18 Total 17 12 0 1 1 3 Dysphagia (17) 15 8 1 0 0 6 Abnormal TFTs (15) 45 24 0 1 11 9 ? Goitre (45) Normal gland Hypothyroid Gland Thyroiditis Solitary / Dominant Nodule MNG Total TUS Result Referral Reason
  • 13. FNA cytology (n=13) neoplasm n=0 13 4 1 8 Total 11 4 0 7 Solitary/ Dominant nodule (11) 2 0 1 1 MNG (2) Insufficient Thyroiditis Benign Total FNA Result FNA
  • 14. Insufficient samples for FNA- outcome (n=4) 1 (adenocarcinoma) Insufficient re-FNA, suspicious USS features 2 Insufficient re-FNA, normal USS features 1 Insufficient FNA Normal USS features Surgery Lost to F/U Discharged
  • 15. Audit Cycle 1. Identify issue TUS access 5. Implementing change One stop clinic 4. Compare 3. Data collection 2. Set criteria Malignancy pick-up rate & Follow up of inconclusive FNA
  • 16. Refer to Endocrine surgeon GP referral – thyroid swelling/goitre/nodules TSH, FT4, FT3, TPO Abs, Ca Sample inadequate /poor to comment but normal US and no increase in nodule size Suspicious or abnormal Abnormal – Endcorine clinic appointment given Normal – refer to one stop diagnostic clinic Clinical assessment USS neck US guided FNA , if suspicious nodule by US criteria Cytology Normal cytology & USS characteristics Sample inadequate/ poor to comment but suspicious USS features Sample inadequate /poor to comment on Discharge Repeat USS- guided FNA within 6 months Sample inadequate /poor to comment but suspicious US features Suspicious or abnormal BRENT RAPID ACCESS ONE STOP THYROID DIAGNOSTIC CLINIC
  • 17. One stop clinic
    • We emailed GPs who wanted to use this system explaining to them our previous audit results
    • MDT approach – The classification used by cytologist – fax to endocrine dept if abnormal cytology
    • Referred (endocrine sec. liaise) urgently to endocrine surgeon
    • GPs notified by letter from endocrine dept of clinical plan & Thyroid USS & FNA results & if follow up is necessary
    Date: Signature: Referral made by: GP details / stamp (inc. name, address, tel, fax) : Language: Interpreter Required: Yes No Ethnicity: Housebound? Postcode: Address: Contact Tel Number: NHS Number: DOB: Sex: Male Female Patient Name : Thyroglobulin (this is useful if patient had total thyroidectomy in the past): Thyroid peroxidase antibody (TPO): FreeT3: Free T4: Corrected Calcium: TSH: Clinical Information: Thyroid Goitre/nodule clinically suspected with or without following conditions ( Please tick) Hoarseness of voice Familial Adenomatous Polyposis Previous neck radiation Recent unexplained weight loss Previous Thyroid cancer Hashimoto’s thyroiditis (hypothyroidism) Family history of thyroid cancer Graves’ hyperthyroidism (past or present) Other information: Recent investigations date: (insert pending if not available yet) REFERRAL FOR THYROID GOITRE/NODULE ULTRASOUND CLINIC Thyroid Ultrasound clinic Jeffrey Kelson Centre, Central Middlesex Hospital Tel: 0208 453 2401, Fax: 020 8453 2415 E-mail: linda.pontello@nwlh.nhs.uk
  • 18. Aim of the audit 2
    • Assess the outcomes of TUS referred only through specialist input – see referral form
    • Compare our practice (before and after change)
    • Determine best practice to follow
  • 19. Method
    • Primary care referrals for TUS were encouraged to use:
      • Referral forms for GPs
      • Risk factors (RCP guidelines of thyroid cancer)
    • Prospectively
    • May 2007 – December 2007
    • Use of clinical & ultrasound scoring criteria: to aid FNA
    • (R. Hatton, BSc thesis, Imperial College, May 2007)
  • 20. Prediction of neoplasia
    • Based on subjective analysis US features, clinical risk &TSH level
    • Prediction
    • Based on subjective evaluation of ultrasound and clinical risk, TSH
    • Non-neoplastic
    • Neoplastic
    • Confidence level
    • Definitely non neoplastic
    • Probably non neoplastic
    • Possibly neoplastic
    • Probably neoplastic
    • 5. Definitely neoplastic
  • 21. Results
    • Audit-Primary care
    • 77 referrals
    • Male (19), female (58)
    • Mean age 42.9
    • (SD 15.96)
    • Audit-Secondary care
    • 68 referrals
    • Male (3), female (65)
    • Mean age 44.8
    • (SD 15.82)
  • 22. FNA cytology (n=23) neoplasm (n=7) 23 1 7 3 12 Total 2 0 0 2 0 Other 12 1 5 1 5 Solitary/ Dominant nodule 9 0 2 0 7 MNG Insufficient Malignancy Reactive LN Benign Total FNA Result FNA
  • 23. Neoplasm (n=7) 1 (female) 6 (5 female) FNA Papillary Follicular
  • 24. Before & After One stop clinic implementation
    • Before
    • Neoplasm rate (n=1)
    • Fewer FNAs (n=13) with lower neoplasm pick-up rate
    • First time insufficient samples for FNA- outcome lost to follow up (n=1)
    • After
    • Neoplasm rate (n=7)
    • More FNAs (n=23) with higher neoplasm pick-up rate
    • First time insufficient samples for FNA- outcome lost to follow up (n=0)
  • 25. Conclusions
    • Primary care clinicians obtain TUS studies in patients without recommended indications prior to referral to an endocrinologist
    • P rimary care access to T US has not proven of value in detecting sinister thyroid pathology
    • In addition, TUS in the community – need to be fast-tracked into one stop clinic for FNA or potentially abandoned altogether
    • Educating primary care to be thyroid cancer aware has increased referrals and FNA rate
  • 26. Conclusions
    • Efficiency in investigating thyroid pathology (clinical efficiency) , as well as rationalisation of resources (cost effectiveness) can be achieved by involving one stop clinic
    • ?Best practice: limit primary care access to TUS
    • One stop clinic will help the governance and quality of the management of thyroid nodules
    • National targets for time to treatment for cancer needs to be observed for these patients
  • 27. Acknowledgements
    • Angie (Imaging dept.)
    • Kay & Theresa (Jeffrey Kelson Diabetes Centre)
    • Staff at ACAD Area 2

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