Variation in the Quality of Thyroid Nodule Evaluations Before Surgical Referral

J Surg Res. 2019 Dec;244:9-14. doi: 10.1016/j.jss.2019.06.024. Epub 2019 Jul 3.


Background: Thyroid nodules are highly prevalent, and owing to their malignant potential, proper evaluation is imperative. The objective of this study was to characterize variation in thyroid nodule evaluations.

Materials and methods: This retrospective review included all consecutive surgical referrals for thyroid nodules from October to December 2017 at a single institution. We determined the proportion of evaluations that contained a thyroid-stimulating hormone (TSH) level and a high-quality ultrasound because these components of thyroid nodule evaluations are common to several evidence-based guidelines.

Results: The study cohort included 64 patients, with a median age of 51.5 y. Primary care providers referred most patients (51.6%), followed by endocrinologists (40.6%), and other specialists (7.8%). In total, 35.9% of evaluations did not include a TSH value, which is vital to any thyroid nodule evaluation. Most evaluations (95.3%) included a dedicated ultrasound, but only 12.3% of ultrasound reports commented on nodule size in three dimensions, structure, echogenicity, and lymph nodes, which we considered the minimum commentary indicative of a high-quality ultrasound. Only 51.5% of evaluations included both a TSH and a thyroid ultrasound. If patients receiving low-quality ultrasound reports were excluded, 9.4% of the entire cohort received a guideline-concordant, high-quality evaluation.

Conclusions: Great variation exists in the quality of thyroid nodule evaluations before surgical referral. Two necessary components of thyroid nodule evaluations that contribute most to the observed deviation from guidelines are obtaining a TSH value and obtaining an ultrasound with enough information to risk stratify the nodule.

Keywords: Fine needle aspiration; Quality of care; Thyroid; Thyroid nodule; Thyroid ultrasound.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Diagnosis, Differential
  • Female
  • Guideline Adherence / standards
  • Guideline Adherence / statistics & numerical data
  • Humans
  • Male
  • Middle Aged
  • Practice Guidelines as Topic
  • Practice Patterns, Physicians' / standards
  • Practice Patterns, Physicians' / statistics & numerical data*
  • Primary Health Care / standards
  • Primary Health Care / statistics & numerical data*
  • Quality of Health Care / standards
  • Quality of Health Care / statistics & numerical data*
  • Referral and Consultation / standards
  • Referral and Consultation / statistics & numerical data
  • Retrospective Studies
  • Risk Assessment / standards
  • Risk Assessment / statistics & numerical data
  • Thyroid Gland / diagnostic imaging
  • Thyroid Neoplasms / blood
  • Thyroid Neoplasms / diagnosis*
  • Thyroid Neoplasms / surgery
  • Thyroid Nodule / blood
  • Thyroid Nodule / diagnosis*
  • Thyroid Nodule / surgery
  • Thyroidectomy
  • Thyrotropin / blood
  • Ultrasonography / statistics & numerical data


  • Thyrotropin