Effect of implementation of standardized reporting and biopsy guidelines for incidental thyroid nodules on the frequency of benign thyroid surgery

From the 2021 HVPAA National Conference

Derek Nguyen (Johns Hopkins Medicine), Xueying Hu, Alice Yu, Pamela Johnson, Jenny Hoang, Javad Azadi


Incidental thyroid nodules are a common finding on CT and MRI exams. The majority are benign, but their discovery has resulted in extraneous thyroid ultrasounds (US), US-guided biopsies and thyroidectomies. To reduce unnecessary intervention, guidelines for US evaluation of incidentally detected thyroid nodules have been developed by the American College of Radiology (ACR) and the American Thyroid Association (ATA).

In 2016, our radiology department implemented standardized management recommendations for thyroid nodules incidentally identified on CT and MRI studies, which harmonized the ACR and ATA recommendations. In the same time period, the US department began following Ti-Rads criteria for biopsy decision making, although this was not mandated. We previously reported decrease in subsequent thyroid ultrasounds (28% decline) and ultrasound-guided biopsies (13% decline) in an interrupted time-series analysis. In this study, we evaluated the effect of a standardized incidental thyroid reporting macro on the rate of benign and malignant thyroidectomies.


The IRB at our institution acknowledged this retrospective study as a quality improvement project exempt from approval. The standardized thyroid dictation macro was created in collaboration with our endocrine specialists and implemented in May 2017 and adherence by radiologists monitored monthly. We compared the number of surgeries for incidental thyroid nodules between January 1-December 3, 2016 (pre-intervention group) and January 1- December 31, 2018 (post-intervention group). Cases were identified by searching common procedural technology (CPT) codes in the billing database. Though chart review, we included only patients who underwent US, US-guided biopsy and surgery for incidental thyroid nodules identified on MRI or CT. Patients with symptoms, goiter, lab abnormalities, or unknown indications were excluded.

Pathology reports for patients that met inclusion criteria were reviewed and classified as benign or malignant, and we compared the rates of pathology-proven benign thyroid nodule and thyroid malignancy in pre-intervention group and the post-intervention group using the Chi-squared test. For all analyses, p < 0.05 was considered statistically significant.


In the pre-intervention group, of the 143 patients who underwent ultrasound-guided thyroid biopsy and thyroidectomy, and 21% (30/143)) were referred for an incidentally discovered thyroid nodule. In the post-intervention group, out of 120 patients who underwent thyroid biopsy and thyroidectomy, 27% (32/120) were referred for an incidental thyroid nodule.

Among those patients who had thyroidectomies performed for incidental thyroid nodules, 47% (14/30) had a benign diagnosis in the preintervention group and 53% (16/30) had a malignant diagnosis. In the post-intervention group, 25% (8/32) had a benign diagnosis and 75% (24/32) had a malignant diagnosis. This reduction in benign thyroidectomies in the post-intervention group did not reach statistical significance (p = 0.075).


After implementation of a standardized dictation macro for incidental thyroid nodules, we observed a trend towards decrease in rate of benign thyroidectomies and an increase in the percentage of malignant thyroidectomies in patients with incidentally identified thyroid nodules. Although this did not reach statistical significance, this likely is a result of small numbers.

Standardized recommendations for incidentally discovered thyroid nodules may reduce unnecessary thyroidectomies in patients with benign thyroid nodules.

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