Incidental Thyroid Nodules: Benefits of Adhering to JACR 2015 Consensus Management Recommendations

From the 2018 HVPAA National Conference

Taylor English (Johns Hopkins Department of Radiology), Alice Goldman (Johns Hopkins Department of Radiology), Jenny Yan (Johns Hopkins School of Medicine), Pamela Johnson (Johns Hopkins Department of Radiology), Sheila Sheth (Johns Hopkins School of Medicine)


Incidental thyroid nodules are common. Most thyroid cancer is indolent with low mortality. Increased ITN detection contributed to tripling thyroid cancer incidence over thirty years without changing the 0.5% mortality rate. Diagnosis and management of US patients with papillary cancer was associated with a cost of $1.6 billion in 2013.


Assess the financial impact and patient care outcomes of eliminating unnecessary workups by retrospectively applying ACR consensus recommendations for managing incidental thyroid nodules (ITN) to a cohort of patients who had undergone ultrasound and fine needle aspiration (FNA) of ITN.


IRB approved, retrospective review of 249 consecutive adult patients who underwent FNA between 2012-2016 for an incidental thyroid nodule identified on CT or MRI. Patients with ITN with suspicious CT/MR features (as defined by ACR White Paper) were excluded. Radiology and pathology reports were reviewed for all patients who would not have undergone further evaluation with US and US-guided biopsy based on age and size recommendations from the ACR:

  • age < 35, nodule < 1 cm: no additional imaging in low risk patient
  • age < 35, nodule > 1 cm: ultrasound advised
  • age > 35, nodule < 1.5 cm: no additional imaging in low risk patient
  • age > 35, nodule > 1.5 cm: ultrasound advised


The vast majority of patients with ITN that did not meet the size threshold for which ACR recommends further evaluation were benign. This cohort represents approximately 30% (71/249) of patients with ITN. In 7 patients in whom FNA was not benign, further evaluations and treatments had no measurable benefit with regard to extending their quality of life or life expectancy.


This study demonstrates that adherence to the ACR consensus recommendations could spare 30% of US-guided biopsies for ITN with no measurable negative consequence to patients. Extrapolating a 30% reduction to the estimated 600,000 thyroid biopsies performed yearly in the US translates to a potential charge reduction of $100 million from the US-guided biopsy alone, with additional cost savings from the pathologic analysis of the FNA specimen and unnecessary surgery in some patients.

Implications for the Patient

Adopting the ACR consensus recommendations can increase patient care value by reducing diagnostic test overuse and costs, without negatively affecting patient outcomes. In addition to the analysis performed in this cohort, patients with indeterminate FNA results may undergo unnecessary surgery contributing to even higher risks, costs and negative patient experience.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog