Managing incidental thyroid nodules identified on cross-sectional imaging: standardized radiology report recommendations to reduce unnecessary imaging and biopsy

From the 2018 HVPAA National Conference

Pam Johnson (Johns Hopkins Department of Radiology), Ken Lee (Armstrong Institute, Johns Hopkins Hospital), Taylor English (Johns Hopkins Department of Radiology), Alice Goldman (Johns Hopkins Department of Radiology), Sheila Sheth (NYU Langone Health), Karen Horton (Johns Hopkins Department of Radiology)


Thyroid nodules are commonly identified incidental findings on imaging. Many patients with benign nodules undergo unnecessary surgery or serial ultrasound imaging in the setting of an inconclusive fine needle aspiration (FNA).


To standardize recommendations for managing thyroid nodules based on ACR White Paper guidelines, with the aim of reducing unnecessary thyroid ultrasound, biopsy, follow up imaging and surgery.


A set of standardized management recommendations for incidental, asymptomatic thyroid nodules was created with Powerscribe picklists, to be included in CT and MRI report impressions. Guidelines were designed based on the ACR White Paper using age (35 years) and size (1 cm and 1.5 cm) thresholds. After conferring with our endocrinologists, the recommendations were modified for nodules measuring 1.0-1.4 cm as follows:

  • age < 35, nodule < 1 cm: no additional imaging in low risk patient
  • age < 35, nodule > 1 cm: ultrasound advised
  • age > 35, nodule < 1 cm: no additional imaging in low risk patient
  • age > 35, nodule 1-1.4 cm: additional imaging at provider’s discretion
  • age > 35, nodule > 1.5 cm: ultrasound advised

After a 3 month pilot, all radiology faculty, fellows and residents were instructed that compliance would be measured beginning July 2017. To gauge compliance, neck and chest CT reports are searched for strings that would identify all thyroid nodules (denominator) and reports that included the recommendations (numerator), and these data are compiled into monthly utilization dashboards.

In September 2017, the ultrasound division began using a ACR TiRads template to characterize and define management of all thyroid nodules referred for ultrasound imaging.


Utilization of the standardized recommendations for incidental thyroid nodules in CT reports rose from 40% in June 2017 to 70% by December 2017 (Figure 1). For the 8 months from July 2017 through February 2018, total number of thyroid ultrasounds decreased by 28% (from 765 to 553, p=0.003) (Figure 2), and total number of thyroid biopsies decreased by 13% (from 507 to 428, p=0.02) (Figure 3) compared to the same time period in 2016-17.

Cost savings for US-guided biopsy supplies was $3,198 and US-guided biopsy charge reduction totaled $40,170 over this 8 month period, translating to estimated annual cost reduction of $4,797 and charge reduction of $60,255, respectively.

Additional analysis will be conducted to measure cost savings resulting from reductions in pathology processing of biopsy specimens. Rate of cancer detection with US-guided biopsy and rate of unnecessary surgery for benign disease will also be compared for time periods before and after these interventions.


Standardized consensus-based recommendations for thyroid nodules in ultrasound and CT reports reduce unnecessary thyroid ultrasound and US-guided thyroid biopsies in a nonintrusive manner. Our set of CT recommendations are less stringent than the ACR White Paper guidelines with respect to avoiding ultrasound for incidental nodules, but nonetheless contributed to significant declines in both thyroid ultrasound and US-guided thyroid biopsies. Future analyses will determine the number of surgeries avoided to fully gauge the value of this intervention.

Implications for the Patient

Thyroid nodules are often benign, and malignant nodules are typically indolent. Avoiding unwarranted work-up of these nodules protects patients from the experience, risks and costs of an unnecessary thyroid biopsy and surgery.

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