Medical Maximizing Preferences and Beliefs About Cancer Among US Adults.

Importance: Medical overutilization contributes to significant health care expenditures and exposes patients to questionably beneficial surgery and unnecessary risk. Objectives: To understand public attitudes toward medical utilization and the association of these attitudes with beliefs about cancer. Design, Setting, and Participants: In this cross-sectional survey study conducted from August 26 to October 28, 2020, US-based, English-speaking adults were recruited from the general public using Prolific Academic, a research participant platform. Quota-filling was used to obtain a sample demographically representative of the US population. Adults with a personal history of cancer other than nonmelanoma skin cancer were excluded. Statistical analysis was completed in July 2022. Main Outcome and Measures: Medical utilization preferences were characterized with the validated, single-item Maximizer-Minimizer Elicitation Question. Participants preferring to take action in medically ambiguous situations (hereafter referred to as "maximizers") were compared with those who leaned toward waiting and seeing (hereafter referred to as "nonmaximizers"). Beliefs and emotions about cancer incidence, survivability, and preventability were assessed using validated measures. Logistic regression modeled factors associated with preferring to maximize medical utilization. Results: Of 1131 participants (mean [SD] age, 45 [16] years; 568 women [50.2%]), 287 (25.4%) were classified as maximizers, and 844 (74.6%) were classified as nonmaximizers. Logistic regression revealed that self-reporting very good or excellent health status (compared with good, fair, or poor; odds ratio [OR], 2.01 [95% CI, 1.52-2.65]), Black race (compared with White race; OR, 1.88 [95% CI, 1.22-2.89]), high levels of cancer worry (compared with low levels; OR, 1.62 [95% CI, 1.09-2.42]), and overestimating cancer incidence (compared with accurate estimation or underestimating; OR, 1.58 [95% CI, 1.09-2.28]) were significantly associated with maximizing preferences. Those who believed that they personally had a higher-than-average risk of developing cancer were more likely to be maximizers (23.6% [59 of 250] vs 17.4% [131 of 751]; P = .03); this factor was not significant in regression analyses. Conclusions and Relevance: In this survey study of US adults, those with medical maximizing tendencies more often overestimated the incidence of cancer and had higher levels of cancer-related worry. Targeted and personalized education about cancer and its risk factors may help reduce overutilization of oncologic care.

Making Choices: A Multi-institutional, Longitudinal Cohort Study Assessing Changes in Treatment Outcome Valuation for Low-Risk Thyroid Cancer.

OBJECTIVE: To evaluate the relative importance of treatment outcomes to patients with low-risk thyroid cancer (TC). SUMMARY BACKGROUND DATA: Overuse of total thyroidectomy (TT) for low-risk TC is common. Emotions from a cancer diagnosis may lead patients to choose TT resulting in outcomes that do not align with their preferences. METHODS: Adults with clinically low-risk TC enrolled in a prospective, multi-institutional, longitudinal cohort study from 11/2019-6/2021. Participants rated treatment outcomes at the time of their surgical decision and again 9 months later by allocating 100 points amongst 10 outcomes. T-tests and Hotelling's T 2 statistic compared outcome valuation within and between subjects based on chosen extent of surgery (TT vs. lobectomy). RESULTS: Of 177 eligible patients, 125 participated (70.6% response) and 114 completed the 9-month follow-up (91.2% retention). At the time of the treatment decision, patients choosing TT valued the risk of recurrence more than those choosing lobectomy and the need to take thyroid hormone less ( P <0.05). At repeat valuation, all patients assigned fewer points to cancer being removed and the impact of treatment on their voice, and more points to energy levels ( P <0.05). The importance of the risk of recurrence increased for those who chose lobectomy and decreased for those choosing TT ( P <0.05). CONCLUSION: The relative importance of treatment outcomes changes for patients with low-risk TC once the outcome has been experienced to favor quality of life over emotion-related outcomes. Surgeons can use this information to discuss the potential for asthenia or changes in energy levels associated with total thyroidectomy.

Assessing Fear of Thyroid Cancer in the General U.S. Population: A Cross-Sectional Study.

Background: This study aimed to measure fear of thyroid cancer in the general U.S. population and identify factors associated with a high level of thyroid cancer-specific fear that may contribute to overtreatment. Methods: We conducted a cross-sectional survey using Prolific Academic Ltd.®, an online survey platform. The survey was administered in August 2020 to English speaking adults (>17 years) in the United States who were registered with Prolific. The target sample was stratified to represent the demographics of the U.S. population. A validated, eight-item breast cancer fear scale was adapted to measure thyroid cancer-specific fear. Multivariate logistic regression identified factors significantly associated with high levels of thyroid cancer-specific fear. Results: Of the 1136 respondents (94.3% eligibility), 50.4% were female, 74.1% White, and the mean age was 45 years (SD = 16 years). Overall, 47.5% of respondents had high levels of thyroid cancer-specific fear. Multivariate regression demonstrated that age <40 years (OR = 2.46 vs. 65+ [95% confidence interval {CI} = 1.60-3.80]) and female gender (OR = 1.48 vs. male [CI = 1.13-1.93]) were associated with high levels of thyroid cancer fear. Believing thyroid cancer (OR = 2.71 [CI = 1.99-3.69]) and cancer in general are serious (OR = 1.53 [CI = 1.13-2.08]) were also associated with high levels of thyroid cancer fear. Respondents who overestimated thyroid cancer incidence (OR = 1.64 [CI = 1.25-2.13]) and believed they had a high chance of developing cancer (OR = 1.70 [CI = 1.19-2.42]) were also more likely to have high fear of thyroid cancer. Conclusion: Thyroid cancer-specific fear is prevalent in U.S. adults particularly in females and those younger than 40 years. Because disease-specific fear is associated with overtreatment, targeted education about the seriousness, incidence, and risk factors for developing thyroid cancer may decrease public fear and possibly overtreatment related to "scared decision-making."

The invisible work of transfer centre nurses: A qualitative study of strategies to overcome communication challenges.

AIMS: To explore the role of transfer centre nurses and how they facilitate communication between referring and accepting providers during calls about interhospital transfers, including their strategies to overcome communication challenges. DESIGN: A qualitative interview study. METHODS: We conducted semi-structured interviews with 17 transfer centre nurses at one tertiary medical centre from March to August 2019, asking participants to describe their work. We performed content analysis, applying codes based on the Relational Coordination Framework and generating emergent codes, then organized codes in higher-order concepts. We followed the COREQ checklist. RESULTS: Transfer centre nurses employed multiple strategies to mitigate communication challenges. When referring providers had misconceptions about the transfer centre nurse's role and the accepting hospital's processes, the nurses informed referring providers why sharing information with them was necessary. If providers expressed frustrations or lacked understanding about their counterpart's caseload, the nurses managed providers' emotions by letting them "vent," explaining the other provider's situational context and describing the hospital's capabilities. Some nurses also mediated conflict and sought to break the tension if providers debated about the best course of action. When providers struggled to share complete and accurate information, the nurses hunted down details and 'filled in the blanks'. CONCLUSION: Transfer centre nurses perform invisible work throughout the lifespan of interhospital transfers. Nurses' expert knowledge of the transfer process and hospitals' capabilities can enhance provider communication. Meanwhile, providers' lack of knowledge of the nurse's role can impede respectful and efficient transfer conversations. Interventions to support and optimize the transfer centre nurses' critical work are needed. IMPACT: This study describes how transfer centre nurses facilitate communication and overcome challenges during calls about interhospital transfers. An intervention that supports this critical work has the potential to benefit nurses, providers and patients by ensuring accurate and complete information exchange in an effective, efficient manner that respects all parties. PATIENT OR PUBLIC CONTRIBUTION: This study was designed to capture the perspectives and experiences of transfer centre nurses themselves through interviews. Therefore, it was not conducted using input or suggestions from the public or the patient population served by the organization.

What do patients want to know about surgery for low-risk thyroid cancer? A qualitative study.

BACKGROUND: Shared decision-making about treatment for low-risk thyroid cancer requires patients and surgeons to work together to select treatment that best balances risks and expected outcomes with patient preferences and values. To participate, patients must be activated and ask questions. We aimed to characterize what topics patients prioritize during treatment decision-making. METHODS: We identified substantive questions by patients with low-risk (cT1-2, N0) thyroid cancer during audio-recorded consultations with 9 surgeons at 2 unique health care systems. Logistics questions were excluded. Qualitative content analysis was used to identify major themes among patients' questions and surgeon responses. RESULTS: Overall, 28 of 30 patients asked 253 substantive questions, with 2 patients not asking any substantive questions (median 8, range 0-25). Patients were 20 to 71 years old, mostly White (86.7%) and female (80.0%). The questions addressed extent of surgery, hormone supplementation, risk of cancer progression, radioactive iodine, and etiology of thyroid cancer. When patients probed for a recommendation regarding extent of surgery, surgeons often responded indirectly. When patients asked how surgery could impact quality of life, surgeons focused on oncologic benefits and surgical risk. Patients commonly asked about hormone supplementation and radioactive iodine. CONCLUSION: Patient questions focused on the decision regarding extent of surgery, quality of life, and nonsurgical aspects of thyroid cancer care. Surgeon responses do not consistently directly answer patients' questions but focus on the risks, benefits, and conduct of surgery itself. These findings suggest an opportunity to help surgeons with resources to improve shared decision-making by providing information that patients prioritize.

The relative importance of treatment outcomes to surgeons' recommendations for low-risk thyroid cancer.

BACKGROUND: The treatment of low-risk thyroid cancer is controversial. We evaluated the importance of treatment outcomes to surgeons' recommendations. METHODS: A cross-sectional survey asked thyroid surgeons for their treatment recommendations for a healthy 45-year-old patient with a solitary, low-risk, 2-cm papillary thyroid cancer. The importance of the 10 treatment outcomes (survival, recurrence, etc.) to their recommendation was evaluated using constant sum scaling, a method where 100 points are allocated among the treatment outcomes; more points indicate higher importance. The distribution of points was compared between surgeons recommending total thyroidectomy and surgeons recommending lobectomy using Hottelling's T2 test. RESULTS: Of 165 respondents (74.3% response rate), 35.8% (n = 59) recommended total thyroidectomy and 64.2% (n = 106) lobectomy. The importance of the 10 treatment outcomes was significantly different between groups (P < .05). Surgeons recommending total thyroidectomy were most influenced by the risk of recurrence (19.1 points; standard deviation 16.5) and rated this 1.6-times more important than those recommending lobectomy. Conversely, surgeons recommending lobectomy placed high emphasis on need for hormone replacement (14.3 points; standard deviation 15.4), rating this 3.1-times more important than those recommending total thyroidectomy. CONCLUSION: Surgeons who recommend total thyroidectomy and those who recommend lobectomy differently prioritize the importance of cancer recurrence and thyroid hormone replacement. Understanding how surgeons' beliefs influence their recommendations is important for ensuring patients receive treatment aligned with their values.

The Influence of Emotions on Treatment Decisions About Low-Risk Thyroid Cancer: A Qualitative Study.

Background: Little is known about the role of emotions in treatment decisions for thyroid cancer. We aimed to characterize the emotional content of patient-surgeon communication during decision-making about low-risk thyroid cancer treatment. Methods: We audio-recorded conversations about treatment for clinically low-risk thyroid cancer or biopsy suspicious for thyroid cancer between patients (n = 30) and surgeons (n = 9) in two diverse, academic hospitals in the United States. Inductive and deductive content analyses were used to characterize the emotional content in verbatim transcripts. Results: Patients' expression of emotion focused on primarily on their diagnosis and treatment outcomes. Patients commonly expressed negative emotions like fear and anxiety about "the C-word" and worried about the cancer growing or spreading. In response, most surgeons used education, as opposed to empathy or validation, to reassure patients, often highlighting low probabilities of adverse events. Surgeons emphasized the "slow-growing" nature and excellent prognosis of thyroid cancer compared with other malignancies. When discussing treatment options, surgeons often described alternatives in terms of their emotional outcomes. Some described total thyroidectomy as providing "peace of mind" or a "sense of completeness," warning that cancer or thyroid tissue remaining in the body with active surveillance or lobectomy might "worry" or "bother" patients. Surgeons supported deliberation by reassuring patients that there are "two right answers" and "no rush" to decide. Conclusions: Patients express negative emotions during treatment decision-making. In response, surgeons often miss opportunities to provide empathy in addition to education. Surgeons and patients both acknowledge patient fear and anxiety as a reason to choose thyroidectomy instead of active surveillance. Peace of mind gained by patients and surgeons as a result of thyroidectomy may lead to overtreatment of patients with low-risk thyroid cancer.

Informed Consent and Informed Decision-Making in High-Risk Surgery: A Quantitative Analysis.

BACKGROUND: Informed consent is an ethical and legal requirement that differs from informed decision-making-a collaborative process that fosters participation and provides information to help patients reach treatment decisions. The objective of this study was to measure informed consent and informed decision-making before major surgery. STUDY DESIGN: We audio-recorded 90 preoperative patient-surgeon conversations before major cardiothoracic, vascular, oncologic, and neurosurgical procedures at 3 centers in the US and Canada. Transcripts were scored for 11 elements of informed consent based on the American College of Surgeons' definition and 9 elements of informed decision-making using Braddock's validated scale. Uni- and bivariate analyses tested associations between decision outcomes as well as patient, consultation, and surgeon characteristics. RESULTS: Overall, surgeons discussed more elements of informed consent than informed decision-making. They most frequently described the nature of the illness, the operation, and potential complications, but were less likely to assess patient understanding. When a final treatment decision was deferred, surgeons were more likely to discuss elements of informed decision-making focusing on uncertainty (50% vs 15%, p = 0.006) and treatment alternatives (63% vs 27%, p = 0.02). Conversely, when surgery was scheduled, surgeons completed more elements of informed consent. These results were not associated with the presence of family, history of previous surgery, location, or surgeon specialty. CONCLUSIONS: Surgeons routinely discuss components of informed consent with patients before high-risk surgery. However, surgeons often fail to review elements unique to informed decision-making, such as the patients' role in the decision, their daily life, uncertainty, understanding, or patient preference.

Thyroid Lobectomy for Low-Risk Papillary Thyroid Cancer: A National Survey of Low- and High-Volume Surgeons.

BACKGROUND: The 2015 American Thyroid Association guidelines endorsed lobectomy for patients with low-risk papillary thyroid cancer (PTC) measuring 1-4 cm. Attitudes about the use of lobectomy for these patients are lacking, particularly from low-volume surgeons who perform the majority of thyroidectomies in the US. METHODS: A survey was mailed to 1000 surgeons stratified by specialty (500 general surgeons and 500 otolaryngologists) registered with the American Medical Association, to evaluate beliefs and practices about the extent of surgery for low-risk PTC. Comparisons examined differences by surgeon volume. RESULTS: Of 320 respondents who have performed thyroidectomy since 2015 (150 general surgeons, 170 otolaryngologists), 206 (64.4%) were low volume (< 26 thyroidectomies/year). The proportion of surgeons recommending lobectomy for low-risk PTC measuring 1.1 to < 4 cm ranged from 43.1 to 2.6%. High-volume surgeons recommended lobectomy more frequently for PTC measuring 1.1-3 cm, although this was not statistically significant. Thirty-three percent of respondents believed lobectomy is underused for low-risk PTC, while 10.0% believed it is overused. Additionally, 19.6% of respondents believed recurrence is more likely after lobectomy than total thyroidectomy, and 3.3% believed mortality is higher. Few believed quality of life is better after lobectomy (12.3%). Low-volume surgeons were less likely to be aware guidelines support lobectomy for low-risk PTC 1-4 cm (p < 0.001) and less likely to use clinical practice guidelines (p = 0.004). CONCLUSIONS: Most surgeons do not support lobectomy for patients with low-risk PTC > 1 cm. Awareness of guidelines and concerns about increased risk of recurrence after lobectomy may drive surgeons' preference for total thyroidectomy.

Active surveillance for thyroid Cancer: a qualitative study of barriers and facilitators to implementation.

BACKGROUND: The 2015 American Thyroid Association guidelines supported active surveillance (AS) as a strategy for managing select low-risk thyroid cancers. Data examining physicians' attitudes about the acceptability of this option are limited. This study aimed to characterize the barriers and facilitators to implementing AS as perceived by practicing endocrinologists and surgeons in the United States. METHODS: We conducted 24 semi-structured interviews probing physicians' attitudes toward AS for patients with small, low-risk thyroid cancer. We used deductive content analysis guided by a well-known model of guideline implementation. Analysis characterized concepts and themes related to AS implementation as physician, guideline, or external factors. We performed member checking to validate results. RESULTS: The most prominent barriers to AS were related to physician factors, although guideline-specific and external barriers were also observed. Physician attitudes towards AS comprised the majority of physician-related barriers, while lack of knowledge about the guideline was also discussed. Participants' concerns about the potential negative outcomes resulting from observing a cancer were notable as were the lack of confidence in performing and offering surveillance. Beliefs about patient expectations and lack of knowledge about the guideline were also identified as barriers to offering surveillance. Guideline-specific and external barriers included the vagueness of surveillance protocols, lack of data supporting active surveillance, and societal beliefs about cancer. Facilitators of active surveillance included patients' desire to avoid surgery and shared decision-making. CONCLUSIONS: Barriers and facilitators of active surveillance for low-risk thyroid cancers exist at multiple levels. Strategies to increase adoption of active surveillance should focus on physicians' attitudes, patient expectations, data supporting surveillance outcomes, and promoting societal-level acceptance of surveillance.

NATIONAL SURVEY OF ENDOCRINOLOGISTS AND SURGEONS REGARDING ACTIVE SURVEILLANCE FOR LOW-RISK PAPILLARY THYROID CANCER.

OBJECTIVE: Active surveillance for low-risk papillary thyroid cancer (PTC) was endorsed by the American Thyroid Association guidelines in 2015. The attitudes and beliefs of physicians treating thyroid cancer regarding the active surveillance approach are not known. METHODS: A national survey of endocrinologists and surgeons treating thyroid cancer was conducted from August to September 2017 via professional society emails. This mixed-methods analysis reported attitudes toward potential factors impacting decision-making regarding active surveillance, beliefs about barriers and facilitators of its use, and reasons why physicians would pick a given management strategy for themselves if they were diagnosed with a low-risk PTC. Survey items about attitudes and beliefs were derived from the Cabana model of barriers to guideline adherence and theoretical domains framework of behavior change. RESULTS: Among 345 respondents, 324 (94%) agreed that active surveillance was appropriate for at least some patients, 81% agreed that active surveillance was at least somewhat underused, and 76% said that they would choose surgery for themselves if diagnosed with a PTC of ≤1 cm. Majority of the respondents believed that the guidelines supporting active surveillance were too vague and that the current supporting evidence was too weak. Malpractice and financial concerns were identified as additional barriers to offering active surveillance. The respondents endorsed improved information resources and evidence as possible facilitators to offering active surveillance. CONCLUSION: Although there is general support among physicians who treat low-risk PTC for the active surveillance approach, there is reluctance to offer it because of the lack of robust evidence, guidelines, and protocols.

Adoption of Active Surveillance for Very Low-Risk Differentiated Thyroid Cancer in the United States: A National Survey.

CONTEXT: Active surveillance (AS) of thyroid cancer with serial ultrasounds is a newer management option in the United States. OBJECTIVE: This work aimed to understand factors associated with the adoption of AS. METHODS: We surveyed endocrinologists and surgeons in the American Medical Association Masterfile. To estimate adoption, respondents recommended treatment for 2 hypothetical cases appropriate for AS. Established models of guideline implementation guided questionnaire development. Outcome measures included adoption of AS (nonadopters vs adopters, who respectively did not recommend or recommended AS at least once; and partial vs full adopters, who respectively recommended AS for one or both cases). RESULTS: The 464 respondents (33.3% response) demographically represented specialties that treat thyroid cancer. Nonadopters (45.7%) were significantly (P < .001) less likely than adopters to practice in academic settings, see more than 25 thyroid cancer patients/year, be aware of AS, use applicable guidelines (P = .04), know how to determine whether a patient is appropriate for AS, have resources to perform AS, or be motivated to use AS. Nonadopters were also significantly more likely to be anxious or have reservations about AS, be concerned about poor outcomes, or believe AS places a psychological burden on patients. Among adopters, partial and full adopters were similar except partial adopters were less likely to discuss AS with patients (P = .03) and more likely to be anxious (P = .04), have reservations (P = .03), and have concerns about the psychological burden (P = .009) of AS. Few respondents (3.2%) believed patients were aware of AS. CONCLUSION: Widespread adoption of AS will require increased patient and physician awareness, interest, and evaluation of outcomes.

Factors associated with physicians' recommendations for managing low-risk papillary thyroid cancer.

BACKGROUND: The 2015 American Thyroid Association endorsed less aggressive management for low-risk papillary thyroid cancer (LR-PTC). We aimed to identify factors influencing physicians' recommendations for LR-PTC. METHODS: We surveyed members of three professional societies and assessed respondents' recommendations for managing LR-PTC using patient scenarios. Multivariable logistic regression models identified clinical and non-clinical factors associated with recommending total thyroidectomy (TT) and active surveillance (AS). RESULTS: The 345 respondents included 246 surgeons and 99 endocrinologists. Physicians' preference for their own management if diagnosed with LR-PTC had the strongest association with their recommendation for TT and AS (TT: OR 12.3; AS: OR 7.5, p < 0.001). Physician specialty and stated patient preference were also significantly associated with their recommendations for both management options. Respondents who received information about AS had increased odds of recommending AS. CONCLUSIONS: Physicians' recommendations for LR-PTC are strongly influenced by non-clinical factors, such as personal treatment preference and specialty.

Patients' Reaction to Diagnosis with Thyroid Cancer or an Indeterminate Thyroid Nodule.

Introduction: Little is known about the experiences and concerns of patients recently diagnosed with thyroid cancer or an indeterminate thyroid nodule. This study sought to explore patients' reactions to diagnosis with papillary thyroid cancer (PTC) or indeterminate cytology on fine needle aspiration. Methods: We conducted semistructured interviews with 85 patients with recently diagnosed PTC or an indeterminate thyroid nodule before undergoing thyroidectomy. We included adults with nodules ≥1 cm and Bethesda III, IV, V, and VI cytology. The analysis utilized grounded theory methodology to create a conceptual model of patient reactions. Results: After diagnosis, participants experienced shock, anxiety, fear, and a strong need to "get it out" because "it's cancer!" This response was frequently followed by a sense of urgency to "get it done," which made waiting for surgery difficult. These reactions occurred regardless of whether participants had confirmed PTC or indeterminate cytology. Participants described the wait between diagnosis and surgery as difficult, because the cancer or nodule was "still sitting there" and "could be spreading." Participants often viewed surgery and getting the cancer out as a "fix" that would resolve their fears and worries, returning them to normalcy. The need to "get it out" also led some participants to minimize the risk of complications or adverse outcomes. Education about the slow-growing nature of PTC reassured some, but not all patients. Conclusions: After diagnosis with PTC or an indeterminate thyroid nodule, many patients have strong emotional reactions and an impulse to "get it out" elicited by the word "cancer." This reaction can persist even after receiving education about the excellent prognosis. Understanding patients' response to diagnosis is critical, because their emotional reactions likely pose a barrier to implementing guidelines recommending less extensive management for PTC.

Effect of Transfer Status on Outcomes of Emergency General Surgery Patients.

INTRODUCTION: Transferred emergency general surgery (EGS) patients are a vulnerable, high acuity population. The outcomes of and health care utilization among transferred (TRAN) as compared to directly admitted (DA) patients have been studied primarily using single institution or hospital system data which limits generalizability. We evaluated these outcomes among EGS patients using a national database. METHODS: We identified encounters of patients aged ≥18 years with a diagnosis of EGS as defined by the American Association for the Surgery of Trauma in the 2008-2011 Nationwide Inpatient Sample (NIS). Multivariable regression analyses determined if transfer status independently predicted in-hospital mortality (logistic regression) and morbidity (presence of any complication among those who survived to discharge; logistic regression), cost (log-linear regression), and duration of stay (among those who survived to discharge; log-linear regression) accounting for the NIS sampling design. RESULTS: We identified 274,145 TRAN (57,885 unweighted) and 10,456,100 DA (2,187,132 unweighted) encounters. On univariate analysis, TRAN patients were more likely to have greater comorbidity scores, have Medicare insurance, and reside in an area with a lesser median household income compared to DA patients (p<0.0001). Mortality was greater in the TRAN vs DA groups (4.4% vs 1.6%; p<0.0001). Morbidity (presence of any complication) was also greater among TRAN patients (38.8% vs 26.1%; p<0.0001). Morbidity among TRAN patients was primarily due to urinary- (13.7%), gastrointestinal- (12.9%), and pulmonary-related (13.3%) complications. Median duration of hospital stay was 4.3 days for TRAN vs 3.0 days for DA (p<0.0001) patients. Median cost was greater for TRAN patients ($8,935 vs $7,167; p<0.0001). Regression analyses determined that after adjustment, TRAN patients had statistically significantly greater mortality, morbidity, and cost as well as longer durations of stay. CONCLUSIONS: EGS patients who are transferred experience increased in-hospital morbidity and mortality as well as increased durations of stay and cost. As the population and age of patients diagnosed with EGS conditions increase while the EGS workforce decreases, the need for inter-hospital transfers will increase. Identifying risk factors associated with worse outcomes among transferred patients can inform the design of initiatives in performance improvement and direct the finite resources available to this vulnerable patient population.

From Overdiagnosis to Overtreatment of Low-Risk Thyroid Cancer: A Thematic Analysis of Attitudes and Beliefs of Endocrinologists, Surgeons, and Patients.

Introduction: The optimal management for patients with small, low-risk thyroid cancer is often debated. We aimed to characterize the attitudes and beliefs of providers and patients about management of small, low-risk thyroid cancer and how they relate to overtreatment. Methods: We conducted 34 semi-structured interviews with surgeons (n = 12), endocrinologists (n = 12), and patients with <1.5 cm papillary thyroid cancer (n = 10). Interviews probed about diagnosis and treatment decision-making, including nonoperative options. We used thematic analysis to identify themes related to overtreatment and created concept diagrams to map observed relationships between themes. Results: When providers discussed management of small, low-risk thyroid cancer, most felt that overtreatment was a problem, and some brought it up without prompting. Providers often believed that overtreatment results from overdiagnosis and relayed how the process commonly starts with incidental discovery of a thyroid nodule on imaging. Providers viewed biopsy of the nodule as a reflexive or habitual action. They ascribed inappropriate biopsy to lack of adherence to or knowledge of guidelines, radiologist recommendations, and the desire of patients and physicians to minimize diagnostic uncertainty. Providers described subsequent cancer diagnosis as an event that "opens Pandora's box" and often provokes a strong instinctive, culturally rooted need to proceed with surgery-specifically total thyroidectomy. Consequently, most providers felt that it is easier to prevent overdiagnosis than overtreatment and recommended strategies such as improving guideline adherence, resetting patients' expectations, and engaging the media. In contrast, patients did not bring up or openly discuss overtreatment or overdiagnosis. Some patients described the seemingly automatic process from an incidental finding to surgery. Their statements confirmed that the "need to know" was a major motivation for biopsying their nodule. Patients felt that once they had a cancer diagnosis, surgery was a foregone conclusion. Patients admitted their knowledge about thyroid nodules and cancer was low, leaving room for education about the need for biopsy and less extensive treatment options. Conclusions: Surgeons' and endocrinologists' attitudes and beliefs about overtreatment focus on the automaticity of overdiagnosis. Both patients and providers are cognizant of the cascade of clinical events that propel patients from incidental discovery of a thyroid nodule to surgery.

A Qualitative Analysis of the Preoperative Needs of Patients With Papillary Thyroid Cancer.

BACKGROUND: Thyroid cancer patients report unmet needs after diagnosis. However, little is known about their specific needs. Therefore, we sought to characterize the needs of patients with thyroid cancer before undergoing surgery. MATERIAL AND METHODS: We conducted semistructured interviews with 32 patients with papillary thyroid cancer after their preoperative surgical consultation. Data were analyzed using thematic content analysis. RESULTS: The central need of patients with thyroid cancer was a strong patient-surgeon relationship characterized by informational and emotional support, and respect for the patient as a person. Patients preferred disease- and treatment-related information to be individualized and to take into account aspects of their daily life. They wanted adequate time for asking questions with thoughtful answers tailored to their case. Patients additionally desired emotional support from the surgeon characterized by empathy and validation of their cancer experience. They particularly wanted surgeons to address their fears and anxiety. Patients also highly valued the surgeons' ability to see beyond their disease and acknowledge them as a unique person with respect to their occupation, psychosocial state, and other individual characteristics. When surgeons met patients' needs, they felt reassured, comfortable with their cancer diagnosis, and prepared for treatment. Suboptimal support increased patients' anxiety particularly when they felt the surgeon minimized their concerns. CONCLUSIONS: Preoperatively, patients with thyroid cancer desire a strong patient-surgeon relationship. They rely on the surgeon to provide adequate informational and emotional support and respect them as individuals. In turn, patients feel reassured and prepared for treatment.

Characteristics and Timing of Interhospital Transfers of Emergency General Surgery Patients.

BACKGROUND: Transferred emergency general surgery (EGS) patients have increased morbidity, mortality, and costs, yet little is known about the characteristics of such transfers. Increasing specialization and a decreasing general surgery workforce have led to concerns about access to care, which may lead to increased transfers. We sought to evaluate the reasons for and timing of transfers for EGS diagnoses. METHODS: We performed a retrospective medical record review of patients transferred to a tertiary academic medical center between January 4, 2014 and March 31, 2016 who had an EGS diagnosis (bowel obstruction, appendicitis, cholecystitis/cholangitis/choledocholithiasis, diverticulitis, mesenteric ischemia, perforated viscus, or postoperative surgical complication). RESULTS: Three hundred thirty-four patients were transferred from 70 hospitals. Transfer reasons varied with the majority due to the need for specialized services (44.3%) or a surgeon (26.6%). Imaging was performed in 95.8% and 35.3% had surgeon contact before transfer. The percentage of patients who underwent procedures at referring facilities was 7.5% (n = 25), while 60.6% (n = 83) underwent procedures following transfer. Mean time between transfer request and arrival at the accepting hospital was lower for patients who subsequently underwent a procedure at the accepting hospital compared to those who did not for patients originating in emergency departments (2.6 versus 3.4 h, P < 0.05) and inpatient units (6.9 versus 14.3 h, P < 0.05). CONCLUSIONS: Interhospital transfers for EGS conditions are frequently motivated by a need for a higher level of care or specialized services as well as a need for a general surgeon. Understanding reasons for transfers can inform decisions regarding the allocation and provision of care for this vulnerable population.