Nondiagnostic Fine-Needle Aspiration Biopsy of Thyroid Nodules: Outcomes and Determinants.

Background: Nondiagnostic results are common following fine-needle aspiration biopsy (FNAB) of thyroid nodules, but recommendations for the management of these patients vary. We sought to determine the outcomes and predictors of nondiagnostic FNABs in a single-center cohort of patients undergoing thyroid nodule evaluation. Methodology: We identified all first time ultrasound-guided FNABs performed between May 2007 and June 2013 at the Beth Israel Deaconess Medical Center Thyroid Nodule Clinic and examined demographic data, follow-up ultrasounds, repeated FNABs, and histopathologic findings. We examined the likelihood of diagnostic findings and of cancer with increasing numbers of nondiagnostic evaluations with their exact binomial confidence intervals [CIs] and potential predictors of nondiagnostic status using generalized estimating equations. Results: During the six-year period, 2234 unique individuals underwent ultrasound-guided FNAB of a thyroid nodule. The probability of obtaining a diagnostic biopsy declined from 84.4% [95% CI 82.8-85.8%] for initial FNABs to 57.6% [CI 50.8-64.2%] for the first re-FNAB and further to 42.4% [CI 25.5-60.8%] for second re-FNABs. Adjusted risk of nondiagnostic FNAB strongly increased with increasing numbers of previous biopsies and was also higher among whites. The overall rate of diagnosis of malignancy after a nondiagnostic FNAB was 8.1% [CI 4.2-13.7%] and was similar regardless of the number of previous nondiagnostic aspirations. Conclusion: Following an initial nondiagnostic FNAB, the probability of yielding a diagnostic result declines with each sequential repeat FNAB. Nonetheless, a tangible possibility of malignancy remains even after repeated nondiagnostic FNABs.

Building a Quality Management System for a Thyroid Nodule Clinic.

BACKGROUND: There are few published quality metrics relevant to fine-needle aspirations (FNA) of the thyroid and endocrinology. With the development of a Thyroid Nodule Clinic within an academic practice, the Division of Endocrinology, in collaboration with the Department of Medicine Quality Improvement Team, established a system to monitor the results and follow-up of thyroid biopsies to ensure patient safety and to prevent adverse clinical outcomes attributable to delayed or incomplete follow-up. METHODS: All FNA performed are identified using billing data from the Thyroid Nodule Clinic. Results were followed using the Beth Israel Deaconess Online Medical Record (OMR) system, and information is collected on documented follow-up plan and actions taken. Missing data are flagged for review. Over the reporting period, the monitoring process and categories were modified to account for adoption of the Bethesda reporting criteria and implementation of gene expression classifier testing. Specific workflow plans were developed for each cytopathologic classification. RESULTS: Between July 2007 and June 2014, 3895 FNAs were performed. The quality improvement tracking process found that 3856/3895 (99%) biopsy cases had documented follow-up since initiation of the project. CONCLUSION: This monitoring process has ensured quality patient care, with confidence that patients having FNAs are receiving documented necessary follow-up for treatment of their nodular conditions. This system serves as a potential model for others to use in their endocrine practice in managing the results of thyroid nodule biopsies.