Goffredo Paolo, Roman Sanziana A, Sosa Julie A
1 Department of Surgery, University of Milano-Bicocca , Monza, Italy .
Thyroid. 2014 Mar;24(3):463-71. doi: 10.1089/thy.2013.0319. Epub 2013 Oct 29.
There is wide variability in the degree of adherence to guideline recommendations among caregivers. Our aim was to determine the clinical impact of the 2006 guidelines from the American Thyroid Association (ATA) on the management of differentiated thyroid cancer (DTC) in the United States.
The Surveillance, Epidemiology and End Results (SEER) database (2004-2009) was employed. Patients were divided into two groups based on receipt of care before (DTC 04-06) and after (DTC 07-09) the release of the 2006 ATA guidelines. Adherence was determined with a chi-square test and binary logistic regression. Survival was analyzed with the Kaplan-Meier method and log-rank test.
A total of 12,816 patients with DTC were identified between 2004 and 2006, and 14,514 between 2007 and 2009 (DTC 07-09). Adherence to Recommendation 26 (surgery) tended to increase in DTC 07-09 (82.2% vs. 83.2%, p=0.083). Factors associated with discordant practice among the DTC 07-09 group were older age, treatment in the Northeast, having more than one primary cancer, tumor size >4 cm, and follicular and Hürthle cell histologies. Factors associated with accordance were treatment in the Midwest, level II-VI metastases, having lymph nodes examined, AJCC Stage III, and presenting with distant metastases. Patients treated in accordance with Recommendation 26 showed prolonged disease-specific survival (p<0.001). A trend toward more adherence to Recommendation 27 (lymphadenectomy) was observed over time (68.4% vs. 69.7%, p=0.065). Adherence to Recommendation 27 was not associated with disease-specific survival (p=0.539). Less discordance from guidelines was seen for cancers that were 2.1-4 cm, extrathyroidal, and greater than Stage I. Overall accordance with Recommendation 32 (radioactive iodine [RAI] ablation) increased in DTC 07-09 compared to DTC 04-06 (61.7% vs. 57.5% respectively, p<0.001), and this was associated with improved disease-specific survival in DTC 07-09 (p<0.001). Predictors of care discordant with guidelines were patient age ≥ 65 years, living in the Northeast, and not undergoing total thyroidectomy. Factors associated with RAI use in accordance with guidelines were married status, treatment in the South, and having more than one lymph node examined.
Care in accordance with evidence-based guidelines for DTC is associated with improved patient outcomes. Ongoing efforts should be undertaken to propagate guidelines to reduce variation in care and improve overall quality of care.
护理人员对指南建议的遵循程度存在很大差异。我们的目的是确定美国甲状腺协会（ATA）2006年指南对分化型甲状腺癌（DTC）管理的临床影响。
采用监测、流行病学和最终结果（SEER）数据库（2004 - 2009年）。根据2006年ATA指南发布之前（DTC 04 - 06）和之后（DTC 07 - 09）接受治疗的情况将患者分为两组。通过卡方检验和二元逻辑回归确定遵循情况。采用Kaplan - Meier方法和对数秩检验分析生存率。
2004年至2006年共识别出12816例DTC患者，2007年至2009年（DTC 07 - 09）有14514例。DTC 07 - 09组对建议26（手术）的遵循率有上升趋势（82.2%对83.2%，p = 0.083）。DTC 07 - 09组中与不一致做法相关的因素包括年龄较大、在东北部接受治疗、患有不止一种原发性癌症、肿瘤大小>4 cm以及滤泡性和许特莱细胞组织学类型。与一致做法相关的因素包括在中西部接受治疗、II - VI级转移、进行了淋巴结检查、美国癌症联合委员会（AJCC）III期以及出现远处转移。按照建议26接受治疗的患者疾病特异性生存期延长（p<0.001）。随着时间的推移，观察到对建议27（淋巴结清扫）的遵循有上升趋势（68.4%对69.7%，p = 0.065）。对建议27的遵循与疾病特异性生存期无关（p = 0.539）。对于2.1 - 4 cm、甲状腺外以及I期以上的癌症，与指南的不一致性较少。与DTC 04 - 06相比，DTC 07 - 09中对建议32（放射性碘[RAI]消融）的总体遵循率有所提高（分别为61.7%对57.5%，p<0.001），这与DTC 07 - 09中改善的疾病特异性生存期相关（p<0.001）。与指南护理不一致的预测因素为患者年龄≥65岁、居住在东北部以及未接受全甲状腺切除术。与按照指南使用RAI相关的因素包括婚姻状况、在南部接受治疗以及检查了不止一个淋巴结。
按照DTC循证指南进行护理与改善患者预后相关。应持续努力传播指南，以减少护理差异并提高整体护理质量。
