Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.
Department of Otolaryngology-Head and Neck Surgery, Department of Surgery, The Scarborough Hospital, Toronto, Ontario, Canada.
JAMA Otolaryngol Head Neck Surg. 2021 Apr 1;147(4):343-349. doi: 10.1001/jamaoto.2020.5233.
Although most thyroid nodules are benign, the potential for malignant neoplasms is associated with unnecessary workup in the form of imaging, fine-needle aspiration, and diagnostic surgery. The American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) is commonly used to assess the malignant neoplasm risk potential of thyroid nodules imaged by ultrasonography. However, standardized reporting of ACR TI-RADS descriptors is inconsistent.
To increase the documentation rate of ACR TI-RADS thyroid nodule characteristics to 80% in 18 months.
DESIGN, SETTING, AND PARTICIPANTS: This prospective interrupted time series quality improvement study was conducted from December 1, 2018, to March 31, 2020, at a tertiary outpatient head and neck clinic among 229 patients who had at least 1 documented thyroid nodule identified on bedside clinic ultrasonography. Data analysis was performed throughout the entire study period because this was a quality improvement study with iterative small cycle changes; final analysis of the data was performed in April 2020.
The primary outcome was the documentation rates of 6 ACR TI-RADS ultrasonographic descriptors. Secondary outcomes included nodule fine-needle aspiration biopsy rate and physician-reported clinic flow efficiency.
A total of 229 patients had at least 1 documented thyroid nodule and were included in the analysis. Size was the most frequently documented nodule characteristic (72 of 74 [97.3%]) at baseline, followed by echogenic foci (31 of 74 [41.9%]), composition (23 of 74 [31.1%]), echogenicity (17 of 74 [23.0%]), margin (6 of 74 [8.1%]), and shape (1 of 74 [1.4%]). After 3 Plan, Do, Study, Act (PDSA) cycles, the final intervention consisted of a standardized ultrasonography reporting form and educational initiatives for surgical trainees. After the third PDSA cycle (n = 36), reporting of nodule size, echogenic foci, and composition increased to 100%. Similarly, reporting of echogenicity (34 of 36 [94.4%]), shape (28 of 36 [77.8%]), and margin (25 of 36 [69.4%]) all increased. This represented a cumulative 90.3% documentation rate (195 of 216), a 56.5% increase from baseline (95% CI, 50.0%-61.9%). The standardized reporting form was used in 83.3% of eligible thyroid ultrasonography cases (30 of 36) after PDSA cycle 3, demonstrating good fidelity of implementation. There were no unintended consequences associated with clinic workflow, as a balancing measure, reported by staff surgeons.
This study suggests that implementation of an ACR TI-RADS-based reporting form in conjunction with educational initiatives improved documentation of ultrasonographic thyroid nodule characteristics, potentially allowing for improved bedside risk stratification and communication among clinicians.
尽管大多数甲状腺结节是良性的，但恶性肿瘤的潜在风险与影像学、细针抽吸和诊断性手术等不必要的检查形式有关。美国放射学院甲状腺成像报告和数据系统（ACR TI-RADS）常用于评估超声成像甲状腺结节的恶性肿瘤风险。然而，ACR TI-RADS 描述符的标准化报告并不一致。
在 18 个月内将 ACR TI-RADS 甲状腺结节特征的文档记录率提高到 80%。
设计、设置和参与者：这是一项前瞻性中断时间序列质量改进研究，于 2018 年 12 月 1 日至 2020 年 3 月 31 日在一家三级门诊头颈诊所进行，共有 229 名患者参与，这些患者在床边诊所超声检查中至少有 1 个已确定的甲状腺结节。整个研究期间都进行了数据分析，因为这是一项具有迭代小周期变化的质量改进研究；最终数据分析于 2020 年 4 月进行。
主要结果是 ACR TI-RADS 超声描述符的文档记录率。次要结果包括结节细针抽吸活检率和医生报告的临床流程效率。
共有 229 名患者至少有 1 个记录在案的甲状腺结节，被纳入分析。在基线时，大小是最常记录的结节特征（74 个中有 72 个[97.3%]），其次是回声焦点（74 个中有 31 个[41.9%]）、成分（74 个中有 23 个[31.1%]）、回声（74 个中有 17 个[23.0%]）、边界（74 个中有 6 个[8.1%]）和形状（74 个中有 1 个[1.4%]）。经过 3 个计划、执行、研究、行动（PDSA）循环后，最终干预措施包括标准化超声报告表和针对外科实习生的教育计划。在第三次 PDSA 循环（n=36）后，结节大小、回声焦点和成分的报告率增加到 100%。类似地，回声（34 个中的 36 个[94.4%]）、形状（28 个中的 36 个[77.8%]）和边界（25 个中的 36 个[69.4%]）的报告率均有所增加。这代表着累计 90.3%的文档记录率（195 个中的 216 个），比基线增加了 56.5%（95%CI，50.0%-61.9%）。在 PDSA 循环 3 之后，在符合条件的 36 例甲状腺超声检查病例中，有 83.3%（30 例）使用了标准化报告表，这表明实施的忠实度良好。工作人员外科医生报告称，临床工作流程没有出现意外后果。
本研究表明，在超声成像中实施基于 ACR TI-RADS 的报告表并结合教育计划，可以提高超声甲状腺结节特征的文档记录率，从而有可能改善床边风险分层和临床医生之间的沟通。
