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S. Abou Azar and P. Angelos
because staining of tissue blue makes identication of parathyroid glands and
nerves very difcult.
– Consider use of intraoperative nerve monitoring.
– Treatment should not be worse than overall disease outcome.
References
1. Camenzuli C, DiMarco AN, Isaacs KE, Grant Y, Jackson J, Alsa A, Harvey C, Barwick TD,
Tolley N, Palazzo FF.The changing face of re-operative parathyroidectomy: a single-Centre
comparison of 147 parathyroid reoperations. Ann Royal Coll Surg England. 2021;103:29–34.
2. Karakas E, Müller H-H, Schlosshauer T, Rothmund M, Bartsch DK.Reoperations for primary
hyperparathyroidism—improvement of outcome over two decades. Langenbeck’s Arch Surg.
2012;398:99–106.
3. Latge A, Riehm S, Vix M, Bani J, Ignat M, Pretet V, Helali M, Treglia G, Imperiale
A. 18F-uorocholine pet and 4D-CT in patients with persistent and recurrent primary hyper-
parathyroidism. Diagnostics. 2021;11:2384.
4. Vaghaiwalla TM, Khan ZF, Lew JI. Review of intraoperative parathormone monitoring with
the miami criterion: A 25-Year experience. World J Surg Proced. 2016;6(1):1. https://doi.
org/10.5412/wjsp.v6.i1.1.
5. Hendricks A, Lenschow C, Kroiss M, Buck A, Kickuth R, Germer C-T, Schlegel N.Evaluation
of diagnostic efcacy for localization of parathyroid adenoma in patients with primary hyper-
parathyroidism undergoing repeat surgery. Langenbeck’s Arch Surg. 2021;406:1615–24.
6. Yamada T, Ikuno M, Shinjo Y, Hiroishi A, Matsushita S, Morimoto T, Kumano R, Yagihashi
K, Katabami T.Selective venous sampling for primary hyperparathyroidism: how to perform
an examination and interpret the results with reference to thyroid vein anatomy. Jpn J Radiol.
2017;35:409–16.
7. Hillary SL, Guillermet S, Brown NJ, Balasubramanian SP. Use of methylene blue and
near-infrared uorescence in thyroid and parathyroid surgery. Langenbeck’s Arch Surg.
2017;403:111–8.
8. Tummers QRJG, Schepers A, Hamming JF, Kievit J, Frangioni JV, van de Velde CJH,
Vahrmeijer AL.Intraoperative guidance in parathyroid surgery using near-infrared uores-
cence imaging and low-dose methylene blue. Surgery. 2015;158:1323–30.
9. Tang W, Sun W, Niu X, Wang X, Wang X, Zhang M, Wang R, Jiang W, Jiang D, Zhao
C. Evaluating the safety and efcacy of microwave ablation in treatment of cervical meta-
static lymph nodes of papillary thyroid carcinoma compared to repeat surgery. Int J Hyperth.
2022;39:813–21.
10. Harari A, Sippel RS, Goldstein R, Aziz S, Shen W, Gosnell J, Duh Q-Y, Clark OH.Successful
localization of recurrent thyroid cancer in re-operative neck surgery using ultrasound-guided
methylene blue dye injection. J Am Coll Surg. 2012;215:555–61.
Chapter 30
Disparities inEndocrine Surgery Care
CaitlinB.Finn andRachelR.Kelz
Introduction
• Surgical disparities can exist at each of the ve phases of surgical care: preopera-
tive, perioperative, intraoperative, postoperative, and post-discharge [1].
• Disparities in care within the United States impact many groups of patients,
including but not limited to members of historically marginalized racial or ethnic
groups, members of the lesbian, gay, bisexual, and transgender communities,
those living with low income, people with disabilities, older adults, members of
certain religious groups, people who lack English prociency, and those from
immigrant or rural populations.
• Intersectionality refers to the concept that inequities along multiple dimensions
(e.g., race and disability) can be mutually reinforcing, such that members of
multiple vulnerable groups may face unique forms of discrimination. Efforts to
address disparities must consider the interactions between each factor to ade-
quately promote equity.
• For this chapter, we adopt the conceptual framework for surgical disparities
described by Torain etal. (2016) [2], where factors contributing to disparities can
be classied into patient factors, provider factors, system and access issues, clini-
cal care and quality, and post-operative care and rehabilitation (Fig.30.1).
C. B. Finn · R. R. Kelz (*)
Center for Surgery and Health Economics, Department of Surgery, University of
Pennsylvania, Philadelphia, PA, USA
e-mail: cbf2003@nyp.org; Rachel.Kelz@pennmedicine.upenn.edu
Switzerland AG 2024
R. M. Gartland, J. A. Lee (eds.), Endocrine Surgery Clerkship, Contemporary
Surgical Clerkships, https://doi.org/10.1007/978-3-031-62091-1_30
267© The Author(s), under exclusive license to Springer Nature
268
Fig. 30.1 Conceptual
model of factors
contributing to surgical
disparities
Patient Factors
C. B. Finn and R. R. Kelz
• Complex interactions between demographic and socioeconomic factors impact
healthcare access, delivery, and outcomes.
• Social determinants of health are the environmental conditions under which a
person lives, including economic stability, access to quality education, neighbor-
hood environment, food security, and community context. Social determinants of
health are important to consider when addressing disparities in care.
• A large body of literature demonstrates inferior surgical outcomes for patients
who are members of historically marginalized racial and ethnic groups [3, 4], in
part, resulting from a history of structural racism and racial discrimination [5].
Severity ofDisease
• Patients belonging to historically marginalized racial and ethnic groups may be
referred for surgery at more advanced stages of disease for both benign and
malignant endocrine conditions relative to White patients.
– Benign goiter—more compressive symptoms and larger gland size [ 6].
– Well-differentiated thyroid cancer—larger tumors and more advanced dis-
ease [7, 8].
– Primary hyperparathyroidism—higher calcium levels, higher PTH levels, and
lower rates of complete preoperative evaluation [9].
30 Disparities inEndocrine Surgery Care
269
Burden ofComorbidities
• Numerous factors may contribute to a higher burden of comorbidities in minority
groups, including limited access to primary care, environmental hazards, and
socioeconomic stressors.
• For example, compared to White patients, Black patients with Graves’ disease
are more likely to have higher rates of hypertension, congestive heart failure, and
higher ASA classication [10].
• In one study among patients with primary aldosteronism who underwent adrenal
vein sampling, Black patients had a longer duration of hypertension and more
comorbidities than patients in other racial groups [11].
Provider Factors
• Healthcare providers may have both conscious and unconscious biases that
impact decision-making and patient outcomes.
• Providers who lack cultural competence may have difculty communicating and
forming trusting relationships with their patients.
Referral toSurgery
• Studies have shown that patients in at-risk groups are often referred later and/or
less often. For example:
– Only 30% of Medicare patients with primary hyperparathyroidism receive
surgery within a year of diagnosis, with even lower rates of surgery among
elderly patients [12].
– Patients of Black or Asian race with primary hyperparathyroidism have lower
rates of surgical evaluation compared to White patients [13].
– Black patients experience a longer interval between diagnosis and surgical
referral for benign thyroid disease [6] and hyperparathyroidism [14].
– Patients with primary hyperparathyroidism who do not speak English or
Spanish as a primary language have lower rates of surgical referral [13] and
parathyroidectomy [15].
Communication
• Patient-centered communication is critical in endocrine surgery, given the impor-
tance of shared decision-making.
270
• Person-rst language demonstrates appropriate respect for patients by putting
the individual before their diagnosis or condition. For example, referring to a
patient as a “patient with a disability” is preferable to a “disabled patient,” and
“person with diabetes” is preferable to “a diabetic.”
• In surveys of patients presenting for evaluation of thyroid nodules, patients
belonging to historically marginalized racial groups were more likely to rate
their surgeon’s communication poorly [16].
• The Affordable Care Act requires federally funded hospitals to provide qualied
interpreter services for patients who lack English prociency (Section 1557).
C. B. Finn and R. R. Kelz
System andAccess Issues
• Federal and local policies impact access to medical care, most notably through
insurance coverage.
• Access to high-quality hospitals and surgeons is limited for some groups, con-
tributing to disparities in surgical outcomes.
Insurance Access
• Compared to privately insured patients, those without insurance are more likely
to present with advanced papillary thyroid cancer, yet are less likely to receive
total thyroidectomy, lymph node dissection, and adjuvant radioactive iodine
ablation [17].
• Efforts to expand access to insurance coverage, such as Medicaid expansion via
the Affordable Care Act, increase the ability of patients to receive health care.
• Medicaid expansion was associated with increased treatment at the highest vol-
ume centers for patients with papillary thyroid cancer [18].
Provider Access
• Patients of Black race or Hispanic ethnicity are more than twice as likely to
undergo parathyroidectomy at a low-volume hospital compared to non-Hispanic
White patients. Similarly, patients who are underinsured (e.g., uninsured or ben-
eciaries of Medicaid) are more than six times as likely to undergo parathyroid-
ectomy at a low-volume hospital compared to privately insured patients [19].
• Network analyses of primary care providers who treat Black patients demon-
strate narrower referral networks for Black patients relative to White patients,
indicating differences in referral patterns by race [20].
30 Disparities inEndocrine Surgery Care
271
Clinical Care andQuality
• Differences in hospital-or health system-level structures or processes of care
may lead to different outcomes for their patient populations.
Clinical Decision-Making
• Shah etal. examined concordance with the American Thyroid Association guide-
lines in care delivered to patients with well-differentiated thyroid cancer among
different racial groups. Black patients were more often undertreated with surgery
and radioactive iodine, while White patients were more likely to be overtreated
with radioactive iodine [21].
• Another study found that patients treated at community hospitals are less likely
to receive surgery for resectable adrenocortical carcinoma than patients treated at
academic facilities [22].
Use ofTechnologies
• Patients belonging to minority race or ethnicities are less likely to receive intra-
operative nerve monitoring than White patients [23].
Post-operative Care andRehabilitation
• Surgical management continues beyond the index procedure for patients who
receive endocrine surgery.
• The quality of post-operative care, rehabilitation, and long-term outcomes are
critical to consider following surgery.
Patient-Reported Long-Term Outcomes
• In a study among disease-free patients previously treated for well-differentiated
thyroid cancer, over 40% experience cancer-related worry about death and over
60% worry about recurrence. Patients with a lower educational level, female sex,
Hispanic ethnicity, or Asian race have higher levels of worrying [24].
• Patients with lower educational level and those with Hispanic ethnicity are more
likely to overestimate their risk of thyroid cancer recurrence and mortality [25].
272
C. B. Finn and R. R. Kelz
Financial Toxicity
• In one study of patients undergoing thyroid or parathyroid surgery, mean hospital
charges were substantially lower for White patients ($22,855) compared to Black
($33,292), Hispanic ($31,514), or Asian ($28,450) patients, perhaps related to a
higher burden of complications in historically marginalized groups [26].
• In a study among Hispanic women with thyroid cancer, nearly half (47%)
reported nancial hardship in the 5 years after their diagnosis [27].
Take Action
• All healthcare providers are responsible for providing the best possible care to all
patients.
• It is important for each of us to recognize our own biases and strive to provide
culturally competent care.
• Each medical student brings a unique perspective from their diverse life experi-
ences, education, and knowledge.
• You can take several steps as a student to provide more equitable treatment for
endocrine surgery patients.
Perform High-Quality, Patient-Centered Communication
• Communicate in the patient’s preferred language using trained medical interpret-
ers if necessary.
• Active listening is a critical skill during these conversations.
• Ask patients whether they would like to include caregivers in the discussions
about their care.
– Discuss in detail what to expect before, during, and after surgery.
– Ask patients, “What are your biggest fears regarding your diagnosis or treatment?”
– Ask patients, “How can we support you through your surgery?”
• Provide written summaries of important information for patients to review after
their appointment.
Facilitate Patient Navigation
• Patients belonging to socioeconomically disadvantaged groups may experience
barriers to seeking care, including difculty with scheduling, transportation, or
child care. Simple measures can drastically reduce barriers to care.
30 Disparities inEndocrine Surgery Care
273
– Help patients schedule their physician appointments, imaging, and laboratory
testing for the same day to minimize travel and life disruption.
– Telemedicine can be used for selected patients to provide convenient
follow-up.
– Investigate whether your hospital assists with transportation and parking for
patients in need.
Participate inCollaborative, Interdisciplinary Care
• Many hospitals have social workers, nurse navigators, counselors, dietitians, and
other allied health professionals who can offer valuable services to patients, such
as helping with insurance enrollment.
• Many allied professionals work with community-based organizations that can
provide support beyond the surgical episode.
Get Involved withResearch andLocal Quality
Improvement Efforts
• Ask your attendings whether you can assist with any ongoing efforts to improve
or standardize care.
• For example, decision support tools that are integrated into the electronic medi-
cal record can provide nudges to encourage best practices for endocrine care.
• The next frontier of disparities research is to test and implement interventions to
promote equitable care for all patients.
References
1. New Approach to Surgical Measurement: Phases of Surgical Care|ACS. https://www.facs.org/
advocacy/advocacy- quality/new- approach- to- surgical- measurement- phases- of- surgical- care/.
Accessed 4 Dec 2022.
2. Torain MJ, Maragh-Bass AC, Dankwa-Mullen I, etal. Surgical disparities: a comprehensive
review and new conceptual framework. J Am Coll Surg. 2016;223(2):408–18. https://doi.
org/10.1016/J.JAMCOLLSURG.2016.04.047.
3. Chen DW, Yeh MW. Disparities in thyroid care. Endocrinol Metab Clin N Am.
2022;51(2):229–41. https://doi.org/10.1016/J.ECL.2021.11.017.
4. Davis S, Ullmann TM, Roman S.Disparities in treatment for differentiated thyroid cancer.
Thyroid. 2022;33:287. https://doi.org/10.1089/THY.2022.0432. https://home.liebertpub.
com/thy.
5. Graetz N, Boen CE, Esposito MH.Structural racism and quantitative causal inference: a life
course mediation framework for decomposing racial health disparities. J Health Soc Behav.
2022;63:221465211066108. https://doi.org/10.1177/00221465211066108.
274
6. Kuo LE, Simmons KD, Wachtel H, etal. Racial disparities in initial presentation of benign
thyroid disease for resection. Ann Surg Oncol. 2016;23(8):2571–6. https://doi.org/10.1245/
S10434- 016- 5199- Y.
7. Harari A, Li N, Yeh MW.Racial and socioeconomic disparities in presentation and outcomes
of well-differentiated thyroid cancer. J Clin Endocrinol Metab. 2014;99(1):133–41. https://doi.
org/10.1210/JC.2013- 2781.
8. Weeks KS, Kahl AR, Lynch CF, Charlton ME. Racial/ethnic differences in thyroid cancer
incidence in the United States, 2007-2014. Cancer. 2018;124(7):1483. https://doi.org/10.1002/
CNCR.31229.
9. Fieber J, Goodsell K, Kelz RR, etal. Racial disparities in primary hyperparathyroidism. World
J Surg. 2021;45(1):180. https://doi.org/10.1007/S00268- 020- 05791- W.
10. Beck AC, Sugg SL, Weigel RJ, Belding-Schmitt M, Howe JR, Lal G. Racial disparities in comorbid conditions among patients undergoing thyroidectomy for graves’ disease: an ACS-NSQIP analysis. Am J Surg. 2021;221(1):106–10. https://doi.org/10.1016/j.
amjsurg.2020.05.023.
11. Gershuni VM, Ermer JP, Kelz RR, etal. Clinical presentation and surgical outcomes in primary aldosteronism differ by race. J Surg Oncol. 2020;121(3):456–64. https://doi.org/10.1002/
JSO.25806.
12. Seib CD, Suh I, Meng T, etal. Patient factors associated with parathyroidectomy in older adults
with primary hyperparathyroidism. JAMA Surg. 2021;156(4):334–42. https://doi.org/10.1001/
JAMASURG.2020.6175.
13. Broekhuis JM, Chaves N, Chen HW, Drake FT, James BC. Disparities in time to surgeon
evaluation among patients with primary hyperparathyroidism. Surgery. 2022;173:103. https://
doi.org/10.1016/J.SURG.2022.06.041.
14. Mallick R, Xie R, Kirklin JK, Chen H, Balentine CJ.Race and gender disparities in access
to parathyroidectomy: a need to change processes for diagnosis and referral to surgeons. Ann
Surg Oncol. 2021;28(1):476–83. https://doi.org/10.1245/S10434- 020- 08707- Z/TABLES/3.
15. Broekhuis JM, Chaves N, Chen HW, Drake FT, James BC.Are patients with limited English
prociency less likely to undergo parathyroidectomy for primary hyperparathyoidism? Am J
Surg. 2022;225:236. https://doi.org/10.1016/J.AMJSURG.2022.06.001.
16. Schumm MA, Ohev-Shalom R, Nguyen DT, Kim J, Tseng CH, Zanocco KA. Measuring
patient perceptions of surgeon communication performance in the treatment of thyroid nodules
and thyroid cancer using the communication assessment tool. Surgery. 2021;169(2):282–8.
https://doi.org/10.1016/J.SURG.2020.08.019.
17. Ullmann TM, Gray KD, Limberg J, etal. Insurance status Is associated with extent of treatment for patients with papillary thyroid carcinoma. Thyroid. 2019;29(12):1784–91. https://
doi.org/10.1089/THY.2019.0245. https://home.liebertpub.com/thy.
18. Greenberg JA, Thiesmeyer JW, Ullmann TM, etal. Association of the Affordable Care act with
access to highest-volume centers for patients with thyroid cancer. Surgery. 2022;171(1):132–9.
https://doi.org/10.1016/J.SURG.2021.04.059.
19. Hinson AM, Hohmann SF, Stack BC.Domestic travel and regional migration for parathyroid
surgery among patients receiving Care at Academic Medical Centers in the United States,
2012-2014. JAMA Otolaryngol Head Neck Surg. 2016;142(7):641–7. https://doi.org/10.1001/
JAMAOTO.2016.0509.
20. Landon BE, Onnela JP, Meneades L, O’Malley AJ, Keating NL.Assessment of racial disparities in primary care physician specialty referrals. JAMA Netw Open. 2021;4(1):e2029238.
https://doi.org/10.1001/JAMANETWORKOPEN.2020.29238.
21. Shah SA, Adam MA, Thomas SM, etal. Racial disparities in differentiated thyroid cancer: have
we bridged the gap? Thyroid. 2017;27(6):762–72. https://doi.org/10.1089/THY.2016.0626/
ASSET/IMAGES/LARGE/FIGURE4.JPEG.
22. Tseng J, DiPeri T, Chen Y, et al. Factors associated with non–operative management of
resectable adrenocortical carcinoma. J Surg Res. 2021;267:651–9. https://doi.org/10.1016/J.
JSS.2021.06.013.
C. B. Finn and R. R. Kelz
30 Disparities inEndocrine Surgery Care
23. Al-Qurayshi Z, Randolph GW, Alshehri M, Kandil E.Analysis of variations in the use of
intraoperative nerve monitoring in thyroid surgery. JAMA Otolaryngol Head Neck Surg.
2016;142(6):584–9. https://doi.org/10.1001/JAMAOTO.2016.0412.
24. Papaleontiou M, Reyes-Gastelum D, Gay BL, etal. Worry in thyroid cancer survivors with a
favorable prognosis. Thyroid. 2019;29(8):1080. https://doi.org/10.1089/THY.2019.0163.
25. Chen DW, Reyes-Gastelum D, Wallner LP, etal. Disparities in risk perception of thyroid cancer recurrence and death. Cancer. 2020;126(7):1512. https://doi.org/10.1002/CNCR.32670.
26. Noureldine SI, Abbas A, Tufano RP, etal. The impact of surgical volume on racial disparity in
thyroid and parathyroid surgery. Ann Surg Oncol. 2014;21(8):2733–9. https://doi.org/10.1245/
S10434- 014- 3610- 0/TABLES/2.
27. Chen DW, Reyes-Gastelum D, Veenstra CM, Hamilton AS, Banerjee M, Haymart MR.Financial
hardship among Hispanic women with thyroid cancer. Thyroid. 2021;31(5):752. https://doi.
org/10.1089/THY.2020.0497.
275