Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Introduction: In the United States, social determinants of health have a major impact on healthcare delivery and outcomes in patients with thyroid cancer. In particular, race and insurance status are associated with size of tumors at presentation, symptom burden, and adherence to treatment guidelines. The aim of this study is to examine temporal differences in the diagnosis-to-treatment pathway of thyroid nodules by race and insurance status. We hypothesize that a temporal difference may be present between patients of different racial backgrounds and insurance status.
Methods: All adults (≥18 years) who were referred for a new, dedicated thyroid ultrasound (US) at a tertiary academic medical center between 2017 to 2019 were identified in the electronic medical record. Patients with a documented history of thyroid cancer, previously recorded thyroid US, or who were incarcerated at time of US were excluded. Demographic data was extracted and structured chart review was performed to extract the indication for ultrasound referral, referring provider, nodule size, biopsy recommendation, and whether biopsy was completed. The following dates were abstracted: referral order for US, US performed, and biopsy performed (if indicated). Multivariate linear and logistic regression models were used to analyze the association of race and insurance status with time to US and biopsy, controlling for other factors, including age, gender, comorbidity, and number of preceding visits.
Results: A total of 3,459 patients were identified, of which 1,404 met inclusion criteria. The final cohort had an average age of 52.1 years (SD 16.6), was 77.1% female, 85.7% White, and 64.3% privately insured. The mean time from referral initiating visit to US was 31.8 days (SD 61.5). Most common US indications were suspected palpable nodules (44.7%) and incidental thyroid finding from other imaging (22.0%). Biopsy was recommended in 360 patients following their US (25.6% of total cohort), and, of those, 298 underwent the biopsy (82.8% of those recommended; 21.2% of total cohort). Patients on Medicaid were less likely to obtain a recommended biopsy compared to privately insured patients (OR 0.3 [95%CI 0.1-0.9]). Mean time from US to biopsy was significantly longer in Black as compared to White patients (40.6 vs 17.7 days; p≤0.01) and in Medicaid as compared to privately insured patients (34.0 vs 15.6 days; p≤0.01).
Conclusions: Our data suggests that the diagnosis and treatment of thyroid cancer align with the known systemic inequities in healthcare that disadvantage minority and underinsured patients. This study demonstrates longer referral times, increased number of prior-to-diagnosis healthcare visits, and lower rate of biopsy in Black and underinsured patients.