Variation of thyroidectomy-specific outcomes among hospitals and their association with risk adjustment and hospital performance

IMPORTANCE Current surgical qualitymetrics might be insufficient to fully judge the quality of certain operations because they are not procedure specific. Hypocalcemia, recurrent laryngeal nerve (RLN) injury, and hematoma are considered to be the most relevant outcomes to measure after thyroidectomy. Whether these outcomes can be used as hospital qualitymetrics is unknown. OBJECTIVES To evaluate whether thyroidectomy-specific outcomes vary among hospitals, whether the addition of thyroidectomy-specific variables affects risk adjustment, and whether differences in hospital performance are associated with thyroidectomy-specific care processes. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, patients undergoing thyroidectomies from January 1, 2013, through December 31, 2015, at hospitals participating in the American College of Surgeons' National Surgical Quality Improvement Programwere studied. EXPOSURE Thyroidectomy-related care. MAIN OUTCOMES AND MEASURES Clinically severe hypocalcemia, RLN injury, and clinically significant hematoma within 30 days of thyroid surgery and hospital-level performance variation, change in risk adjustment, and association with processes. RESULTS Overall, 14 540 patients (mean [SD] age, 52.1 [15.0] years; 11 499 [79.1%] female) underwent operations at 98 hospitals. Because operations missing thyroidectomy-specific outcomes were excluded, the numbers of operations and hospitals analyzed differed by outcome. Of 14 540 operations included, clinically severe hypocalcemia occurred in 450 patients (3.3%overall, 0.6%after partial, and 4.7%after subtotal or total thyroidectomy), RLN injury in 755 patients (5.7%overall, 4.2%after partial, and 6.6%after subtotal or total thyroidectomy), and hematoma in 175 patients (1.3%). Hospital performance varied for hypocalcemia and RLN injury but not for hematoma. Hospital performance rankings were largely unaffected by the inclusion of thyroidectomy-specific data in risk adjustment. With regard to processes, patients undergoing thyroidectomies at the best-performing vs worst-performing hospitals less frequently had their postoperative parathyroid hormone level measured (593 [19.9%] vs 457 [31.7%], P < .001) and more often were prescribed oral calcium, Vitamin D, or both (2281 [76.6%] vs 962 [66.8%], P < .001). When profiled by RLN injury, use of energy devices (1517 [69.1%] vs 507 [55.2%], P < .001) and intraoperative nerve monitoring (1223 [55.7%] vs 346 [37.7%], P < .001) were more prevalent at the bestcompared with the worst-performing hospitals. CONCLUSIONS AND RELEVANCE Postoperative hypocalcemia and RLN injury, but not hematoma, potentially could be used as thyroidectomy-specific national hospital quality improvement metrics. Strategies aimed at reducing these complications after thyroidectomy may improve the care of these patients.