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Abstract：
Background: The 2015 American Thyroid Association (ATA) guidelines shifted recommendations toward less aggressive management of papillary thyroid cancer (PTC). Subsequently, several studies demonstrated a trend in performing thyroid lobectomy (TL) over total thyroidectomy (TT). However, regional variation has persisted without a clear indication of what factors may be influencing practice variation. We aimed to evaluate the surgical management of PTC in patients in rural and urban settings to assess trends of TL compared with TT following the implementation of the 2015 ATA guidelines. Methods: A retrospective cohort analysis was performed using the Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2019 of patients with localized PTC <4 cm who underwent TT or TL. Patients were classified as living in urban or rural counties based on the 2013 Rural-Urban Continuum Codes. Procedures performed from 2004 to 2015 were categorized as preguidelines, while those performed from 2016 to 2019 were categorized as postguidelines. Chi-square, Student\'s t-test, logistic regression, and Cochran-Mantel-Haenszel test were used. Results: A total of 89,294 cases were included in the study. Eighty thousand one hundred and fifty (89.8%) were from urban settings and 9144 (9.2%) were from rural settings. Patients from rural settings were older (52 vs. 50 years, p < 0.001) and had smaller nodules (p < 0.001). On adjusted analysis, patients in rural areas were less likely to undergo TT (adjusted odds ratio 0.81, confidence interval [CI] 0.76-0.87). Before the 2015 guidelines, patients in urban settings had a 24% higher odds of undergoing TT compared with those in rural settings (odds ratio 1.24, CI 1.16-1.32, p < 0.001). There was no difference in the proportions of TT and TL based on setting following guideline implementation (p = 0.185). Conclusions: The 2015 ATA guidelines led to a change in overall practice in surgical management of PTC toward increasing TL. While urban and rural practice variation existed before 2015, both settings had an increase in TL following the guideline change, emphasizing the importance of clinical practice guidelines to ensure best practice in both rural and urban settings.
摘要：
背景2015年美国甲状腺协会（ATA）指南将建议转向甲状腺乳头状癌（PTC）的不那么积极的管理。随后，多项研究表明,甲状腺叶切除术(TL)优于甲状腺全切除术(TT).然而,区域差异一直存在，没有明确表明哪些因素可能会影响实践差异。我们旨在评估农村和城市地区PTC患者的手术管理，以评估实施2015年ATA指南后TL与TT的趋势。方法回顾性队列分析使用监测，流行病学,和2004-2019年接受TT或TL的局部PTC<4cm患者的最终结果（SEER）数据库。根据2013年城乡连续体代码，患者被分类为生活在城市或农村县。2004-2015年执行的程序被归类为预指南，而从2016-2019年进行的那些被归类为指南后。卡方，学生t检验，逻辑回归，使用Cochran-Mantel-Haenszel试验。结果共89,294例纳入研究。80,150（89.8％）来自城市环境，9,144（9.2％）来自农村环境。来自农村地区的患者年龄较大（52vs.50年,p<0.001），结节较小（p<0.001）。在调整后的分析中，农村地区患者接受TT的可能性较小(aOR0.81,95CI0.76-0.87).在2015年指南之前，与农村地区相比,城市地区患者接受TT的几率高出24%(OR1.24,95CI1.16~1.32,p<0.001).根据指南实施后的设定，TT和TL的比例没有差异（p=0.185）。结论2015年ATA指南导致PTC手术管理的整体实践朝着增加TL的方向变化。尽管在2015年之前存在城乡实践差异，但在准则变更后，两种设置的TL都有所增加，强调临床实践指南的重要性，以确保在农村和城市环境中的最佳实践。
