Systematic Review/Meta-analysis
Otolaryngology–
ERAS Protocols for Thyroid and
Parathyroid Surgery: A Systematic
Review and Meta-analysis
Kevin Chorath, MD1, Neil Luu1, Beatrice C. Go1,
Alvaro Moreira, MD2, and Karthik Rajasekaran, MD1,3
Abstract
Objective. Enhanced recovery after surgery (ERAS) protocols
are evidenced-based multidisciplinary programs implemented in
the perioperative setting to improve postoperative recovery and
attenuate the surgical stress response. However, evidence on
their effectiveness in thyroid and parathyroid surgery remains
sparse. Therefore, our goal was to investigate the clinical bene-
fits and cost-effectiveness of ERAS protocols for the periopera-
tive management of thyroidectomy and parathyroidectomy.
Data Source. A systematic review of Medline, Scopus, Embase,
and gray literature was performed to identify studies of ERAS or
clinical care protocols for thyroidectomy and parathyroidectomy.
Review Methods. Two reviewers screened studies using
predetermined inclusion criteria. Our primary outcomes
included hospital length of stay and hospital costs. Readmis-
sion and postoperative complication rates composed our
secondary outcomes. Meta-analysis was performed to com-
pare outcomes for patients enrolled in the ERAS protocol
versus standard of care.
Results. A total of 450 articles were identified; 7 (1.6%) met
inclusion criteria with a total of 3082 patients. Perioperative
components in ERAS protocols varied across the studies.
Nevertheless, patients enrolled in ERAS protocols had
reduced hospital length of stay (mean difference, –0.64 days
[95% CI, –0.92 to –0.37]) and hospital costs (in US dollars;
mean difference, –307.70 [95% CI, –346.49 to –268.90]),
without an increase in readmission (odds ratio, 0.75 [95%
CI, 0.29-1.94]) or complication rates (odds ratio, 1.14 [95%
CI, 0.82-1.57]).
Conclusion. There is growing literature supporting the role of
ERAS protocols for the perioperative management of thyr-
oidectomy and parathyroidectomy. These protocols signifi-
cantly reduce hospital length of stay and costs without
increasing complications or readmission rates.
Keywords
PSQI, patient safety, thyroidectomy, parathyroidectomy, oto-
laryngology, ERAS, enhanced recovery after surgery
Received March 17, 2021; accepted May 4, 2021.
Head and Neck Surgery
1–9
Ó American Academy of
Otolaryngology–Head and Neck
Surgery Foundation 2021
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/01945998211019671
http://otojournal.org
T
hyroid and parathyroid operations are frequently
performed procedures. In the United States alone,
.150,000 are performed per year.1 The rate of compli-
cations from these operations is approximately 11%, of which
nearly 70% are a due to bleeding, hypocalcemia, and pulmon-
ary problems.2 Furthermore, it has been estimated that chronic
opioid dependence may develop in 5% of patients undergoing
thyroidectomy and 6% undergoing parathyroidectomy.3 As a
result, several institutions have instituted enhanced recovery
after surgery (ERAS) protocols, aimed at improving the perio-
perative care of patients while decreasing complications.
ERAS protocols are a set of structured clinical pathways
implemented in the perioperative setting to reduce postoperative
physical and psychological stress and thus accelerate recovery.4,5
Over the past 10 years, several studies have highlighted the bene-
fits of these programs, such as reduced hospital length of stay
(LOS), readmission rates, complications, and postoperative
opioid consumptions.6,7 Several components are routinely incor-
porated in these protocols: preoperative counseling, thromboem-
bolic prophylaxis, perioperative antibiotics, body temperature
regulation, fluid management, and multimodal analgesia. The
incorporation of these interventions in an ERAS protocol has sig-
nificantly benefited patient care for a variety of operations,
including head and neck free flap reconstruction, colorectal sur-
gery, hip and knee arthroplasty, and breast cancer surgery.8-10
Our objective therefore was to collate, critically appraise,
and analyze the impact of ERAS protocols and/or clinical
care pathways on LOS, complications, pain management,
readmissions, and costs as compared with the previously
1
Department of Otorhinolaryngology, University of Pennsylvania, Philadel-
phia, Pennsylvania, USA
2
Department of Pediatrics, University of Texas Health–San Antonio, San
Antonio, Texas, USA
3
Leonard Davis Institute of Health Economics, University of Pennsylvania,
Philadelphia, Pennsylvania, USA
This study was submitted as an oral presentation at the 2021 AAO-HNSF
Annual Meeting & OTO Experience; October 3-6, 2021; Los Angeles,
California.
Corresponding Author:
Karthik Rajasekaran, MD, Department of Otorhinolaryngology, University of
Pennsylvania, 800 Walnut St, 18th Floor, Philadelphia, PA 19107, USA.
Email: karthik.rajasekaran@pennmedicine.upenn.edu
2 Otolaryngology–Head and Neck Surgery

established standard of care in patients undergoing thyroidect-

Identification
omy and parathyroidectomy. Records identified through
database searching
Additional records identified
through other sources
(n = 445) (n = 5)

Methods
This systematic review and meta-analysis adhered to the rec- Records after duplicates removed
ommendations from the Cochrane Handbook for Systematic (n = 302)

Reviews of Interventions and PRISMA criteria (Preferred

Screening
Reporting Items for Systematic Reviews and Meta-analyses).11
Records screened Records excluded
(n = 302) (n = 266)
Search Strategy and Selection Criteria
Two authors (K.C., N.L.) systematically searched MEDLINE
Full-text articles Full-text articles excluded,
via PubMed, Scopus, Cochrane Clinical Trial Registry,

Eligibility
assessed for eligibility with reasons
Embase, and gray literature to identify case-control studies, (n = 36) (n = 29)

cohort studies, and case series evaluating ERAS protocols and Review article (6)
Not relevant (15)
clinical care pathways in patients undergoing thyroidectomy Studies included in
Does not evaluate ERAS
(8)
and parathyroidectomy. The search included all articles pub- qualitative synthesis
(n = 7)
lished from database inception to January 5, 2021. Addition-

ally, we manually reviewed references from the identified
articles and conference proceedings.
We used the following set of controlled variables: (‘‘thyr-
oidectomy’’ OR ‘‘total thyroidectomy’’ OR ‘‘hemithyroidect-
omy’’ OR ‘‘partial thyroidectomy’’ OR ‘‘thyroid lobectomy’’
OR ‘‘parathyroidectomy’’ OR ‘‘parathyroid adenoma removal’’)
AND (‘‘ERAS’’ OR ‘‘enhanced recovery after surgery’’ OR
‘‘clinical pathway’’ OR ‘‘clinical care pathway’’ OR ‘‘critical
pathway’’). No limit was placed for language, location, or
sample size for included studies. K.C. and N.L. independently
reviewed the titles and abstracts of all citations to determine suit-
ability based on the study’s primary outcomes. This was fol-
lowed by an independent review of the full text by K.C. and N.L.
to confirm eligibility. Disagreements were resolved by a third
author (K.R.).
Data Extraction and Risk of Bias
Using a standardized collection form, 2 authors (K.C. and
N.L.) independently extracted study data specific for patient
characteristics, operative characteristics, ERAS elements, and
clinical outcomes. Differences in data collection were
assessed by a third investigator (K.R.). Original data were
obtained from tables, graphs, and plots by using Graph Digiti-
zer version 2.26 (GetData) when exact values were not accessi-
ble from the articles. Information presented as median
(interquartile range) was converted to mean (standard devia-
tion) per Wan et al.12 We collected the following data: first
author, year of publication, study design, operative characteris-
tics, age of patients, study period, and other relevant findings.
To assess risk of bias in observational cohort studies, the
National Institutes of Health’s Study Quality Assessment
Tool was used.13 Studies were deemed as having a moderate
risk of bias if they had 2 high-risk components and a high risk
of bias with .4 high-risk components.
Outcomes
The primary outcomes were hospital LOS and hospital costs,
and secondary outcomes consisted of readmission rates and
postoperative complications. Postoperative complications
Included
Studies included in
quantitative synthesis
(meta-analysis)
(n = 7)
Figure 1. PRISMA flowchart of systematic search strategy. ERAS,
enhanced recovery after surgery.
included vocal cord paralysis, persistent hoarseness, bleeding,
infections, reoperation, and postoperative hypocalcemia.
Statistical Analysis
Meta-analysis was performed to generate forest plots. The
effect size of ERAS protocols on hospital LOS and costs was
evaluated via mean differences (MDs) with 95% CIs. Simi-
larly, the estimated effect size of ERAS protocols on post-
operative complications and readmissions was determined
through pooled odds ratios (ORs) with 95% CIs. Subgroup
analysis based on operation type was performed for primary
outcomes. Statistical heterogeneity was assessed with I2, with
thresholds of low (25%-49%), moderate (50%-74%), and
high (75%). Publication bias for our primary outcomes was
assessed with funnel plots, and asymmetry of the funnel was
evaluated with Egger’s regression test. All statistical analyses
were performed in R Studio per the dmetar package.14
Results
Study Selection
Our electronic search yielded 450 citations, which were sub-
sequently screened by title and abstract for inclusion criteria
(Figure 1). Among these, 36 publications were reviewed in
full, and 7 studies were selected for qualitative and quantita-
tive analysis. The included studies, with a description of their
design and population, are summarized in Table 1. The stud-
ies were published from 2000 to 2020. Three studies were per-
formed in the United States,15-17 while the remaining were
conducted in Singapore,18 Spain,19 Korea,20 and the United
Kingdom.21 All studies employed a prospective cohort
design, of which 6 used a historical cohort as a representation
of traditional perioperative management.
Chorath et al 3

6 15.6
6 14.4

6 12.4
6 11.7
6 15.5
Patient and Operative Characteristics
Age, yb A total of 3082 patients were included for qualitative and
Control

48.0
46.0
51.4
49.8
67.5
55.9
quantitative synthesis. For patients undergoing a total thyroi-
NR dectomy, 728 were enrolled in the ERAS group and 593 in the
control group. Among those undergoing a thyroid lobectomy,
No.

55
150
112
425
145
42
464
541 were in the ERAS group and 467 in the cohort group. For
those patients undergoing a parathyroidectomy, 420 were in
15.6
15.3

11.9
15.5
16.3
the ERAS group and 333 in the control group.
Age, yb

44.0 6
47.2 6

47.6 6
62.0 6
54.7 6 ERAS Elements
ERAS

50.0
NR

Table 2 summarizes the elements of the ERAS protocols in

each study. These protocols were assessed for the presence or
No.

41
143
345
256
216
34
654

absence of the following elements commonly seen in ERAS

protocols: preadmission education, perioperative nutrition,
No. of patients

thromboembolic and antibiotic prophylaxis, nausea and vomit-

ing prophylaxis, standardized anesthetic protocol, hypothermia
96
293
457
681
361
76
1118

prevention, perioperative fluid management, perioperative

anesthesia protocol, pain management, postoperative mobiliza-
tion, wound care, urinary catheterization, and drain manage-
ment. The most common elements reported in these protocols
Thyroidectomy and parathyroidectomy

Thyroidectomy and parathyroidectomy

Thyroidectomy and parathyroidectomy

were preadmission education (6 studies) and postoperative

pain management (6 studies). In contrast, no studies included
thromboembolic prophylaxis, hypothermia prevention, and
urinary catheterization management as part of their clinical
Operation

pathways.
Parathyroidectomy

Primary Outcomes
Table 1. Characteristics of Studies Describing ERAS Protocols for Thyroid and Parathyroid Surgery.

Thyroidectomy
Thyroidectomy

Thyroidectomy

Effect of ERAS Protocols on Hospital LOS. A total of 3082

patients (7 studies) were evaluated for quantitative analysis,
with 1689 in the intervention group and 1393 in the control
(Figure 2). Patients enrolled in ERAS protocols had
Each study is based on a prospective cohort and historical control (unless noted otherwise).

reduced hospital LOS as compared with the control group

International Archives of Otorhinolaryngology
Journal of the American College of Surgeons

(MD = –0.64 days [95% CI, –0.92 to –0.37]). Heterogeneity

for this outcome was high (I2 = 100%). Subgroup analysis
based on operation type revealed significant reduction in
hospital LOS for parathyroidectomy (MD = –0.57 days
[95% CI, –0.97 to –0.17]), thyroid lobectomy (MD = –0.66
Abbreviations: ERAS, enhanced recovery after surgery; NR, not reported.
Journal

days [95% CI, –1.08 to –0.24]), and total thyroidectomy

Asian Journal of Surgery
The American Surgeon

The American Surgeon

(MD = –0.91 days [95% CI, –1.76 to –0.06]).

Effect of ERAS on Hospital Costs. A total of 1577 patients (4
Head and Neck

studies) were evaluated for quantitative analysis, with 847

in the intervention group and 730 in the control group
Surgery

(Figure 3). Patients in the ERAS group had lower hospital

costs as compared with the control group (in US dollars;
MD = –307.70 [95% CI, –346.49 to –268.90]). Heterogene-
Study is based on a prospective cohort.
Singapore

ity for this outcome was high (I2 = 99%). Subgroup analysis
Location

Values are presented as mean 6 SD.

Korea

based on type of operation revealed a significant reduction

Spain

UK
US

US

US

in hospital costs for parathyroidectomy (MD = –299.05

[95% CI, –338.65 to –259.45]), thyroid lobectomy (MD =
Soria-Aledo (2008)19
Ramanujam (2005)18

–431.65 [95% CI, –732.14 to –131.17]), and total thyroi-

Kulkarni (2011)16,c

dectomy (MD = –572.28 [95% CI, –825.13 to –319.42]).

Markey (2000)15

Kwon (2018)20
Sinha (2020)21
Study (Year)a

Yip (2021)17

Secondary Outcomes
Effect of ERAS on Postoperative Complications. A total of 1187
patients (4 studies) were evaluated for quantitative analysis,
b
c
a
4 Otolaryngology–Head and Neck Surgery

Table 2. Components of ERAS Protocols Across Studies.a

Study 1 2 3 4 5 6 7 8 9 10 11 12 13

Markey (2000)15 ü ü ü ü ü ü ü
Ramanujam (2005)18 ü ü ü ü ü ü ü
Soria-Aledo (2008)19 ü ü ü ü ü ü ü
Kulkarni (2011)16 ü ü ü ü ü
Kwon (2018)20 ü ü ü ü ü ü ü ü
Sinha (2020)21 ü ü ü ü
Yip (2021)17 ü ü ü ü ü
Abbreviation: ERAS, enhanced recovery after surgery.
a
(1) Preadmission education (2) perioperative nutritional care, (3) prophylaxis against thromboembolism, (4) antibiotic prophylaxis, (5) postoperative nausea
and/or vomiting prophylaxis, (6) standard anesthetic protocol, (7) preventing hypothermia, (8) perioperative fluid management, (9) pain management, (10)
postoperative mobilization, (11) postoperative wound care, (12) urinary catheterization, and (13) drain care.

Figure 2. Forest plot showing effect size of hospital length of stay between enhanced recovery after surgery and control. MD, mean difference.

with 738 in the intervention group and 449 in the control
group (Table 3). There was no difference in the incidence
of postoperative complications between the ERAS and con-
trol groups (OR = 1.14 [95% CI, 0.82-1.57]). Heterogeneity
for this outcome was low (I2 = 0%).
Effect of ERAS on Readmissions. A total of 2332 patients (4 stud-
ies) were evaluated for quantitative analysis, with 1289 in the
intervention group and 1043 in the control group (Table 3).
There was no difference in readmission rates between the
ERAS and control groups (OR = 0.75 [95% CI, 0.29-1.94]).
Heterogeneity for this outcome was low (I2 = 0%).
Risk of Bias and Publication Bias
A summary of risk of bias among the studies is presented in
the appendix (Supplemental Table S1, available online). All 7
studies were deemed as having a moderate risk of bias. Nota-
bly, none of the studies provided a sample size justification,
Chorath et al
Figure 3. Forest plot showing effect size of costs between enhanced recovery after surgery and control. MD, mean difference.
Table 3. Stratification of Estimated Effect Size on Secondary
Outcomes.a
Outcome Odds ratio (95% CI) P value
Readmission 0.75 (0.29-1.94) .59
Complications 1.14 (0.82-1.57) .90
a
Studies, n = 4. I2 = 0%.
blinded the outcome assessors, or accounted for potential con-
founding variables in the results. Publication bias was
assessed with funnel plots (Supplemental Figures S1 and S2).
Egger’s test resulted in P \ .05, indicating the presence of
asymmetry in the funnel plot.
Discussion
Our systematic review and meta-analysis of 7 studies showed
that ERAS protocols were associated with reduced hospital
LOS and costs, without increasing complication or readmis-
sion rates. To our knowledge, this is the first review evaluat-
ing the perioperative role of ERAS protocols for patients
undergoing thyroid and parathyroid operations.
The surgical management of thyroid and parathyroid dis-
ease has evolved significantly in the last 100 years.22 Once
considered dreaded operations with definite grim outcomes,
these are now among the most common procedures performed
around the world. Despite improvements in diagnostic ima-
ging, refinements in surgical technique, and optimization of
intraoperative monitoring, complications still occur.23-25 It
would therefore be beneficial to develop perioperative strate-
gies, such as an ERAS protocol, to improve outcomes and
5
facilitate recovery. The findings from this study build on the
breadth of literature supporting the role of these protocols for
a variety of other operations.
The fundamental concept behind ERAS is to develop and
implement a protocol that improves recovery through
research, education, audit, and implementation of evidence-
based practice.5,26,27 Although there is no formalized consen-
sus review for the optimal perioperative care in thyroid and
parathyroid surgery, many of the components in the ERAS
protocols reviewed in this study have been well described. For
instance, the role for perioperative nutritional care and vita-
min D/calcium supplementation in preventing symptoms has
been studied at length and shown to be beneficial.28,29 Addi-
tionally, a number of studies have validated a standardized
anesthetic protocol with cervical nerve blocks, which has led
to reduced postoperative antiemetic use, operating room time,
and LOS.30-33
Evidence supporting other common ERAS components are
less robust and somewhat controversial. For example, the rou-
tine use of surgical drains in thyroid surgery remains quite
varied. In an international survey evaluating perioperative
practices in thyroid surgery, 60% of surgeons either never
place a drain or place a drain less than half the time for thyroid
lobectomy.34 Another area of contention is antibiotic prophy-
laxis in clean surgery. A recent systematic review assessing
the effectiveness of antibiotic prophylaxis for thyroid and
parathyroid surgery demonstrated that it was not effective in
reducing the incidence of surgical site infections.35 Last, the
need for venous thromboembolism prophylaxis for thyroid
and parathyroid surgery remains controversial, with several
large-scale studies reporting a low incidence of thromboem-
bolic events following these operations. As such, venous
6 Otolaryngology–Head and Neck Surgery
thromboembolism prophylaxis should be considered for only
select high-risk patients.36-38 Ultimately, the development of
an ERAS protocol for these operations will require a thorough
review of the available evidence and a multidisciplinary dis-
cussion across several professionals involved in the periopera-
tive management of these patients.
In terms of outcomes, LOS was the most commonly
assessed in these studies, as it is considered a surrogate
marker for a patient’s functional status.39 Even though LOS
after thyroid and parathyroid surgery is quite short, even out-
side of patients enrolled in ERAS, pooled analysis from this
study demonstrated a statistically significant reduction in hos-
pital LOS with ERAS protocols. It is likely that reduction of
LOS is due to adoption of predefined discharge criteria,
which decreases the possibility of patients staying longer than
required. In accord with this, there has been an increasing
focus on outpatient management of surgical procedures such
as thyroidectomy and parathyroidectomy. In fact, in 2013 the
American Thyroid Association released its consensus recom-
mendations that defined eligibility criteria for outpatient
thyroidectomy, including set pre-, intra-, and postoperative
factors that should be considered.40 Not surprising, many of
the recommendations highlighted in this consensus statement
are similar to traditional clinical care pathways, such as pread-
mission education, adequate pain control, postoperative
mobilization, and perioperative nutritional care. This is corro-
borated by a systematic review by Lee et al, which demon-
strated that outpatient thyroidectomy may be as safe as
inpatient thyroidectomy in appropriately selected patients.41
The benefits from a reduction in LOS are not insignificant.
In other major operations (eg, colorectal surgery), there has
been ample literature to show that this can reduce postopera-
tive complications, such as infections, ileus, and pneumo-
nia.42 However, in our analysis for thyroid and parathyroid
surgery, no difference was noted in postoperative complica-
tions rates between the ERAS and control groups. This is
likely due to the fact that complication rates for these opera-
tions are low in general, even without ERAS protocols; there-
fore, an even larger sample size would be required to discern
any potential benefits for clinical care pathways for this out-
come. Even so, based on this evidence, it is reasonable to
assume that introduction of ERAS protocols is safe and does
not lead to worse outcomes for patients. Furthermore, hospital
costs were significantly lower among those enrolled in ERAS
protocols. Decreased costs seen with ERAS protocols mostly
result from the reduction in hospital LOS, which is a major
driver of resource utilization and cost.43 While this is not the
main objective of the ERAS protocol, it is still worth high-
lighting, especially in light of the current health care climate
and efforts related to cost containment.
One of the major concerns with implementation of ERAS
protocols is the heightened risk of readmissions.44 This is
especially important as it relates to thyroid and parathyroid
surgery, since previous studies have reported readmission
rates between 0.9% and 5.6%, most commonly due to disor-
ders of mineral metabolism and hypocalcemia.45,46 The other
major complication of these operations is the potential for
postoperative bleeding leading to a central neck hematoma.
Prior studies have reported that 50% of postoperative bleeding
occurs within 6 hours after surgery, suggesting that by keep-
ing patients in the hospital overnight, a readmission can be
avoided.40,47,48 The findings from this study, however, align
with several other investigations, which demonstrated that
ERAS protocols do not negatively influence readmission
rates.9,49,50 Some documented predictors of readmission have
included decreased functional status, perioperative hypocal-
cemia, and malignancy.45,51 Considering this, we believe that
one of the key criteria for implementing ERAS protocols
should be careful patient selection and discharge education to
manage these complications should they arise outside the
hospital.
In most of the selected studies, medical/surgical complica-
tions and LOS were the primary outcomes of interest; how-
ever, one of the primary goals of ERAS is functional recovery
and adequate pain control in the perioperative setting. Only 1
study in this analysis evaluated these important outcomes.17
Fortunately, this study demonstrated 72% reduction in mean
opioid consumption in the hospital, and a significant popula-
tion of patients were entirely opioid free. We attribute this
finding to our use of various opioid-sparing regimens and
multimodal analgesic combinations for pain control. In the
current opioid epidemic in which we live, perioperative
opioid abuse has been linked to future abuse, requiring sur-
geons to carefully consider and evaluate their prescribing
practices.52,53 Because of this, the use of multimodal analge-
sia as part of ERAS protocols and clinical pathways is an
important step in lowering systemic opioid abuse and improv-
ing physician stewardship.
Having reviewed all the studies in this systematic review
as well as utilizing components from other ERAS protocols,
we recommend that the following components be utilized
in an ERAS protocol for thyroid and parathyroid surgery:
preadmission education, thromboembolic and antibiotic pro-
phylaxis, nausea and vomiting prophylaxis, standardized
anesthetic protocol, perioperative fluid management, perio-
perative anesthesia protocol, pain management, postoperative
mobilization, urinary catheterization, and drain management.
The current protocol at the senior author’s institution consists
of education from a nurse practitioner about the surgery as
well as the expected perioperative care. In terms of throm-
boembolic prophylaxis, patients wear sequential compression
devices during surgery. No perioperative antibiotics are
given. A standardized anesthetic protocol was developed by
the anesthesia department in conjunction with the otolaryn-
gologists. All patients get only nonnarcotic medication for
pain management, specifically acetaminophen and ibuprofen.
The majority of cases are outpatient, which increases the like-
lihood of postoperative mobilization. No patients get a urinary
catheter, unless surgery is expected to take .4 hours. Finally,
drains are not routinely placed.
There are several limitations to this study. Although we
performed a thorough literature review, there is a chance that
we could have missed some articles that met our criteria. One
limitation common to other meta-analyses is the presence of
Chorath et al
heterogeneity. We noted heterogeneity in treatment effects
for some of our outcomes in this study. This degree of hetero-
geneity is expected when we consider the differences in com-
ponents incorporated in each institution’s clinical pathway.
Specific components of ERAS protocols should be explored
and standardized across future studies. The funnel plot estab-
lished the presence of publication bias, so our effect size may
overestimate the true benefit. Several studies had components
with a high risk of bias, which makes it difficult to reproduce
these findings. Even though perioperative pain management
is an important outcome for the clinical care pathway, only 1
study evaluated this outcome in detail. There can be several
challenges when implementing a perioperative risk reduction
program like this; however, very few studies addressed over-
all compliance rates for specific components of the protocols.
Conclusion
A limited number of cohort studies have evaluated implemen-
tation of clinical care pathways for thyroid and parathyroid
surgery. Findings from this study suggest that integrations of
these programs reduce hospital LOS and costs without
increasing complication rates or readmissions. Further studies
are necessary to standardize these multimodal care pathways
and better characterize the impact of these programs on func-
tional outcomes and postoperative pain management.
Author Contributions
Kevin Chorath, conception, acquisition, analysis, interpretation of
data, manuscript preparation, final approval; Neil Luu, acquisition,
analysis, interpretation of data, manuscript preparation, final approval;
Beatrice C. Go, manuscript preparation, final approval; Alvaro
Moreira, manuscript preparation, final approval; Karthik Rajasekaran,
conception, analysis, interpretation of data, manuscript preparation, final
approval.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.
Supplemental Material
Additional supporting information is available in the online version
of the article.
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