title: Clinical and socioeconomic factors influence treatment decisions in Graves' disease.
abstract: BACKGROUND
  Definitive treatment of Graves' disease includes radioactive iodine (RAI) and thyroidectomy, but utilization varies. We hypothesize that, in addition to clinical reasons, there are socioeconomic factors that influence whether a patient undergoes thyroidectomy or RAI.
  
  
  METHODS
  Patients treated for Graves' disease between August 2007 and September 2013 at our university hospital were included. A comparative analysis of clinical and socioeconomic factors was completed.
  
  
  RESULTS
  Of 427 patients, 300 (70 %) underwent RAI, whereas 127 (30 %) underwent surgery. Multiple factors were associated with surgery: younger age (mean 36 vs. 41 years, p < 0.01), female gender (33 vs. 19 % males, p = 0.01), black race (56 vs. 28 % nonblack, p < 0.01), Medicaid or uninsured (43 vs. 27 % private insurance or Medicare, p < 0.01), ophthalmopathy (38 vs. 26 %, p < 0.01), goiter (35 vs. 23 %, p < 0.01), and lowest quartile of median household income (38 vs. 27 % upper three quartiles, p = 0.03). Thyroidectomy increased annually, with 52 % undergoing surgery during the final year (p < 0.01). Adjusting for confounding, younger age (odds ratio [OR] 1.04; 95 % confidence interval [CI] 1.02, 1.05), female gender (OR 2.06; 95 % CI 1.06, 4.01), ophthalmopathy (OR 2.35; 95 % CI 1.40, 3.96), and later year of treatment (OR 1.66; 95 % CI 1.41, 1.95) remained significantly associated with surgery.
  
  
  CONCLUSIONS
  Surgery has now become the primary treatment modality of choice for Graves' disease at our institution. Clinical factors are the main drivers behind treatment choice, but patients with lower SES are more likely to have clinical features best treated with surgery, underlying the importance of improving access to quality surgical care for all patients.
authors.affiliation: Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, WI, USA, elfenbein@surgery.wisc.edu.
authors.forename: Dawn M
authors.initials: DM
authors.lastname: Elfenbein
authors.forename: David F
authors.initials: DF
authors.lastname: Schneider
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Havlena
authors.forename: Herbert
authors.initials: H
authors.lastname: Chen
authors.forename: Rebecca S
authors.initials: RS
authors.lastname: Sippel
mesh_terms: D000328:Adult; D000367:Age Factors; D003657:Decision Making; D005260:Female; D005500:Follow-Up Studies; D006111:Graves Disease / Q000523:psychology* / Q000601:surgery*; D054625:Healthcare Disparities; D006801:Humans; D008297:Male; D011379:Prognosis; D011446:Prospective Studies; D012959:Socioeconomic Factors; D013965:Thyroidectomy / Q000523:psychology*