Reduction in relapse rate of radioiodine therapy in patients of toxic multinodular goiter: a quality improvement project

Radioiodine (131I) therapy is the definitive treatment of toxic multinodular goiter (TMNG). Treatment failure may result in relapse after 131I therapy. The present study was undertaken to reduce treatment failure rate of 131I therapy in TMNG patients. Multiple causes may have lead to treatment failure of 131I in TMNG patients making it difficult to establish a direct cause-effect relationship and take corrective action. Therefore, the JURAN methodology of quality improvement was applied. The treatment failure rate in 80 TMNG patients treated with 131I in the period 2003-06 was 29%. The root cause analysis identified delay in decision to radioablate and concomitant antithyroid drugs (ATD) with 131I therapy as factors leading to relapse. In 2007, a change in management was introduced with decision to radioablate all TMNG patients not remitting at 1 year of ATD and to withdraw ATD for 2 weeks prior to 131I therapy. A total of 63 patients of TMNG followed the changed protocol between 2007 and 2009. Further analysis showed that one of the factors identified in the initial brainstorming (high iodide pool in the patient) had not been addressed in the protocol currently followed. The protocol was modified to include patient preparation and implemented after standardization. The post-131I relapse rate in patients treated after implementation of the new protocol from 2007 to 2009 was 18% which further reduced to 16% in 2011 after modification of the protocol. The failure rate of 131I therapy in TMNG reduced from 29% to 16% through standardization of the treatment procedure achieved by the use of Juran Methodology that helped to identify process-related defects. (author)