The role of insurance status in molecular testing for thyroid nodules with indeterminate cytology

The aim of the study was to evaluate the effect of health insurance status on rate of molecular testing (MT) and subsequent thyroidectomy in patients with indeterminate thyroid nodules in a real-world high-volume clinical setting.

This is a single-center, retrospective study of patients who underwent fine-needle aspiration and had Bethesda III-IV cytology results between 2014 and 2022. We excluded patients with prior thyroid cancer, thyroidectomy, or incomplete insurance data. We utilized multivariable logistic regression to identify significant predictors of MT utilization and surgical intervention; specifically examining the role of insurance status and clinical symptoms.

A total of 448 patients were included (median age: 52 years, 79% women) with 79% of patients undergoing MT; with an associated 27-percentage-point (34% vs 61%, P < .001) reduction in thyroidectomy. Lack of MT was the strongest predictor of surgery (adjusted odds ratios [aOR]: 4.50, 95% confidence interval [CI]: 2.71-7.47, P < .001). However, uninsured/self-pay patients had 68% lower odds of MT (aOR: 0.32, 95% CI: 0.12-0.88, P = .026) and approximately 19-percentage-point higher thyroidectomy rate compared to insured patients (59% vs 40%). Thyroid-related compression symptoms were also significantly associated with increased rate of thyroidectomy (aOR: 1.86, P = .007) and an appropriate reduction in MT utilization (aOR: 0.62, P = .046).

Despite high MT penetration at an academic medical center, lack of health insurance poses a critical barrier to evidence-based risk stratification leading to higher rates of diagnostic lobectomy. While symptoms appropriately drove surgical management, expanding affordable MT access may mitigate barriers to care for patients with thyroid nodules.