Incidentaloma, Data Analysis
By Gener J Aviles-Rodriguez for Juan Quispe
Sociodemographic variables
| Total (N=120) |
|
|---|---|
| Age | |
| Mean (SD) | 58.3 (14.5) |
| Median [Min, Max] | 59.0 [18.0, 89.0] |
| Sex | |
| Female | 85 (70.8%) |
| Male | 35 (29.2%) |
| Race | |
| White | 96 (80.0%) |
| Black/African-American | 10 (8.3%) |
| American Indian/Alaska Native | 2 (1.7%) |
| Native Hawaiian/Pacific Islander | 1 (0.8%) |
| Asian | 5 (4.2%) |
| Other | 4 (3.3%) |
| Missing | 2 (1.7%) |
| Ethnicity | |
| Non-Hispanic | 82 (68.3%) |
| Hispanic | 36 (30.0%) |
| Missing | 2 (1.7%) |
| Smoke | |
| Never | 67 (55.8%) |
| Current | 23 (19.2%) |
| Former | 29 (24.2%) |
| Unknown | 1 (0.8%) |
| Insurance | |
| Unknown | 11 (9.2%) |
| MediCal/Medicaid | 13 (10.8%) |
| Medicare | 41 (34.2%) |
| Tri-Care/LLUMC Insurance | 5 (4.2%) |
| PPO | 25 (20.8%) |
| HMO | 25 (20.8%) |
Visualization of Categorical Sociodemographic Variables
Visualization of Continuous Sociodemographic Variables
Normality Tests
##
## Shapiro-Wilk normality test
##
## data: data$Age
## W = 0.97925, p-value = 0.06069Given that the \(p-value\) is \(>0.05\) we can assume that the data follows, most likely, a normal distribution.
Cinical Follow up Variables
| Total (N=120) |
|
|---|---|
| Referring Dx side | |
| Right | 43 (35.8%) |
| Left | 65 (54.2%) |
| Bilateral | 12 (10.0%) |
| Months - Incidentaloma Finding to ES | |
| Mean (SD) | 11.5 (19.3) |
| Median [Min, Max] | 4.25 [0, 109] |
| Missing | 1 (0.8%) |
| Referring specialty | |
| Endocrinology | 21 (17.5%) |
| Thoracic Surgery | 2 (1.7%) |
| General Surgery/MIS | 15 (12.5%) |
| Family Medicine | 25 (20.8%) |
| Medical Oncology | 2 (1.7%) |
| ENT | 5 (4.2%) |
| Internal Medicine | 20 (16.7%) |
| Cardiology | 2 (1.7%) |
| Obstetrics and Ginegolocy | 4 (3.3%) |
| Urology | 3 (2.5%) |
| Vascular Surgery | 2 (1.7%) |
| Hematology/Oncology | 2 (1.7%) |
| Gastroenterology | 6 (5.0%) |
| Surgical Oncology | 3 (2.5%) |
| Pediatrics | 1 (0.8%) |
| Transplant Surgery | 2 (1.7%) |
| Geriatrics | 2 (1.7%) |
| Emergency Medicine | 1 (0.8%) |
| Nephrology | 1 (0.8%) |
| Other (self) | 1 (0.8%) |
| Type of Surgeon Being Referred to | |
| Surgical Oncologist/General Surgeon | 15 (12.5%) |
| Endocrine Surgeon | 105 (87.5%) |
| Biopsy | |
| No | 112 (93.3%) |
| Yes | 8 (6.7%) |
| Non Guideline Totals | |
| Mean (SD) | 2.43 (2.89) |
| Median [Min, Max] | 2.00 [0, 17.0] |
| Adrenalectomy | |
| No | 71 (59.2%) |
| Yes | 49 (40.8%) |
| Final Size on Pathology / OR | |
| - | 1 (0.8%) |
| . | 12 (10.0%) |
| 0 | 71 (59.2%) |
| 106 | 1 (0.8%) |
| 13 | 1 (0.8%) |
| 14 | 1 (0.8%) |
| 15 | 1 (0.8%) |
| 20 | 2 (1.7%) |
| 25 | 3 (2.5%) |
| 28 | 1 (0.8%) |
| 30 | 1 (0.8%) |
| 35 | 2 (1.7%) |
| 40 | 1 (0.8%) |
| 41 | 2 (1.7%) |
| 43 | 1 (0.8%) |
| 45 | 3 (2.5%) |
| 49 | 1 (0.8%) |
| 54 | 1 (0.8%) |
| 55 | 1 (0.8%) |
| 60 | 2 (1.7%) |
| 65 | 5 (4.2%) |
| 70 | 1 (0.8%) |
| 75 | 1 (0.8%) |
| 80 | 1 (0.8%) |
| 82 | 1 (0.8%) |
| 85 | 1 (0.8%) |
| 94 | 1 (0.8%) |
| Final size on Imaging | |
| 10 mm | 1 (0.8%) |
| 14 mm | 2 (1.7%) |
| 14x11x10 mm | 1 (0.8%) |
| 16 x 13 mm | 1 (0.8%) |
| 17 mm | 1 (0.8%) |
| 18 x 12 mm | 1 (0.8%) |
| 180 x 168 x 150 mm | 1 (0.8%) |
| 21 mm | 1 (0.8%) |
| 22mm | 1 (0.8%) |
| 27 mm | 1 (0.8%) |
| 28 x 19 mm | 1 (0.8%) |
| 30 mm | 2 (1.7%) |
| 30 x 20 mm | 1 (0.8%) |
| 33 mm | 1 (0.8%) |
| 34 x 22 mm | 1 (0.8%) |
| 35 mm | 1 (0.8%) |
| 42 mm | 1 (0.8%) |
| 46 mm | 1 (0.8%) |
| 47 x 46 mm | 1 (0.8%) |
| 56 x 51 x 58 mm | 1 (0.8%) |
| 8 mm | 1 (0.8%) |
| 82 x 100 mm | 1 (0.8%) |
| 87 x 80 x 91 mm | 1 (0.8%) |
| 9 mm | 1 (0.8%) |
| L 57 x 37 x 56 mm | 1 (0.8%) |
| L 24 x 23 mm | 1 (0.8%) |
| L 10mm | 1 (0.8%) |
| L 12mm x 10mm; R 11mm x 9mm | 1 (0.8%) |
| L 13 mm | 1 (0.8%) |
| L 17mm | 1 (0.8%) |
| L 2.6 x 1.8 mm | 1 (0.8%) |
| L 20mm | 1 (0.8%) |
| L 28 mm | 1 (0.8%) |
| L 61 x 50 mm | 1 (0.8%) |
| L 8 x 10 mm | 1 (0.8%) |
| L 10x7mm | 1 (0.8%) |
| L 11.5 x 12 mm | 1 (0.8%) |
| L 14mm | 1 (0.8%) |
| L 17 x 19 mm | 1 (0.8%) |
| L 21x40mm | 1 (0.8%) |
| L 24 x 21 mm | 1 (0.8%) |
| L 25x20mm | 1 (0.8%) |
| L 26 mm; R 8 mm | 1 (0.8%) |
| L 27x23x25mm | 1 (0.8%) |
| L 28 mm | 1 (0.8%) |
| L 29 x 22 x 25 mm | 1 (0.8%) |
| L 30 mm | 1 (0.8%) |
| L 34 mm | 1 (0.8%) |
| L 37x34mm | 1 (0.8%) |
| L 38x40x41mm | 1 (0.8%) |
| L 40mm + smal 12mm | 1 (0.8%) |
| L 48 mm | 1 (0.8%) |
| L 48 x 43 x 46 mm | 1 (0.8%) |
| L 75 x 89 mm | 1 (0.8%) |
| L 76 x 70 x 90 mm | 1 (0.8%) |
| L 82x100mm | 1 (0.8%) |
| L increase size; R same | 1 (0.8%) |
| NA | 1 (0.8%) |
| No reported | 1 (0.8%) |
| Not done | 1 (0.8%) |
| R 22 x 17 x 18 mm | 1 (0.8%) |
| R 3.4 X 2.8 cm | 1 (0.8%) |
| R 45 mm | 1 (0.8%) |
| R 105 x 87 mm | 1 (0.8%) |
| R 105mm | 1 (0.8%) |
| R 15 x 10mm | 1 (0.8%) |
| R 2 mm | 1 (0.8%) |
| R 20 mm | 1 (0.8%) |
| R 22 x 19 mm | 1 (0.8%) |
| R 24 x 21 mm; L 25 x 21 mm | 1 (0.8%) |
| R 25x20x27mm | 1 (0.8%) |
| R 32mm | 1 (0.8%) |
| R 38 x 19 mm; L 46 x 27 mm | 1 (0.8%) |
| R 45mm | 1 (0.8%) |
| R 50mm | 1 (0.8%) |
| R 52mm | 1 (0.8%) |
| R 53mm, L 20mm | 1 (0.8%) |
| R 54mm, L 22mm | 1 (0.8%) |
| R 55 x 37 x 39 mm | 1 (0.8%) |
| R 60 x 45 mm | 1 (0.8%) |
| R 62x48x64mm | 1 (0.8%) |
| R 88 x 64 x 78 mm | 1 (0.8%) |
| same | 4 (3.3%) |
| Same | 31 (25.8%) |
| Missing | 1 (0.8%) |
| AACE/ AAES Guidelines TOTAL | |
| 0 | 51 (42.5%) |
| 1 | 22 (18.3%) |
| 2 | 17 (14.2%) |
| 3 | 11 (9.2%) |
| 4 | 11 (9.2%) |
| 5 | 2 (1.7%) |
| 6 | 1 (0.8%) |
| 7 | 3 (2.5%) |
| 9 | 2 (1.7%) |
Categorical Clinical
Numeric Clinical
Imaging Variables
Laboratory Variables
Results in Time
Visualizing Amount of Months from Diagnosis to ES Stratyfied by Year (2011-2019)
- There is one patient from 2010, it was added to the 2011 subgroup.
Contingency Table of Amount of Studies Ordered by Patient Corresponding to Non-Guidelines and AACE/AAES Guidelines
|
Studies Matching AACE/ AAES Guidelines
|
|||||||||
|---|---|---|---|---|---|---|---|---|---|
| 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 9 | |
| Studies NOT Matching Guidelines | |||||||||
| 0 | 22 | 9 | 3 | 1 | 2 | 0 | 0 | 0 | 0 |
| 1 | 15 | 2 | 2 | 0 | 1 | 1 | 0 | 0 | 0 |
| 2 | 9 | 5 | 4 | 3 | 2 | 0 | 0 | 0 | 0 |
| 3 | 0 | 2 | 3 | 0 | 0 | 0 | 0 | 0 | 0 |
| 4 | 4 | 1 | 1 | 4 | 0 | 0 | 0 | 1 | 0 |
| 5 | 0 | 1 | 1 | 1 | 3 | 1 | 0 | 0 | 0 |
| 6 | 1 | 1 | 0 | 1 | 2 | 0 | 1 | 0 | 1 |
| 7 | 0 | 0 | 1 | 1 | 0 | 0 | 0 | 0 | 0 |
| 8 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| 9 | 0 | 0 | 2 | 0 | 0 | 0 | 0 | 1 | 0 |
| 10 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 |
| 12 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 |
| 17 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 |
Total Costs
Extra explorations on Total Costs
## Warning: Number of labels is greater than default palette color count.
## Try using another color `palette` (and/or `package`).
Analysis of statistical difference between total cost per year studied using Kruskall-Wallis test:
| .y. | n | statistic | df | p | method |
|---|---|---|---|---|---|
| totalCost | 120 | 10.59837 | 12 | 0.564 | Kruskal-Wallis |
The result indicates groups are most likely not statistically different when comparing total costs.
Analysis of statistical difference between total cost per referring specialty studied using Kruskall-Wallis test:
| .y. | n | statistic | df | p | method |
|---|---|---|---|---|---|
| totalCost | 120 | 34.69653 | 19 | 0.0152 | Kruskal-Wallis |
The result indicates groups are most likely statistically different when comparing total costs. We proceed with a post-hoc analysis using Dunn test.
## Kruskal-Wallis rank sum test
##
## data: x and g
## Kruskal-Wallis chi-squared = 34.6965, df = 19, p-value = 0.02
##
##
## Comparison of x by g
## (Benjamini-Hochberg)
## Col Mean-|
## Row Mean | Cardiolo Emergenc Endocrin ENT Family M Gastroen
## ---------+------------------------------------------------------------------
## Emergenc | -0.447687
## | 0.8458
## |
## Endocrin | -1.970262 -0.888800
## | 0.4881 0.6835
## |
## ENT | -0.882994 -0.173868 1.445405
## | 0.6762 0.9359 0.5220
## |
## Family M | -0.831756 -0.061688 2.860780 0.260365
## | 0.6880 0.9926 0.2007 0.8881
## |
## Gastroen | -1.734790 -0.803747 0.089800 -1.119157 -1.771283
## | 0.4251 0.7026 0.9746 0.5880 0.4405
## |
## General | -1.376251 -0.472214 1.248336 -0.575599 -1.300650 0.787597
## | 0.5010 0.8287 0.5368 0.7892 0.5403 0.7058
## |
## Geriatri | -0.144290 0.329875 1.775278 0.710534 0.635402 1.558071
## | 0.9450 0.8386 0.4504 0.7198 0.7676 0.5034
## |
## Hematolo | -0.036072 0.418234 1.921516 0.839879 0.782668 1.690610
## | 0.9975 0.8231 0.4946 0.6926 0.7045 0.4318
## |
## Internal | -1.329824 -0.427367 1.510031 -0.494915 -1.250035 0.924273
## | 0.5366 0.8364 0.5081 0.8133 0.5499 0.6619
## |
## Medical | -0.367940 0.147265 1.473054 0.443222 0.331053 1.284156
## | 0.8413 0.9532 0.5243 0.8386 0.8426 0.5404
## |
## Nephrolo | -2.061719 -1.397792 -1.042527 -1.630674 -1.876701 -1.026392
## | 0.6212 0.4970 0.6137 0.4549 0.4602 0.6094
## |
## Obstetri | 0.549820 0.916306 3.545406 1.811102 2.019199 2.932016
## | 0.8019 0.6632 0.0745 0.4441 0.4858 0.3199
## |
## Other (s | 0.388781 0.724403 1.889707 1.109069 1.066255 1.752214
## | 0.8334 0.7184 0.4655 0.5840 0.6044 0.4208
## |
## Pediatri | 0.388781 0.724403 1.889707 1.109069 1.066255 1.752214
## | 0.8387 0.7242 0.4857 0.5908 0.6112 0.4329
## |
## Surgical | -1.443634 -0.666448 0.227097 -0.792945 -1.156507 0.139439
## | 0.5142 0.7440 0.9115 0.7068 0.5665 0.9437
## |
## Thoracic | -0.577161 -0.023562 1.190328 0.193155 0.046339 1.027914
## | 0.7935 1.0000 0.5487 0.9247 0.9944 0.6144
## |
## Transpla | -2.020064 -1.201688 -0.759507 -1.531444 -1.917203 -0.739273
## | 0.5151 0.5519 0.7146 0.4974 0.4768 0.7219
## |
## Urology | -1.828252 -0.970515 -0.341759 -1.273717 -1.731140 -0.357100
## | 0.4423 0.6304 0.8435 0.5351 0.4171 0.8404
## |
## Vascular | -0.995603 -0.365218 0.624875 -0.306978 -0.523087 0.515429
## | 0.6193 0.8385 0.7658 0.8532 0.8097 0.8112
## Col Mean-|
## Row Mean | General Geriatri Hematolo Internal Medical Nephrolo
## ---------+------------------------------------------------------------------
## Geriatri | 1.184573
## | 0.5473
## |
## Hematolo | 1.328332 0.108217
## | 0.5299 0.9646
## |
## Internal | 0.145741 -1.135263 -1.281184
## | 0.9491 0.5796 0.5356
## |
## Medical | 0.887471 -0.223650 -0.331867 0.833694
## | 0.6783 0.9092 0.8470 0.6923
## |
## Nephrolo | -1.441791 -1.943907 -2.032266 -1.501770 -1.761297
## | 0.4979 0.4931 0.5336 0.5060 0.4369
## |
## Obstetri | 2.687183 0.716432 0.591473 2.669933 0.974680 2.684389
## | 0.2282 0.7201 0.7858 0.1802 0.6328 0.1972
## |
## Other (s | 1.464145 0.506594 0.418234 1.427139 0.689203 2.122196
## | 0.5132 0.8081 0.8284 0.4945 0.7284 0.5842
## |
## Pediatri | 1.464145 0.506594 0.418234 1.427139 0.689203 2.122196
## | 0.5231 0.8137 0.8337 0.5030 0.7341 0.6426
## |
## Surgical | -0.445639 -1.285572 -1.404118 -0.535626 -1.040575 1.045491
## | 0.8420 0.5468 0.4992 0.8037 0.6090 0.6176
## |
## Thoracic | 0.609537 -0.432871 -0.541088 0.551580 -0.209220 1.590469
## | 0.7745 0.8425 0.8044 0.8061 0.9163 0.4825
## |
## Transpla | -1.307247 -1.875774 -1.983992 -1.394029 -1.652124 0.412343
## | 0.5420 0.4435 0.4988 0.4925 0.4456 0.8230
## |
## Urology | -1.000787 -1.670189 -1.788736 -1.102714 -1.425193 0.741423
## | 0.6208 0.4397 0.4514 0.5833 0.4880 0.7259
## |
## Vascular | 0.053669 -0.851312 -0.959530 -0.012646 -0.627662 1.248813
## | 0.9938 0.6878 0.6345 1.0000 0.7690 0.5436
## Col Mean-|
## Row Mean | Obstetri Other (s Pediatri Surgical Thoracic Transpla
## ---------+------------------------------------------------------------------
## Other (s | 0.000000
## | 1.0000
## |
## Pediatri | 0.000000 0.000000
## | 1.0000 1.0000
## |
## Surgical | -2.348910 -1.553658 -1.553658
## | 0.3975 0.4862 0.4968
## |
## Thoracic | -1.216268 -0.860031 -0.860031 0.811385
## | 0.5597 0.6857 0.6921 0.7014
## |
## Transpla | -2.882389 -2.038157 -2.038157 -0.769235 -1.442903
## | 0.2500 0.5637 0.6070 0.7113 0.5057
## |
## Urology | -2.808616 -1.857725 -1.857725 -0.430015 -1.196003 0.384617
## | 0.1891 0.4289 0.4448 0.8395 0.5503 0.8319
## |
## Vascular | -1.699443 -1.201688 -1.201688 0.353005 -0.418441 1.024461
## | 0.4347 0.5590 0.5663 0.8389 0.8390 0.6049
## Col Mean-|
## Row Mean | Urology
## ---------+-----------
## Vascular | 0.737623
## | 0.7176
##
## alpha = 0.05
## Reject Ho if p <= alphaAnalysis of statistical difference between total cost per type of surgeon being referred to using Kruskall-Wallis test:
| .y. | n | statistic | df | p | method |
|---|---|---|---|---|---|
| totalCost | 120 | 1.361791 | 1 | 0.243 | Kruskal-Wallis |
Results indicate that, most likely, groups are not statistically significant.
CT A/P with and without Contrast after Imaging Index
We begin by selecting those patients in which the Index Imaging for Incidentaloma is positive to ´CT A/P w/ and w/o contrast´, we then obtain the following number of patients:
## [1] 28Of those 28 patients we compare ´AACE/ AAES Guidelines TOTAL´ and ´CT A/P W/WO Contrast´ to see if the study was repeated:
## CT A/P W/WO Contrast
## AACE/ AAES Guidelines TOTAL 0 1 2
## 0 13 0 0
## 1 2 1 0
## 2 3 1 3
## 3 0 1 0
## 4 2 2 0
## 5 0 0 0
## 6 0 0 0
## 7 0 0 0
## 9 0 0 0Further explorations with number of studies perfromed per patient
This part of the analysis was done including the following variables:
## [1] "Index Imaging for Incidentaloma" "CT A/P W/WO Contrast"
## [3] "Aldosterone" "Renin"
## [5] "ODST" "Plasma Metanephrines"
## [7] "AACE/ AAES Guidelines TOTAL" "CT chest W/ and W/O contrast"
## [9] "CT Chest Non-contrast" "CT Chest contrast"
## [11] "CT A/P non-contrast" "CT A/P contrast"
## [13] "CT adrenal protocol" "MRI Abd W/O"
## [15] "MRI Abd W/contrast" "MRI Abd W and W/O"
## [17] "PET/CT" "Ultrasound"
## [19] "Urine Aldoster" "ACTH"
## [21] "Salivary cortisol" "Urine cortisol"
## [23] "Plasma cortisol" "Urine Metanephrines"
## [25] "Urine Catecholamines" "Plasma Catecholamines"
## [27] "Urine VMA" "DHES1 Sulfate"
## [29] "Testosterone Total" "Androstenedione"
## [31] "FSH and LH" "Prolactin"
## [33] "Chromogranin A" "17-OH Progesterone"
## [35] "5-HIAA" "Estrogen Total"
## [37] "Estradiol"Exploring total number of studies per year
Do patients with a longer wait in months from Incidentaloma finding to ES end up with more studies?
Do imaging studies raise the total cost more than Non-imaging studies?
For this comparisons we considered the following as imaging studies:
## [1] "Index Imaging for Incidentaloma" "CT A/P W/WO Contrast"
## [3] "CT chest W/ and W/O contrast" "CT Chest Non-contrast"
## [5] "CT Chest contrast" "CT A/P non-contrast"
## [7] "CT A/P contrast" "CT adrenal protocol"
## [9] "MRI Abd W/O" "MRI Abd W/contrast"
## [11] "MRI Abd W and W/O" "PET/CT"
## [13] "Ultrasound"Towards an Integration of a Publication
Original Ideas
Research question: Do earlier referral saves the patient to undergo from studies that do not contribute to clinical decision resulting in less patient inconvenience and cost?
Objective: To suggest that Primary Care Provider (PCP) refer patients with Adrenal Incidentaloma sooner to Endocrine Surgery.
Alternative Hypothesis: Is better to refer the patient to Endocrine Surgery unless the PCP is familiar with guidelines and is comfortable with deciding whether an Adrenal Incidentaloma should undergo or not surgery.
Outcome Measure: Workup Guidelines 2009