5. Recommendations

The Committee reviewed 17 endocrinology items and made recommendations based on evidence and clinical expertise, in consultation with relevant stakeholders. The item-level recommendations can be found in Sections 5.1–5.66. A summary item recommendation table can be found in Appendix A. In step 1 of its review, the Committee did not identify any low-volume obsolete items. In step 2, it classified two items as priority 1, nine items as priority 2 and six items as priority 3.

The Committee’s recommendations (prior to broader stakeholder consultation) are that one item should be deleted and its services should no longer be provided under the MBS, and that 16 items should be changed. Changes focus on encouraging best practice and simplifying the MBS to improve patient care, primarily by consolidating item numbers, improving the clarity of descriptors (with the support of explanatory notes) and providing clinical guidance for appropriate use through explanatory notes.

The recommendations are presented in item groups below, with higher priority groups presented first.

5.1 Thyroidectomy: Items 30296–7, 30306 and 30308–10

Table 4: Item introduction table for items 30296-7, 30306 and 30308-10

Item Descriptor
[date last amended]
Schedule fee Services FY2014/15 Benefits FY2014/15 Services 5 year annual avg. growth

30296

Thyroidectomy, total. (Anaes.) (Assist.) [1992]

$1,023.7

2,929

$2,124,549

4.2%

30297

Thyroidectomy following previous thyroid surgery. (Anaes.) (Assist.) [1992]

$1,023.7

593

$431,022

2.8%

30306

Total hemithyroidectomy. (Anaes.) (Assist.) [1992]

$798.65

2,741

$1,548,317

2.5%

30308

Bilateral subtotal thyroidectomy. (Anaes.) (Assist.) [1992]

$798.65

32

$13,343

-5.3%

30309

Thyroidectomy, subtotal for thyrotoxicosis. (Anaes.) (Assist.) [1992]

$1,023.7

68

$46,197

11.2%

30310

Thyroid, unilateral subtotal thyroidectomy or equivalent partial thyroidectomy. (Anaes.) (Assist.) [1991]

$457.4

198

$48,476

8.8%


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6 Recommendations that are eventually made for consideration by the Government will not necessarily reflect the final recommendations made to the Taskforce by the Committee after consultation. As stated, the Taskforce will consider these recommendations, and it may alter recommendations to bring items in line with broader changes that are being made. Additionally, the wording or structuring of item descriptors and explanatory notes may be changed to ensure consistency with the language and structure of the MBS. It should also be noted that the recommendations focus on the services provided by the items. Specific item numbers may be altered during implementation of the eventual recommendations proposed by the Minister for Health. For example, where the Committee has requested that services for item A be consolidated under item B, the actual item number for item B may be changed in some circumstances.


5.1.1 Items 30296 and 30309

Recommendation 1
  • ΔConsolidate item 30309 under item 30296.
  • ΔLeave the descriptor for item 30296 unchanged.
  • ΔAdd the following explanatory notes: “Total Thyroidectomy or total hemithyroidectomy are the most appropriate procedures in the majority of circumstances when a thyroidectomy is required. The preferred procedure for thyrotoxicosis is total thyroidectomy (item 30296). Item X [note: item to be created, see recommendations for items 30308 and 30309 below] is to be used only in uncommon circumstances where a subtotal or partial thyroidectomy is indicated and includes a subtotal lobectomy, nodulectomy, or isthmusectomy or equivalent partial thyroidectomy." These explanatory notes are recommended for all thyroidectomy items other than 30297, please see recommendations for items 30306, 30308 and 30310 for further rationale. (Explanatory notes are not currently provided for these items.)

Rationale

The recommendations focus on modernising and simplifying item numbers to reflect best clinical practice. They are based on the following observations.

  • ΔThe position of the Committee is that procedures previously performed under item 30309 should be performed as a total thyroidectomy under item 30296. This view is supported by the literature which highlights that total thyroidectomy is preferable to sub-total thyroidectomy. The American Thyroid Association and American Association of Clinical Endocrinologists’ Management Guidelines for thyrotoxicosis state: “If surgery is chosen as treatment for thyrotoxicosis management or Graves’ disease, near-total or total thyroidectomy should be performed” (Guidelines 40 and 24).[4] Furthermore, a review by Snook, Stalberg and Sidhu (2007) states: “Total thyroidectomy for benign multinodular goitres is not only a safe procedure but is efficacious in preventing recurrent disease.”[5]
  • ΔMBS data also indicates comparatively limited use for item 30309. For example, in FY2014/15 sub-total thyroidectomies for thyrotoxicosis under item 30309 were only performed 69 times compared to total thyroidectomies under item 30296, which were performed 2,929 times.[6]
  • ΔItem 30309 has the same schedule fee as item 30296, and consolidating the items should therefore have no impact on patient access.
  • ΔThe proposed item for partial or subtotal thyroidectomy below (see recommendations for items 30308 and 30310) can be used in the uncommon circumstances when a subtotal thyroidectomy for thyrotoxicosis is required.

5.1.2 Item 30306

Recommendation 2
  • ΔLeave the item descriptor unchanged.
  • ΔAdd the following explanatory notes: “Total Thyroidectomy or total hemithyroidectomy are the most appropriate procedures in the majority of circumstances when a thyroidectomy is required. The preferred procedure for thyrotoxicosis is total thyroidectomy (item 30296). Item X [note: item to be created, see recommendations for items 30308 and 30309 below] is to be used only in uncommon circumstances where a subtotal or partial thyroidectomy is indicated and includes a subtotal lobectomy, nodulectomy, or isthmusectomy or equivalent partial thyroidectomy." These explanatory notes are recommended for all thyroidectomy items other than 30297, please see recommendations for items 30296 and 30309, and 30308 and 30310 for further rationale. (Explanatory notes are not currently provided for this item.)

Rationale

The recommendations focus on encouraging best clinical practice and are based on the following observations.

  • ΔThe position of the Committee is that a total hemithyroidectomy performed under Item 30306, is the most appropriate treatment in the majority of circumstances compared to a unilateral subtotal or equivalent partial thyroidectomy performed under item 30310. This is supported by the American Thyroid Association’s Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer, which state: “When surgery is considered for patients with a solitary, cytologically indeterminate nodule, thyroid lobectomy (hemithyroidectomy) is the recommended initial surgical approach” (Recommendation 19).[7]
  • ΔThe Committee considered deleting item 30310 and requiring services to be provided under item 30306. However, it decided that an item number is required for the uncommon circumstances when a unilateral subtotal or equivalent partial thyroidectomy is indicated as under item 30310. Therefore, to encourage use of item 30306 instead of item 30310, the Committee recommends adding the proposed explanatory notes in line with clinical guidelines.

5.1.3 Items 30308 and 30310

Recommendation 3
  • ΔConsolidate items 30308 and 30310 into one item for the uncommon circumstances when a partial or subtotal thyroidectomy is indicated. The proposed item descriptor is as follows: “Partial or subtotal thyroidectomy (Anaes.) (Assist.)”
  • ΔAdd the following explanatory notes: “Total Thyroidectomy or total hemithyroidectomy are the most appropriate procedures in the majority of circumstances when a thyroidectomy is required. The preferred procedure for thyrotoxicosis is total thyroidectomy (item 30296). Item X [note: item to be created] is to be used only in uncommon circumstances where a subtotal or partial thyroidectomy is indicated and includes a subtotal lobectomy, nodulectomy, or isthmusectomy or equivalent partial thyroidectomy." These explanatory notes are recommended for all thyroidectomy items other than 30297. (Explanatory notes are not currently provided for these items.)

Rationale

The recommendations focus on modernising and simplifying item numbers to reflect best clinical practice. They are based on the following observations.

  • ΔAs stated above, the position of the Committee is that total thyroidectomies (30296) and total hemithyroidectomies (30306) should be performed in the majority of circumstances; Whereas subtotal or equivalent partial thyroidectomies performed under items 30310 and 30308, are only indicated in uncommon circumstances. Again, this is supported by the literature cited above.[4], [5], [7]
  • ΔMBS data also indicates that Items 30308 and 30310 are rarely performed procedures. In FY2014/15, item 30310 was used only 198 times, and item 30308 was only used 32 times. To provide a point of comparison, item 30306 was used 2,741 times, and item 30296 was used 2,929 times during the same period.[6] Furthermore, the use of item 30306 has been declining steadily by 5.3 per cent per year over the last five years.[2]
  • ΔThe Committee wishes to make it clear that partial and subtotal thyroidectomies should only be used in uncommon circumstances. They intend to do this by consolidating the items for these procedures into one item with a clear item descriptor, and highlighting when this item should be used by the aid of explanatory notes.

5.1.4 Item 30297

Recommendation 4
  • ΔLeave the item descriptor unchanged.
  • ΔAdd the following explanatory notes: “This procedure is for re-exploratory thyroid surgery where prior thyroid surgery and associated scar tissue increases the complexity of surgery. For completion hemithyroidectomy on the contralateral side to a previous hemi thyroidectomy for thyroid cancer, item 30306 is the appropriate item.” (Explanatory notes are not currently provided for this item.)

Rationale

The recommendations focus on encouraging best clinical practice, based on the following observations.

  • ΔCommittee members agreed that this item should not be used as a completion procedure, and that it is incorrectly claimed in some cases.
  • ΔIt was noted that there are currently no explanatory notes for this item. The Committee felt that including explanatory notes would further promote best practice.

5.2 Parathyroid: Items 30315, 30317–8 and 30320

Table 5: Item introduction table for items 30315, 30317-8 and 30320

Item Descriptor
[date last amended]
Schedule fee Services FY2014/15 Benefits FY2014/15 Services 5 year annual avg. growth

30315

Parathyroid operation for hyperparathyroidism. (Anaes.) (Assist.) [1992]

$1,139.90

2,020

$1,713,523

8.6%

30317

Cervical reexploration for recurrent or persistent hyperparathyroidism. (Anaes.) (Assist.) [1992]

$1,364.90

125

$127,685

14.3%

30318

Mediastinum, exploration of, via the cervical route, for hyperparathyroidism (including thymectomy). (Anaes.) (Assist.) [1992]

$907.60

524

$169,638

13.3%

30320

Mediastinum, exploration of, via mediastinotomy, for hyperparathyroidism (including thymectomy). (Anaes.) (Assist.) [1992]

$1,364.90

7

$5,956

11.8%


Recommendation 5
  • ΔAmend the descriptors for all four items to promote best practice and improve ease of use. Proposed item descriptors are provided below.
    • – 30315: Minimally invasive parathyroidectomy. Removal of 1 or more parathyroid adenoma through a small cervical incision for an image localised adenoma including thymectomy, not to be claimed with itself or items 30316, 30317 or 30320. (Anaes.) (Assist.)
    • – 30316 (previously 30318): Open parathyroidectomy, exploration and removal of 1 or more adenoma or hyperplastic glands via a cervical incision including thymectomy and cervical exploration of the mediastinum when performed. Not to be claimed with itself or items 30315, 30317 or 30320. (Anaes.) (Assist.)
    • – 30317: Redo parathyroidectomy. Cervical re-exploration for persistent or recurrent hyperparathyroidism including thymectomy and cervical exploration of the mediastinum, not to be claimed with itself or items 30315, 30316 or 30320. (Anaes.) (Assist.)
    • – 30320: Removal of a mediastinal parathyroid adenoma via sternotomy or mediastinal thorascopic approach, not to be claimed with itself or items 30315, 30316 or 30317. (Anaes.) (Assist.)
  • ΔChange item number 30318 to 30316 to make the order of item numbers more intuitive.
  • ΔThe Committee advises that the revised item 30316 has a similar scope of practice to item 30315 and should have the same schedule fee.

Rationale

The recommendations focus on simplifying item numbers to reflect best clinical practice. They are based on the following observations.

  • ΔExisting parathyroid item descriptors are unclear, do not reflect modern use of the items and allow for unintended and intended misuse. The Committee’s position is that this results in inappropriate co-claiming. For example, in FY2014/15, item 30318 was co-claimed with item 30315 on 465 occasions—90 per cent of 30318 claims. It was also co-claimed with item 30317 on 40 occasions. Items 30315 and 30320 were co-claimed on two occasions.[8]
  • ΔThe Committee agreed that the anticipated volume split between the new items is approximately 50 per cent minimally invasive parathyroidectomy and 50 per cent open parathyroidectomy.[9], [10]

5.3 Synacthen stimulation test: Item 30097

Table 6: Item introduction table for item 30097

Item Descriptor
[date last amended]
Schedule fee Services FY2014/15 Benefits FY2014/15 Services 5 year annual avg. growth

30097

Personal performance of a Synacthen Stimulation Test, including associated consultation; by a medical practitioner with resuscitation training and access to facilities where life support procedures can be implemented. [2006]

$97.15

955

$78,224

10.6%


Recommendation 6
  • ΔChange the item descriptor to require a basal cortisol quantitation prior to a Synacthen stimulation test. The proposed item descriptor is provided below.
  • ΔPersonal performance of a Synacthen Stimulation Test, including associated consultation; by a medical practitioner with resuscitation training and access to facilities where life support procedures can be implemented, if serum cortisol at 0830-0930 hours in the preceding month has been measured at greater than 100 nmol/L but less than 400 nmol/L; or in a patient in intensive care where adrenal insufficiency is suspected.
  • ΔAdd explanatory notes to guide best practice. (Explanatory notes are not currently provided for this item.) Proposed explanatory notes are provided below.
    • – A 0900h serum cortisol (0830-0930) less than 100 nmol/L indicates adrenal deficiency and a Synacthen Test is not required.
    • – A 0900h serum cortisol (0830-0930) greater than 400 nmol/L indicates adrenal sufficiency and a Synacthen Test is not required.

Rationale

The recommendations focus on encouraging best clinical practice and are based on the following observations.

  • ΔIn the last five years, use of this item has increased by an annual average of 10.6 per cent, resulting in a total service volume of 977 in FY2014/15.[2] The Committee agreed that this growth and the resulting service volume are higher than expected and a likely indication of over-testing and the provision of low-value care for patients. Over-testing can occur when a basal cortisol quantitation is (i) not taken and the results would have proven a Synacthen test to be redundant, or (ii) taken and not interpreted appropriately to avoid a redundant Synacthen test.[11]–[13] The Committee felt that this problem could be addressed by adding a requirement to the item descriptor to undertake a basal cortisol quantitation, along with clear rules describing when a Synacthen test is appropriate, supported by explanatory notes.
  • ΔThere is consensus in the relevant literature that a morning serum cortisol of <100nmol/L is an appropriate lower bound cut-off. There is less consensus regarding the upper bound, but a conservative evaluation of the most relevant literature was conducted and the Committee agreed with the recommendation of >400 nmol/L.[14]–[16]

5.4 Thyroglossal cyst: Items 30313 and 30314

Table 7: Item introduction table for items 30313 and 30314

Item Descriptor
[date last amended]
Schedule fee Services FY2014/15 Benefits FY2014/15 Services 5 year annual avg. growth

30313

Thyroglossal cyst, removal of. (Anaes.) (Assist.) [1991]

$272.95

45

$7,628

-5.3%

30314

Thyroglossal cyst or fistula or both, on a person 10 years of age or over. Radical removal of, including thyroglossal duct and portion of hyoid bone. (Anaes.) (Assist.) [1992]

$457.40

260

$84,185

3.0%


Recommendation 7
  • ΔDelete7 item 30313, and instead use item 30314.
  • ΔChange the item descriptor for item 30314 to read: “Sistrunks procedure. Excision of a thyroglossal duct cyst or fistula including removal of the body of the hyoid bone. (Anaes.) (Assist.)”

Rationale

The recommendations focus on modernising the MBS by removing obsolete items that encourage sub-optimal clinical practice. They are based on the following observations.

  • ΔItem 30313 is obsolete as it has a higher cyst recurrence rate than item 30314. The recurrence rate after removing a cyst is 30 per cent, compared to less than 10 per cent after removing a cyst/tract and body of the hyoid bone.[17]
  • ΔClinical practice is changing, reflecting a shift away from using obsolete item 30313. The service volume for item 30313 has declined by an average of 5.3 per cent per year over the last five years, and the service volume for item 30314 has increased by 3 per cent per year.[2]
  • ΔThere are no access issues caused by the minimum age specified in item 30314 as an equivalent item number (30326) exists for patients under 10 years of age.

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7Describes when an item is recommended for removal from the MBS and its services will no longer be provided under the MBS.


5.5 Tumour removal: Items 30321, 30323–4 and 36500

Table 8: Item introduction table for items 30321, 30323–4 and 36500

Item Descriptor
[date last amended]
Schedule fee Services FY2014/15 Benefits FY2014/15 Services 5 year annual avg. growth

30321

Retroperitoneal neuroendocrine tumour, removal of. (Anaes.) (Assist.) [1992]

$907.60

13

$7,053

-9.1%

30323

Retroperitoneal neuroendocrine tumour, removal of, requiring complex and extensive dissection. (Anaes.) (Assist.) [1992]

$1,364.90

97

$87,826

1.5%

30324

Adrenal gland tumour, excision of. (Anaes.) (Assist.) [1992]

$1,364.90

275

$267,754

6.8%

36500

Adrenal gland, excision of partial or total. [1991]

$924.70

56

$25,530

9.2%


Recommendation 8
  • ΔConsolidate item 30321 under item 30323.
  • ΔChange the descriptor for item 30323 to read: “Excision of phaeochromocytoma or extraadrenal paraganglioma via endoscopic or open approach. (Anaes.) (Assist.)”
  • ΔChange the descriptor for item 30324 to read: “Excision of an adrenocortical tumour or hyperplasia via endoscopic or open approach. (Anaes.) (Assist.)”
  • ΔConsolidate item 36500 under item 30324. (Item 36500 was assigned to the Urology Clinical Committee. This recommendation will be referred to this committee or to the Urological Society of Australia and New Zealand directly.)

Rationale

The recommendations focus on encouraging best practice and simplifying the MBS to ensure high-value care for patients.8 They are based on the following observations.

  • ΔThere is overlap between the item descriptors for items 30321 and 30323. The items are differentiated based on the clinician’s judgment of whether the procedure was “complex and extensive,” which warrants an extra $457. The Committee acknowledged that the “complex and extensive” procedure (item 30323) is the most appropriate treatment in the majority of circumstances, but that the item’s schedule fees encourage clinicians to bill the “complex and extensive” item number regardless. This can be seen in the MBS data: service volume for the less expensive item (30321) has declined by an average of 9 per cent per year over the last five years, accounting for just 13 per cent of the service volume for item 30323 in FY2014/15; the more expensive item (30203), meanwhile, has been growing modestly by 1.5 per cent year on year for the last five years.[2]
  • ΔThere is overlap between items 30324 and 36500, which creates confusion for providers and leads to inconsistent billing and treatment of patients. The Committee agreed that item 30324 aligns with best practice, and that consolidating item 36500 under item 30324 would encourage best-practice patient care and have a minimal impact on access. The Committee noted that item 36500 allows for the removal of normal adrenal glands and suggested that there should be no additional rebate for removing normal adrenal tissue when performed as part of nephrectomy. Only 56 procedures were performed under item 36500 in FY2014/15.

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8 Services of proven efficacy reflecting current best medical practice, or for which the potential benefit to consumers exceeds the risk and costs.


5.6 Administration of thyrotropin alfa-rch: Item 12201

Table 9: Item introduction table for item 12201

Item Descriptor
[date last amended]
Schedule fee Services FY2014/15 Benefits FY2014/15 Services 5 year annual avg. growth

12201

Administration, by a specialist or consultant physician in the practice of his or her specialty, of thyrotropin alfa-rch (recombinant human thyroid-stimulating hormone), and arranging services to which both items 61426 and 66650 apply, for the detection of recurrent well-differentiated thyroid cancer in a patient if: (a) the patient has had a total thyroidectomy and 1 ablative dose of radioactive iodine; and (b) the patient is maintained on thyroid hormone therapy; and (c) the patient is at risk of recurrence; and (d) on at least 1 previous whole body scan or serum thyroglobulin test when withdrawn from thyroid hormone therapy, the patient did not have evidence of well-differentiated thyroid cancer; and (e) either: (i) withdrawal from thyroid hormone therapy resulted in severe psychiatric disturbances when hypothyroid; or (ii) withdrawal is medically contra-indicated because the patient has: (a) unstable coronary artery disease; or (b) hypopituitarism; or (c) a high risk of relapse or exacerbation of a previous severe psychiatric illness—applicable once only in a 12 month period. [2004]

$2,392.90

184

$427, 895

2.2%


Recommendation 9
  • ΔChange the item descriptor to make the nuclear scan (item 61426) optional, rather than obligatory. The proposed wording change is provided below, highlighted in italics.
    • – Administration, by a specialist or consultant physician in the practice of his or her specialty, of thyrotropin alfa-rch (recombinant human thyroid-stimulating hormone), and arranging diagnostic imaging as necessary and pathology services under item 66650.
  • ΔIt should be noted that the Committee is proposing the creation of new items that may be used instead of item 66650, which may make it necessary to amend the numbering of this item if adopted.
  • ΔThe Committee also wishes to refer this item to the Nuclear Medicine Working Group to review whether other indications in the item descriptor should be removed.

Rationale

The recommendations focus on encouraging best practice and are based on the following observations.

  • ΔThe Committee agreed that the associated nuclear scan (item 61426) is not always clinically required and should be optional, rather than a mandatory component of the service. This is in line with Recommendations 66 and 67 of the 2015 American Thyroid Association’s Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer.[7]
  • ΔPathology quantitation (item 66650) or the equivalent is necessary and its requirement should remain.[7]
  • ΔThe cost of the drug should continue to be included. Although it accounts for the large majority of the schedule fee ($1,802.17), the drug is used as part of a diagnostic test and cannot be included on the PBS, as per PBS rules.
  • ΔThe Committee noted that although the item should have restrictions to ensure that only the appropriate patients receive services under this item, the current indications could be reduced to allow access to a wider patient group. This decision would require an extensive review of the existing guidelines, literature and data, including an appropriate cost–benefit analysis of the outcomes. The Committee noted that the Nuclear Medicine Working Group may wish to review this item, and that a process should perhaps be created to conduct such a review, if the working group agrees it is necessary.

5.7 Broader issues

During the review of the thyroid and parathyroid-related surgical items, the Committee noted that a large number of surgeons perform relatively few thyroid and parathyroid surgical procedures each year, according to MBS data. In FY2014/15, for example, 56 per cent of the 455 thyroid and parathyroid surgical providers performed five or fewer MBS-funded procedures.[18] In light of evidence from the international literature, which suggests that volume is correlated with outcomes, the Committee created a working group to explore this further.

Based on the findings of this working group, the Committee concluded that this data is incomplete, and that it can only serve as a rough proxy for service volumes as it does not include procedures conducted on public patients in the public hospital system, where many surgeons also practise. The Committee also emphasised that low volumes are to be expected in the Australian setting, where many regionally-based surgeons provide patients with access to a broad range of high-quality local services. Many of their most qualified colleagues who practise in regional and remote areas perform a relatively low number of thyroid and parathyroid surgical procedures each year without any known adverse impact on patient outcomes. Furthermore, although certain literature does indicate that volumes are correlated with outcomes, particularly for higher complexity procedures,[19]–[24] this evidence is not universal for all surgical procedures. There is also no local evidence that patients in regional Australia who undergo surgery performed by surgeons with lower annual volumes have poorer outcomes.

Nonetheless, the Committee agreed that this data is important and should be supplied to the Royal Australasian College of Surgeons and relevant hospitals that are responsible for the development of professional standards and credentialing of individual surgeons. The Committee also noted that all surgeons, regardless of location, should recognise the circumstances when referral to a colleague with greater skills is warranted. It also noted that consumers should be advised of the importance of asking their surgeons about their experience and surgical outcomes, particularly complication rates, to assist them in making informed decisions about their planned surgery.



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