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Patients after thyroid cancer surgery face multiple challenges, including recurrence monitoring, medication adjustment, complication management (e.g., hypoparathyroidism, vocal cord dysfunction), and long-term psychosocial adaptation. Studies confirm that standardized long-term follow-up can raise 5-year survival rates to over 90% and significantly reduce disability and mortality in patients with thyroid dysfunction.
Despite the recognized importance of follow-up, conventional practice has major limitations. The traditional model relies on passive patient return visits, either when symptoms appear or at fixed intervals. Adherence is influenced by patients' health awareness, education, geographic distance, finances, and work obligations. Consequently, loss to follow-up and delayed follow-up are common. Clinical data from China show that follow-up adherence drops from less than 60% at one year post-surgery to below 40% at three years. Many patients experience disease progression or treatment delays, increasing their physical and psychological burden, as well as healthcare costs. Physicians face high clinic workloads, fragmented patient information, and difficulty tracking long-term outcomes. Furthermore, conventional follow-up lacks personalized plans-timing, content, and methods are uniform, making it difficult to meet diverse patient needs. Poor communication and delayed information transfer further undermine follow-up quality.
In response, a patient-centered, proactive, structured, and full-cycle health management approach has become a new direction for chronic cancer care. Our hospital has introduced the "Follow-up Package (Proactive Postoperative Follow-up Program)," an innovative model that integrates several scheduled in-person specialty visits, interdisciplinary referral resources, convenient online consultation channels, and an AI-based automated reminder system into an annual service. This proactive model shifts from "passive patient return" to "active hospital-led management." It clarifies follow-up timelines, diversifies service formats, strengthens doctor-patient communication, and creates a seamless, responsive management loop.
For patients, this approach offers clearer management pathways, stronger support, and improved access to care. For the healthcare system, it enables more efficient disease management through optimized resource allocation and early detection of problems. By transforming follow-up from a passive, episodic task into an active, continuous partnership, the program addresses the key shortcomings of conventional models-low adherence, lack of personalization, and poor communication-and holds promise for better clinical outcomes and more sustainable use of medical resources.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Structured Active Follow-up Group | Experimental |
| |
| Conventional Passive Follow-up Group | No Intervention |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Structured Active Follow-up | Behavioral | Proactive Postoperative Follow-up Program (including scheduled in-person clinic visits, interdisciplinary referrals, online consultation channels, and AI-based automated reminders) |
| Measure | Description | Time Frame |
|---|---|---|
| Completion Rate of Scheduled In-Person Clinic Visits | Compare the proportion of scheduled in-person clinic visits completed within the predefined follow-up time windows (postoperative month 1 ± 7 days, month 3 ± 14 days, month 6 ± 14 days, month 12 ± 30 days) during the first year after surgery between the two groups. Additionally, calculate separately the proportion of patients in each group who completed the in-person clinic visit within each predefined follow-up time window. | 1 month postoperatively;3 months postoperatively;6 months postoperatively;12 months postoperatively |
| Measure | Description | Time Frame |
|---|---|---|
| TSH suppression target achievement rate | Proportion of patients who achieve the TSH suppression goal within the specified measurement time points. | 1 month postoperatively; 3 months postoperatively; 6 months postoperatively; 12 months postoperatively |
| Median time to TSH suppression target achievement |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Yu Feng | Contact | 15183042703 | 1350502131@qq.com |
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| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| West China hospital of Sichuan University | Recruiting | Chengdu | Sichuan | 610041 | China |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 38935379 | Result | Graetz I, Hu X, Kocak M, Krukowski RA, Anderson JN, Waters TM, Curry AN, Robles A, Paladino A, Stepanski E, Vidal GA, Schwartzberg LS. Remote Monitoring App for Endocrine Therapy Adherence Among Patients With Early-Stage Breast Cancer: A Randomized Clinical Trial. JAMA Netw Open. 2024 Jun 3;7(6):e2417873. doi: 10.1001/jamanetworkopen.2024.17873. | |
| 39881145 |
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The median time to achieve the TSH suppression goal within the specified measurement time points. |
| 1 month postoperatively; 3 months postoperatively; 6 months postoperatively; 12 months postoperatively |
| Patient Medication Adherence Score | The Morisky Medication Adherence Scale (MMAS-8) is an internationally recognized, standardized self-reported tool for measuring long-term medication adherence in patients with chronic diseases. It was revised and developed in 2008 by American scholar Donald E. Morisky and his team based on their earlier 4-item questionnaire (MMAS-4). The original intention of its design was to more comprehensively and sensitively capture the multidimensional reasons for poor adherence, including forgetfulness, negligence, dose reduction or discontinuation after symptom improvement, and discontinuation due to side effects or perceived worsening of the condition. The scale was initially developed specifically for chronic diseases requiring long-term medication, such as hypertension, and has since been validated for use in various chronic conditions, including thyroid diseases, diabetes, cardiovascular diseases, HIV/AIDS, and others. The MMAS-8 consists of 8 questions: the first 7 are dichotomous (yes/no | 1 month postoperatively; 3 months postoperatively; 6 months postoperatively; 12 months postoperatively |
| Patient Satisfaction Score | Assessed using the Client Satisfaction Questionnaire (CSQ-8). This satisfaction score is assessed only for patients in the intervention group, to understand their level of satisfaction with the active follow-up intervention. | 1 month postoperatively; 3 months postoperatively; 6 months postoperatively; 12 months postoperatively |
| Completion rate and accuracy rate of key examinations | Whether the thyroid function tests, serum calcium, parathyroid hormone (PTH) tests, and thyroid ultrasound recommended by clinical guidelines and/or the medical team were completed at the time of postoperative outpatient follow-up visits (yes/no), as well as the proportion of missed or unnecessary (excessive) examinations. | 1 month postoperatively; 3 months postoperatively; 6 months postoperatively; 12 months postoperatively |
| Questionnaire completion rate | The proportion of questionnaires completed by patients in both groups at each time point and within one year after surgery. | 1 month postoperatively; 3 months postoperatively; 6 months postoperatively; 12 months postoperatively |
| Timely management rate of post-discharge complications | The time to management of thyroid surgery-related complications occurring after hospital discharge will be collected, and the rate of timely management of complications will be compared between the two groups. | 1 month postoperatively; 3 months postoperatively; 6 months postoperatively; 12 months postoperatively |
| Oncological safety | The proportion of patients in both groups who develop recurrence or distant metastasis during the follow-up period will be collected. | 1 month postoperatively; 3 months postoperatively; 6 months postoperatively; 12 months postoperatively |
| Javidi S, Sadrizadeh S, Sadrizadeh A, Bonakdaran S, Jarahi L. Postoperative complications and long-term outcomes after total and subtotal thyroidectomy: a retrospective study. Sci Rep. 2025 Jan 29;15(1):3705. doi: 10.1038/s41598-024-79860-8. |
| 29509871 | Result | Durante C, Grani G, Lamartina L, Filetti S, Mandel SJ, Cooper DS. The Diagnosis and Management of Thyroid Nodules: A Review. JAMA. 2018 Mar 6;319(9):914-924. doi: 10.1001/jama.2018.0898. |