Diagnosis and Management of Primary Hyperparathyroidism Across the Veterans Affairs Health Care System

Abstract

IMPORTANCE Untreated primary hyperparathyroidism impairs quality of life and incurs substantial costs. Parathyroidectomy is a low-risk, high-success, definitive intervention.OBJECTIVES To determine the appropriateness of diagnostic evaluation for primary hyperparathyroidism in patients with hypercalcemia and the use of parathyroidectomy for the treatment of primary hyperparathyroidism across the Veterans Affairs (VA) health care system. DESIGN, SETTING, AND PARTICIPANTSA retrospective cohort study of veterans with hypercalcemia and primary hyperparathyroidism was conducted from January 1, 2000, through September 30, 2015, using the VA Corporate Data Warehouse, a national electronic health record-based repository. The study included 371 370 veterans with chronic hypercalcemia and 47 158 veterans with biochemical evidence of primary hyperparathyroidism diagnosed by hypercalcemia, elevated serum parathyroid hormone levels, and near-normal serum creatinine levels. Statistical analysis was performed from April 21, 2017, to April 10, 2019. MAIN OUTCOMES AND MEASURESThe proportion of veterans with hypercalcemia who have parathyroid hormone levels evaluated, the proportion of veterans with hyperparathyroidism who are treated surgically, and the factors associated with parathyroidectomy using generalized linear latent and mixed model regression. RESULTSOf 371 370 patients with chronic hypercalcemia, 86 887 (23.4%) received further testing with parathyroid hormone level. Of 47 158 patients meeting diagnostic criteria for primary hyperparathyroidism (42 737 men [90.6%] and 4421 women [9.4%]; mean [SD] age, 67.3 [11.8] years), 6048 (12.8%) underwent parathyroidectomy. Of 5793 patients with primary hyperparathyroidism presenting with a serum calcium level more than 1 mg/dL above the upper limit of normal, 1501 (25.9%) underwent parathyroidectomy. There was a decreasing trend in the use of parathyroidectomy over time. Factors positively associated with parathyroidectomy were nephrolithiasis (odds ratio [OR], 2.23; 95% CI, 1.90-2.61) and non-Hispanic white race/ethnicity (OR, 1.31; 95% CI, 1.17-1.46), while age (OR, 0.95; 95% CI, 0.95-0.96), Elixhauser Comorbidity Index score (OR, 0.76; 95% CI, 0.72-0.80), decreased estimated glomerular filtration rate (OR, 0.52; 95% CI, 0.45-0.60), and diagnosis of osteoporosis (OR, 0.65; 95% CI, 0.52-0.80) were inversely related to surgery.CONCLUSIONS AND RELEVANCE From this study's findings, parathyroid hormone level is infrequently tested in patients with hypercalcemia, suggesting underdiagnosis of primary hyperparathyroidism. Patients meeting diagnostic criteria for primary hyperparathyroidism are undertreated with recommended parathyroidectomy. Similar gaps have previously been observed in non-VA care of primary hyperparathyroidism, suggesting the need for a systematic evaluation of barriers to diagnosis and treatment that informs intervention design.

Investigating the potential underdiagnosis of primary hyperparathyroidism at the University of Arkansas for Medical Sciences

“…Since surgical treatment remains the only treatment for severe/late‐stage PHPT, earlier detection of this condition may allow an opportunity for management of the disease through lifestyle changes and medical means. Some tertiary centers in the United States have published data suggesting large‐scale underdiagnosis of PHPT at their institutions 8‐10 . This research manuscript discusses trends in the diagnosis of PHPT at the University of Arkansas for Medical Sciences (UAMS).…”

A Case Report: Recurrent Hyperparathyroidism After Parathyroidectomy in a Primary Hyperparathyroidism Patient with Chronic Kidney Disease

“…Parathyroidectomy (PTX) is the definitive treatment of PHPT for symptomatic patients [3]. Accumulating evidence show the benefits of PTX, including decreased progression of kidney disease and excellent long-term outcomes [3,4].…”

“…Parathyroidectomy (PTX) is the definitive treatment of PHPT for symptomatic patients [3]. Accumulating evidence show the benefits of PTX, including decreased progression of kidney disease and excellent long-term outcomes [3,4]. According to the current guidelines, PTX is suggested in all symptomatic patients [5], and it is suggested to be more cost-effective than observation or pharmacologic therapy, even when the patient is considered asymptomatic [6].…”

Frequency of Parathyroid Hormone Assessment in the Evaluation of Hypercalcemia. A Comparison Between Patients With and Without a History of Malignancy in a 20-year Dataset of 20,954 Patients

“…Despite a simple means with which to diagnose primary hyperparathyroidism, for various reasons, this is a diagnosis that is often overlooked by lack of and/or incorrect interpretation of biochemical testing. [12][13][14][15][16][17] Multiple studies have shown that only approximately 30% of patients with documented hypercalcemia have ever had a PTH level assessed. [12][13][14][15][16][17] However, the frequency range at different facilities described in a single study varied widely from as low as 4% to as high as 57%.…”

“…[12][13][14][15][16][17] Multiple studies have shown that only approximately 30% of patients with documented hypercalcemia have ever had a PTH level assessed. [12][13][14][15][16][17] However, the frequency range at different facilities described in a single study varied widely from as low as 4% to as high as 57%. 16 Hypercalcemia of malignancy (HCM) is an important complication of malignancy, most often seen in advanced stages of the clinical course of a patient.…”