Surgery for Primary Hyperparathyroidism

Kuo, Eric J.; Al-Alusi, Mostafa A; Du, Lin; Shieh, Albert; Livhits, Masha J.; Leung, Angela M.; Yeh, Michael W.

doi:10.1097/sla.0000000000002474

Cited by 33 publications

(19 citation statements)

References 21 publications

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“…Infrequent use of surgery and poor adherence to management guidelines for PHPT have also been documented in smaller regional, single-center, and Veterans Affairs studies. 9,11,12 This study confirms that poor adherence to guidelines is national in scope, preferentially affecting older adults. Prior studies have documented that age and comorbidity are inversely associated with surgical management of PHPT, 11,12 but our finding that older age remains strongly and independently associated with nonoperative management after accounting for patient frailty in a large, insured patient population suggests that we are not using parathyroidectomy appropriately to prevent morbidity in older adults who are likely to benefit.…”

Section: Discussionsupporting

confidence: 74%

“…9,10 Older adults have a higher absolute risk of morbidity from fractures, nephrolithiasis, and CKD, which suggests they have the greatest potential to benefit from parathyroidectomy in the management of PHPT. However, small studies 11,12 suggest that increasing age is independently associated with delays in surgical referral and decreased likelihood of parathyroidectomy, regardless of the severity of disease or whether consensus guideline criteria are met. Multimorbidity further reduces the odds of surgical management, suggesting nonoperative management is favored owing to concern that the operative risk of older patients with comorbid conditions outweighs any potential benefit.…”

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confidence: 99%

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Patient Factors Associated With Parathyroidectomy in Older Adults With Primary Hyperparathyroidism

et al. 2021

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IMPORTANCE Parathyroidectomy provides definitive management for primary hyperparathyroidism (PHPT), reducing the risk of subsequent fracture, nephrolithiasis, and chronic kidney disease (CKD), but its use among older adults in the US is unknown.OBJECTIVE To identify patient characteristics associated with the use of parathyroidectomy for the management of PHPT in older adults. DESIGN, SETTING, AND PARTICIPANTSThis population-based, retrospective cohort study used 100% Medicare claims from beneficiaries with an initial diagnosis of PHPT from January 1, 2006, to December 31, 2016. Patients were considered to meet consensus guideline criteria for parathyroidectomy based on diagnosis codes indicating osteoporosis, nephrolithiasis, or stage 3 CKD. Multivariable logistic regression was used to identify patient characteristics associated with parathyroidectomy. Data were analyzed from February 11, 2020, to October 8, 2020. MAIN OUTCOMES AND MEASURESThe primary outcome was parathyroidectomy within 1 year of diagnosis. RESULTS Among 210 206 beneficiaries with an incident diagnosis of PHPT (78.8% women; mean [SD] age, 75.3 [6.8] years), 63 136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis. Among the subset of patients who met consensus guideline criteria for operative management (n = 131 723), 38 983 (29.6%) were treated with parathyroidectomy. Patients treated operatively were younger (mean [SD] age, 73.5 [5.7] vs 76.0 [7.1] years) and more likely to be White (90.1% vs 86.0%), to be robust or prefrail (92.1% vs 85.7%), and to have fewer comorbidities (Charlson Comorbidity Index score of 0 or 1, 54.6% vs 44.1%), in addition to being more likely to live in socioeconomically disadvantaged (46.9% vs 40.3%) and rural (18.1% vs 13.6%) areas (all P < .001). On multivariable analysis, increasing age had a strong inverse association with parathyroidectomy among patients aged 76 to 85 years (unadjusted rate, 25.9%; odds ratio [OR], 0.68 [95% CI, 0.67-0.70]) and older than 85 years (unadjusted rate, 11.2%; OR, 0.27 [95% CI, 0.26-0.29]) compared with those aged 66 to 75 years (unadjusted rate, 35.6%), as did patients with moderate to severe frailty (unadjusted rate, 18.9%; OR, 0.60 [95% CI, 0.56-0.64]) compared with robust patients (unadjusted rate, 36.1%) and those with a Charlson Comorbidity Index score of 2 or greater (unadjusted rate, 25.9%; OR, 0.77 [95% CI, 0.75-0.79]) compared with a Charlson Comorbidity Index score of 0 (unadjusted rate, 37.0%). With regard to operative guidelines, a history of nephrolithiasis increased the odds of parathyroidectomy (OR, 1.43 [95% CI,); stage 3 CKD decreased the odds of parathyroidectomy (OR, 0.71 [95% CI, 0.68-0.74]); and osteoporosis showed no association (OR, 1.01 [95% CI, 0.99-1.03]). CONCLUSIONS AND RELEVANCEIn this cohort study, most older adults with PHPT did not receive definitive treatment with parathyroidectomy. Older age, frailty, and multimorbidity were associated with nonoperative management, and guideline recommendations had minimal effect on treatment decisions...

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Section: Discussionsupporting

confidence: 74%

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confidence: 99%

Patient Factors Associated With Parathyroidectomy in Older Adults With Primary Hyperparathyroidism

et al. 2021

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“…2 Neither is this gap a VHA-specific issue, given that a similar underdiagnosis rate has been documented in non-VHA tertiary academic centers and other large systems. 6 The study by Ganesan and colleagues 4 offers some clues that may help remedy the problem. PTH testing was 2-fold to 5-fold higher among those who had appointments with specialists such as nephrologists, urologists, and endocrinologists.…”

Section: Invited Commentarymentioning

confidence: 99%

Underdiagnosis of Primary Hyperparathyroidism—The Need for a System-Level Fix

2020

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“…4 However, the adherence to these practice recommendations on the management and preoperative workup of patients with pHPT is low. [5][6][7] Less than 50% of patients who fulfil the criteria for surgery receive parathyroidectomy, and less than 70% of patients have adequate preoperative imaging studies. 5,6 Because of this nonadherence, the treatment of pHPT may benefit from quality indicator (QI) development.…”

mentioning

confidence: 99%

“…[5][6][7] Less than 50% of patients who fulfil the criteria for surgery receive parathyroidectomy, and less than 70% of patients have adequate preoperative imaging studies. 5,6 Because of this nonadherence, the treatment of pHPT may benefit from quality indicator (QI) development. These QIs can help physicians identify gaps in quality, thereby sparking quality-improvement initiatives to improve care delivery for optimal outcomes.…”

mentioning

confidence: 99%

Quality Indicators for the Diagnosis and Management of Primary Hyperparathyroidism

Noltes

Cottrell

Madani

et al. 2022

JAMA Otolaryngol Head Neck Surg

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IMPORTANCE Primary hyperparathyroidism (pHPT) is a common endocrine disorder with many diagnostic and treatment challenges. Despite high-quality guidelines, care is variable, and there is low adherence to evidence-based treatment pathways.OBJECTIVE To develop quality indicators (QIs) to evaluate the diagnosis and treatment of pHPT that could measure, improve, and optimize quality of care and outcomes for patients with this disease. DESIGN, SETTING, AND PARTICIPANTSThis quality improvement study used a guideline-based approach to develop QIs that were ranked by a Canadian 9-member expert panel of 3 endocrinologists, 3 otolaryngologists, and 3 endocrine surgeons. Data were analyzed between September 2020 and May 2021.MAIN OUTCOMES AND MEASURES Candidate indicators (CIs) were extracted from published primary hyperparathyroidism guidelines and summarized with supporting evidence. The 9-member expert panel rated each CI on the validity, reliability, and feasibility of measurement. Final QIs were selected from CIs using the modified RAND-University of California, Los Angeles appropriateness methodology. All panelists were then asked to rank the top 5 QIs for primary, endocrine, and surgical care.RESULTS Forty QIs were identified and evaluated by the expert panel. After 2 rounds of evaluations and discussion, a total of 18 QIs were selected as appropriate measures of high-quality care. The top 5 QIs for primary, endocrine, and surgical care were selected following panelist rankings. CONCLUSIONS AND RELEVANCEThis quality improvement study proposes 18 QIs for the diagnosis and management of pHPT. Furthermore, the top 5 QIs applicable to physicians commonly treating pHPT, including general physicians, internists, endocrinologists, otolaryngologists, and surgeons, are included. These QIs not only assess the quality of care to guide the process of improvement, but also can assess the implementation of evidence-based guideline recommendations. Using these indicators in clinical practice and health system registries can improve quality and cost-effectiveness of care for patients with pHPT.

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Surgery for Primary Hyperparathyroidism

Abstract: Within an academic health system, consensus guidelines do appear to influence the decision for surgery in patients with PHPT. However, the level of compliance is generally low, and similar to that observed in community practice.

Cited by 33 publications

References 21 publications

Patient Factors Associated With Parathyroidectomy in Older Adults With Primary Hyperparathyroidism

Patient Factors Associated With Parathyroidectomy in Older Adults With Primary Hyperparathyroidism

Underdiagnosis of Primary Hyperparathyroidism—The Need for a System-Level Fix

Quality Indicators for the Diagnosis and Management of Primary Hyperparathyroidism

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