Undertreatment of primary hyperparathyroidism in a privately insured US population: Decreasing utilization of parathyroidectomy despite expanding surgical guidelines

Seib, Carolyn D.; Meng, Tong; Suh, Insoo; Cisco, Robin M.; Lin, Dana T.; Morris, Arden M.; Trickey, Amber W.; Kebebew, Electron

doi:10.1016/j.surg.2020.04.066

Cited by 25 publications

(19 citation statements)

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“…Evidence-based criteria for the operative management of PHPT have expanded significantly since the first consensus guidelines were published in 1991 . However, despite more inclusive surgical guidelines and evidence that operative cure results in benefits across multiple dimensions, including a reduced risk of fractures and symptomatic nephrolithiasis and improved quality of life, rates of parathyroidectomy for the management of PHPT are low and have been declining over time …”

Section: Introductionmentioning

confidence: 99%

“…7 However, despite more inclusive surgical guidelines and evidence that operative cure results in benefits across multiple dimensions, including a reduced risk of fractures 2 and symptomatic nephrolithiasis 3 and improved quality of life, 5,8 rates of parathyroidectomy for the management of PHPT are low and have been declining over time. 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.…”

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confidence: 99%

“…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. 10 However, no population-based, national data are available that describe the management of PHPT among older adults in the US, limiting our ability to identify barriers to definitive treatment.…”

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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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Patient Factors Associated With Parathyroidectomy in Older Adults With Primary Hyperparathyroidism

et al. 2021

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“…Two separate studies found the rate of parathyroidectomy in patients aged 65 years and over who meet criteria for surgery is only around 30%, regardless of whether they have Medicare 45 or private insurance. 46 Sieb et al looked at 210,206 Medicare beneficiaries with PHPT and found that increasing patient age (particularly over 75 years), comorbidities, and frailty score were associated with lower use of parathyroidectomy, despite multi-disciplinary guidelines recommending its use. 45 Further studies are needed to address the underutilization of parathyroidectomy in the geriatric population and provide more specific guidelines for surgery in this patient group.…”

Section: Special Patient Populationsmentioning

confidence: 99%

Advances in the diagnosis and the management of primary hyperparathyroidism

Islam

2021

Therapeutic Advances in Chronic Disease

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The parathyroid glands, one of the last organs to be discovered, are responsible for maintaining calcium homeostasis, and they continue to present the clinician with diagnostic and management challenges that are reviewed herein. Primary hyperparathyroidism (PHPT) comprises the vast majority of pathology of the parathyroid glands. The classic variant, presenting with elevated calcium and parathyroid hormone levels, has been studied extensively, but the current body of literature has added to our understanding of normocalcemic and normohormonal variants of PHPT, as well as syndromic forms of PHPT. All variants can lead to bone loss, kidney stones, declining renal function, and a variety of neurocognitive, gastrointestinal, and musculoskeletal complaints, although the majority of PHPT today is asymptomatic. Surgery remains the definitive treatment for PHPT, and advances in screening, evolving indications for surgery, new imaging modalities, and improvements in intra-operative methods have greatly changed the landscape. Surgery continues to produce excellent results in the hands of an experienced parathyroid surgeon. For those patients who are not candidates for surgery, therapeutic advances in medical management allow for improved control of the hypercalcemic state. Parathyroid cancer is extremely rare; the diagnosis is often made intra-operatively or on final pathology, and recurrence is common. The mainstay of treatment is normalization of serum calcium via surgery and medical adjuncts.

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“…Evidence-based consensus guidelines for the operative management of PHPT have become broader over time, recommending parathyroidectomy for an expanding number of patients with PHPT. 3 However, recent studies have found decreasing national rates of parathyroidectomy among patients with PHPT who are Medicare beneficiaries 4 or privately insured, 5 as well as those receiving care within the Veterans Affairs Health Care System. 6 Race and socioeconomic status (SES) play very importantdbut often overlookeddroles in today's healthcare system.…”

Section: Introductionmentioning

confidence: 99%

Racial disparities in the utilization of parathyroidectomy among patients with primary hyperparathyroidism: Evidence from a nationwide analysis of Medicare claims

Alobuia

Meng

Cisco

et al. 2022

Surgery

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Undertreatment of primary hyperparathyroidism in a privately insured US population: Decreasing utilization of parathyroidectomy despite expanding surgical guidelines

Cited by 25 publications

References 24 publications

Patient Factors Associated With Parathyroidectomy in Older Adults With Primary Hyperparathyroidism

Patient Factors Associated With Parathyroidectomy in Older Adults With Primary Hyperparathyroidism

Advances in the diagnosis and the management of primary hyperparathyroidism

Racial disparities in the utilization of parathyroidectomy among patients with primary hyperparathyroidism: Evidence from a nationwide analysis of Medicare claims

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