In the Journals

Hyperparathyroidism identification lacking, surgical solutions infrequently utilized

Roughly one-quarter of adults with features of primary hyperparathyroidism are actually diagnosed with the condition, and this may be part of the reason parathyroidectomy is not performed regularly as a surgical solution, according to findings published in JAMA Internal Medicine.

“The most recent management guidelines released by the American Association of Endocrine Surgeons suggest that parathyroidectomy should be considered in patients with mild, nonclassic symptoms, if surgical risk is not prohibitive,” Konstantinos I. Makris, MD, assistant professor of surgery in the division of general surgery at Baylor College of Medicine and the director of the Endocrine Surgery Program at the Michael E. DeBakey VA Medical Center in Houston, and colleagues wrote. “Single institution and regional studies have shown that surgery is underutilized for [primary hyperparathyroidism] across various practice settings. The fragmented nature of health care in the United States may be partly accountable.”

Makris and colleagues studied electronic health records from 47,158 adults with hypercalcemia and “hormonal evidence of [primary hyperparathyroidism]” within the Veterans Affairs Corporate Data Warehouse. Using data from January 2000 to September 2015, the researchers recorded how often parathyroid hormone levels were measured, how many parathyroidectomies were performed, and the presence of symptomatic (nephrolithiasis, pathologic fractures) and asymptomatic features (age younger than 50 years; a measure > 1 mg/dL above normal for serum calcium, < 60 mL/min/1.73 m2 in estimated glomerular filtration rate or > 400 mg in 24-hour urine calcium level; and osteoporosis diagnosis) of primary hyperparathyroidism.

Parathyroidectomy prevalence

According to the researchers, parathyroid hormone levels were assessed in 23.4% (n = 86,887) of those with hypercalcemia in the database (n = 371,370), and parathyroidectomy was performed in 12.8% (n = 6,048) of those who were either formally diagnosed with hyperparathyroidism based on diagnostic codes (n = 1,577; 26.1%) or presented with elevated measures of both parathyroid hormone and calcium (n = 4,471; 73.9%).

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Roughly one-quarter of adults with features of primary hyperparathyroidism are actually diagnosed with the condition, and this may be part of the reason parathyroidectomy is not performed regularly as a surgical solution.
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“It is inconceivable to us that surgeons would perform parathyroidectomies on 6,048 patients with only 26.1% of them having a diagnosis of [primary hyperparathyroidism] (as reflected in the ICD-9 codes),” Kelly Wentworth, MD, and Dolores Shoback, MD, both from the division of endocrinology and metabolism in the department of medicine at the University of California, San Francisco, wrote in a commentary that accompanied the study. “These data must be viewed with skepticism.”

Parathyroidectomy was conducted in 67.7% of those with a 24-hour urinary calcium measure of more than 400 mg, in 25.6% of those who were younger than 50 years and in 25.9% of those whose serum calcium reached more than 1 mg/dL above normal, according to the researchers. Twenty-three percent of those with nephrolithiasis and 5.9% of those with pathologic fractures underwent surgery. Individuals with nephrolithiasis were more than twice as likely to undergo parathyroidectomy than those without the condition (OR = 2.23; 95% CI, 1.9-2.61). The likelihood was also doubled for those with higher measures of 24-hour urinary calcium vs. those with lower measures (OR = 2.22; 95% CI, 1.4-3.51). Non-Hispanic white participants were also more likely to have parathyroidectomy than other ethnicities (OR = 1.31; 95% CI, 1.17-1.46), although the researchers reported that this was statistically significant only before sensitivity analysis.

The odds that an individual would receive parathyroidectomy were reduced by 35% if they had osteoporosis (OR = 0.65; 95% CI, 0.52-0.8) and by 48% if they had an eGFR of less than 60 mL/min/1.73 m2 (OR = 0.52; 95% CI, 0.45-0.6) compared with those without these conditions, according to the researchers, noting that there were negative associations between parathyroidectomy incidence and measures of serum creatinine (OR = 0.5; 95% CI, 0.42-0.59) and scores on the Elixhauser comorbidity index (OR = 0.76; 95% CI, 0.72-0.8).

Finding answers

“Our study provides foundational data to guide improvements and underscores the need for practice changes to close these care gaps,” the researchers wrote. “Systematic evaluation of barriers to diagnosis and treatment is needed to design targeted interventions, including the use of health informatics tools and strategies to improve recognition and treatment.”

The researchers noted that there are several technologic solutions that could be developed in this context, including diagnostic algorithms and electronic clinical surveillance.

“We agree with the study investigators’ conclusions that this problem would benefit from the development of computer-based algorithms and the use of artificial intelligence to support clinicians, so that indicated diagnostic testing and risk stratification are performed and management guidelines are heeded,” Wentworth and Shoback wrote, adding that tools such as DXA, parathyroid ultrasonography, sestamibi scanning and 4D CT could all be utilized as well. – by Phil Neuffer

Disclosures: Makris reports he has received grants from Baylor College of Medicine Department of Surgery and nonfinancial support from the Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center. Please see the study for all other authors’ relevant financial disclosures.

Roughly one-quarter of adults with features of primary hyperparathyroidism are actually diagnosed with the condition, and this may be part of the reason parathyroidectomy is not performed regularly as a surgical solution, according to findings published in JAMA Internal Medicine.

“The most recent management guidelines released by the American Association of Endocrine Surgeons suggest that parathyroidectomy should be considered in patients with mild, nonclassic symptoms, if surgical risk is not prohibitive,” Konstantinos I. Makris, MD, assistant professor of surgery in the division of general surgery at Baylor College of Medicine and the director of the Endocrine Surgery Program at the Michael E. DeBakey VA Medical Center in Houston, and colleagues wrote. “Single institution and regional studies have shown that surgery is underutilized for [primary hyperparathyroidism] across various practice settings. The fragmented nature of health care in the United States may be partly accountable.”

Makris and colleagues studied electronic health records from 47,158 adults with hypercalcemia and “hormonal evidence of [primary hyperparathyroidism]” within the Veterans Affairs Corporate Data Warehouse. Using data from January 2000 to September 2015, the researchers recorded how often parathyroid hormone levels were measured, how many parathyroidectomies were performed, and the presence of symptomatic (nephrolithiasis, pathologic fractures) and asymptomatic features (age younger than 50 years; a measure > 1 mg/dL above normal for serum calcium, < 60 mL/min/1.73 m2 in estimated glomerular filtration rate or > 400 mg in 24-hour urine calcium level; and osteoporosis diagnosis) of primary hyperparathyroidism.

Parathyroidectomy prevalence

According to the researchers, parathyroid hormone levels were assessed in 23.4% (n = 86,887) of those with hypercalcemia in the database (n = 371,370), and parathyroidectomy was performed in 12.8% (n = 6,048) of those who were either formally diagnosed with hyperparathyroidism based on diagnostic codes (n = 1,577; 26.1%) or presented with elevated measures of both parathyroid hormone and calcium (n = 4,471; 73.9%).

#
Roughly one-quarter of adults with features of primary hyperparathyroidism are actually diagnosed with the condition, and this may be part of the reason parathyroidectomy is not performed regularly as a surgical solution.
Adobe Stock

“It is inconceivable to us that surgeons would perform parathyroidectomies on 6,048 patients with only 26.1% of them having a diagnosis of [primary hyperparathyroidism] (as reflected in the ICD-9 codes),” Kelly Wentworth, MD, and Dolores Shoback, MD, both from the division of endocrinology and metabolism in the department of medicine at the University of California, San Francisco, wrote in a commentary that accompanied the study. “These data must be viewed with skepticism.”

Parathyroidectomy was conducted in 67.7% of those with a 24-hour urinary calcium measure of more than 400 mg, in 25.6% of those who were younger than 50 years and in 25.9% of those whose serum calcium reached more than 1 mg/dL above normal, according to the researchers. Twenty-three percent of those with nephrolithiasis and 5.9% of those with pathologic fractures underwent surgery. Individuals with nephrolithiasis were more than twice as likely to undergo parathyroidectomy than those without the condition (OR = 2.23; 95% CI, 1.9-2.61). The likelihood was also doubled for those with higher measures of 24-hour urinary calcium vs. those with lower measures (OR = 2.22; 95% CI, 1.4-3.51). Non-Hispanic white participants were also more likely to have parathyroidectomy than other ethnicities (OR = 1.31; 95% CI, 1.17-1.46), although the researchers reported that this was statistically significant only before sensitivity analysis.

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The odds that an individual would receive parathyroidectomy were reduced by 35% if they had osteoporosis (OR = 0.65; 95% CI, 0.52-0.8) and by 48% if they had an eGFR of less than 60 mL/min/1.73 m2 (OR = 0.52; 95% CI, 0.45-0.6) compared with those without these conditions, according to the researchers, noting that there were negative associations between parathyroidectomy incidence and measures of serum creatinine (OR = 0.5; 95% CI, 0.42-0.59) and scores on the Elixhauser comorbidity index (OR = 0.76; 95% CI, 0.72-0.8).

Finding answers

“Our study provides foundational data to guide improvements and underscores the need for practice changes to close these care gaps,” the researchers wrote. “Systematic evaluation of barriers to diagnosis and treatment is needed to design targeted interventions, including the use of health informatics tools and strategies to improve recognition and treatment.”

The researchers noted that there are several technologic solutions that could be developed in this context, including diagnostic algorithms and electronic clinical surveillance.

“We agree with the study investigators’ conclusions that this problem would benefit from the development of computer-based algorithms and the use of artificial intelligence to support clinicians, so that indicated diagnostic testing and risk stratification are performed and management guidelines are heeded,” Wentworth and Shoback wrote, adding that tools such as DXA, parathyroid ultrasonography, sestamibi scanning and 4D CT could all be utilized as well. – by Phil Neuffer

Disclosures: Makris reports he has received grants from Baylor College of Medicine Department of Surgery and nonfinancial support from the Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center. Please see the study for all other authors’ relevant financial disclosures.