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Original Investigation
July 15, 2019

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

Author Affiliations
  • 1Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
  • 2Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research and Development Center of Innovation, Houston, Texas
  • 3Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
  • 4Department of Surgery, University of Texas Southwestern, Dallas
  • 5Veterans Affairs North Texas Health Care System, Dallas
  • 6Department of Medicine, Baylor College of Medicine, Houston, Texas
JAMA Intern Med. 2019;179(9):1220-1227. doi:10.1001/jamainternmed.2019.1747
Key Points

Question  How is primary hyperparathyroidism diagnosed and treated in a large integrated health system using electronic health records?

Findings  In this national cohort study of 371 370 veterans with chronic hypercalcemia, 86 887 (23.4%) were evaluated for primary hyperparathyroidism with serum parathyroid hormone level. Of 47 158 patients with hormonal evidence of primary hyperparathyroidism, 6049 (12.8%) underwent definitive treatment with parathyroidectomy.

Meaning  Primary hyperparathyroidism appears to be underdiagnosed despite the presence of chronic hypercalcemia, and it is undertreated with parathyroidectomy despite surgical indications.

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 Participants  A 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 Measures  The 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.

Results  Of 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.

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    1 Comment for this article
    Follow-up of Laboratory Test Results
    Paul Nelson, M.D., M.S. | Family Health Care, P.C. retired
    Offering primary healthcare is ultimately dependent on its ability to reliably and responsively keep track of a wide variety of delayed decision processes. The apparently low level of endoscopic parathyroid adenoma removal as compared to the incidence of abnormal serum calcium levels should trigger a broad EHR reconfiguration of accountability issues. This study's results  likely reflect an inadequate level of accountability for acting on laboratory test results that are reported after an office visit.  
    CONFLICT OF INTEREST: None Reported
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