E. A. Alore1, J. W. Suliburk1, D. J. Ramsey2, C. J. Balentine3, K. I. Makris1,4 1Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA 2Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research And Development Center Of Innovation,Center For Innovations In Quality, Effectiveness And Safety,Houston, TX, USA 3University of Alabama at Birmingham,Department Of Surgery,Birmingham, AL, USA 4Michael E. DeBakey Veterans Affairs Medical Center,Operative Care Line, Division of General Surgery,Houston, TX, USA
Introduction:
Untreated hyperparathyroidism significantly impairs quality of life and incurs substantial costs to both patients and health care systems. Parathyroidectomy is the only cure for primary hyperparathyroidism (pHPT), yet there is evidence that parathyroidectomy is underutilized in single-institution and regional studies. The purpose of our study is to assess the utilization of parathyroidectomy in pHPT within a national population sample. We hypothesized that parathyroidectomy is underutilized in the treatment of pHPT.
Methods:
We performed a retrospective search of all patients within the national VA corporate data warehouse between 2000-2010. Adults with pHPT were identified using a validated algorithm by meeting the following criteria: elevated serum parathyroid hormone (PTH) level (> 88 pg/mL), elevated serum calcium level (>10.5 mg/dL) and serum creatinine < 2.5 mg/dL. Patients with secondary or tertiary hyperparathyroidism were excluded based on serum creatinine ≥2.5 mg/dL, history of dialysis, or prior renal transplantation. Rates of parathyroidectomy were calculated amongst patients with pHPT. A reverse stepwise logistic regression using p>0.2 as a criterion for removal from the model was used to identify predictive factors of parathyroidectomy.
Results:
Of 383,701 patients with hypercalcemia, 80,250 (20.9%) were tested for PTH. A total of 21,465 patients met diagnostic criteria for pHPT across the VA system during the study period. An average of 1,951 patients (0.03%) per year were diagnosed with pPTH out of an average of 6,997,378 patients treated at the VA per year. Of all patients with pPHT, only 1,679 (7.8%) underwent parathyroidectomy. In a subgroup analysis, of the 1,501 patients with pHPT presenting with serum Ca >11.5 mg/dL (an established indication for parathyroidectomy), only 301 (16.7%) underwent parathyroidectomy. On the reverse stepwise logistic regression, significant predictors of parathyroidectomy included a documented diagnosis of hyperparathyroidism in the medical record by ICD-9 code, high serum calcium level, history of kidney stones, osteoporosis, younger age and normal EGFR (Table 1).
Conclusion:
Despite being the only definitive treatment of pHTP, parathyroidectomy is extraordinarily underutilized nationally within the VA, even when a clear indication for operation exists. Further studies are needed to identify the underlying reasons for this underutilization and guide corrective interventions.
