FROM ANNALS OF SURGERY
A report from the University of Alabama at Birmingham provides further evidence that hyperparathyroidism is often missed in the United States health care system.
Investigators reviewed the electronic health records for 682,704 patients at the university from 2011 to 2015 and identified hypercalcemia (serum calcium greater than 10.5 mg/dL) – usually the first indication of disease – in 10,432 patients. The next step should have been a parathyroid hormone (PTH) measurement, but PTH was measured in only 3,200 patients (31%), and it usually took multiple abnormal calcium levels before PTH was checked, reported Courtney Balentine, MD, and her colleagues at the University of Alabama at Birmingham.
In addition, 592 of 2,666 patients (22%) with both elevated calcium and PTH levels were referred to surgeons for a parathyroidectomy consult, although parathyroidectomy is a low-risk outpatient procedure that cures up to 95% of patients, and surgeons are best suited to discuss the risks and benefits of the procedure with patients, investigators said (Ann Surg. 2017 Jul 3. doi: 10.1097/SLA.0000000000002370 ).
Underdiagnosis and treatment of hyperparathyroidism can lead to fractures, kidney stones, depression, cognitive impairment, hypertension, stroke, and myocardial infarction.
The investigators plan to meet with primary care doctors to hear how they think the problem should be addressed. Alerts and automatic referrals are also being considered for the EHR. “The combination of systems changes and stakeholder engagement is more likely to succeed than focusing on one component to the exclusion of others,” Dr. Balentine and colleagues said.
The issue could be that primary care physicians are just too overwhelmed to notice or be concerned about an isolated abnormal calcium level in an otherwise routine assessment. Or perhaps they assume surgeons come into play only if there are kidney stones, bone changes, or other obvious signs of trouble, they said.
The team has started to look at charts to get a better understanding of what’s going wrong. “I have been a little bit flabbergasted by how many excuses there are for either not checking a PTH or not referring once the diagnosis is there. … ‘This patient probably would not benefit from the surgery; the risk is too high; he or she does not want X, Y, or Z.’ I think if they just refer [patients to surgeons] to have the conversation, we might very well agree with them, but at least we [could] have the conversation with the patient, and I think [that] would make more sense,” Dr. Balentine said in a transcript of a question and answer session that was published with the report.
“Indeed, the recent American Association of Endocrine Surgery guidelines emphasize the importance of referring patients to surgical experts for discussion of treatment options,” the investigators said in the report.
It’s possible that elevated calcium and PTH levels were evaluated and treated at other institutions and so were not captured by the analysis. “Our mean follow-up was 16 months, however, which suggests that most patients were seen in the UAB system long enough to undergo appropriate evaluation and referral.” Also, patients with “two or more abnormal calcium values had similarly low rates of surgical referral, which suggests that loss to follow-up is unlikely to explain our findings,” they said.
The mean age of the cohort was 54 years; 56% of the patients were white, and 61% were women.
The work was supported by the Agency for Healthcare Research and Quality. The authors reported no conflicts of interest.
