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

Sex-Stratified Predictors of Prolonged Operative Time and Hospital Admission in Outpatient Parathyroidectomy

Our retrospective database study investigates sex-stratified predictors of prolonged operative time (POT) and hospital admission following parathyroidectomy for primary hyperparathyroidism (PHPT). The 2016 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried for patients with PHPT undergoing parathyroidectomy. Cases analyzed were all outpatient status, arrived from home, coded as non-emergent, and elective. POT was defined by the 75th percentile. Hospital admission was defined as LOS ≥ 1 day. Univariate and multivariable binary logistic regressions were utilized. Of 7442 cases satisfying inclusion criteria, the majority were female (78.0%) and White (78.5%). Median OT (IQR) for females and males was 77 (58-108) and 81 (61-109) minutes, respectively (P = 0.003). 1965 (33.9%) females and 529 (32.3%) males required hospital admission. Independent predictors of POT included ASA class III/IV (aOR 1.342, 95% CI 1.007-1.788) and obesity (aOR 1.427, 95% CI 1.095-1.860) for males (P < 0.05). Independent predictors of hospital admission included age (aOR 1.008, 95% CI 1.002-1.014), ASA class III/IV (aOR 1.490, 95% CI 1.301-1.706), obesity (aOR 1.309, 95% CI 1.151-1.489), dyspnea (aOR 1.394, 95% CI 1.041-1.865), chronic steroid use (aOR 1.674, 95% CI 1.193-2.351), and COPD (aOR 1.534, 95% CI 1.048-2.245) for females (P < 0.05); and ASA class III/IV (aOR 1.931, 95% CI 1.483-2.516) and bleeding disorder (aOR 2.752, 95% CI 1.443-5.247) for males (P < 0.005). In conclusion, predictors of POT and hospital admission following parathyroidectomy for PHPT differed by patient sex. Identifying patients at risk for POT and hospital admission may optimize healthcare resource utilization. Level of Evidence: IV.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04444-3.

Systematic review of the risk of urolithiasis following parathyroidectomy in patients with primary hyperparathyroidism

OBJECTIVE

Parathyroidectomy (PTX) is the conclusive therapy for primary hyperparathyroidism (PHPT), but its effect on the risk of urolithiasis is inconclusive. We comprehensively reviewed the currently available research to investigate the impact of PTX on the likelihood of urolithiasis among individuals suffering PHPT.

METHODS

Internet-based articles in English language released on Cochrane, PubMed, Scopus, Web of knowledge, and Embase up to September, 2023 were comprehensively reviewed. Each publication in contrast to the incidence, occurrence, or recurrence of urolithiasis after PTX versus medical treatment in PHPT patients was included. The outcome with pooled relative risks (RRs) and corresponding 95% confidence intervals (CIs) was examined employing DerSimonian and Laird's model of random effects. To determine the range of the real effect size of a future study in 95% of all populations, a prediction interval (PI) was also established.

RESULTS

Finally, ten studies involving 74,190 patients were included. Results from randomized-controlled trials (RCTs) and observational studies (OSs) both revealed that PTX did not substantially lessen the vulnerability of urolithiasis among individuals with PHPT (RCTs: pooled relative risk [RR] 0.42, 95%CI 0.13-1.41, p = 0.163; OSs: pooled RR 1.37, 95%CI 0.96 to 1.97, p = 0.084). The PI (RCT: 0.03 to 5.96; OSs: 0.44-4.20) containing 1.0 suggested the possibility of consistent results in future studies. Subgroup and sensitivity analyses supported the above findings, and no evidence showed publication bias.

CONCLUSION

Our analysis from the available RCTs or OSs did not give adequate or exact proof that the average effect of PTX lowers the incidence of urolithiasis among PHPT persons based on the random-effects model. Future research shall take into account the common effect of PTX as well as the prerequisites of preventive stone procedures, which will further help us assess the effectiveness of PTX in reducing kidney calculus comorbidity and develop techniques to avoid stone sequelae in these individuals.

Lithium-associated primary hyperparathyroidism:: An evaluation of screening and referral patterns in a southeastern veteran population

BACKGROUND

Long-term lithium therapy has a well-established but under-recognized association with primary hyperparathyroidism. Rates of hypercalcemia, screening for primary hyperparathyroidism, and referral for parathyroidectomy were evaluated among United States veterans on long-term lithium therapy.

METHODS

Patients undergoing chronic long-term lithium therapy (>12 months) were identified from 1999 to 2022. Demographics, long-term lithium therapy duration, post-treatment calcium, parathyroid hormone, creatinine, and vitamin D levels were abstracted. Rates of screening for hypercalcemia (calcium ≥10.2 mg/dL), primary hyperparathyroidism (parathyroid hormone ≥30 pg/mL in the setting of hypercalcemia), referral for parathyroidectomy, and outcomes were evaluated.

RESULTS

A total of 1,356 patients underwent long-term lithium therapy, 514 of whom received chronic long-term lithium therapy. Baseline characteristics of patients with and without post-treatment hypercalcemia were compared. Of 148 patients with post-treatment hypercalcemia, 112 (74.7%) underwent no further evaluation for primary hyperparathyroidism, while 36 (25.3%) patients had a parathyroid hormone level recorded. Although 33 (91.7%) hypercalcemic patients screened positive for primary hyperparathyroidism, only 5 (13%) were referred for parathyroidectomy. Of the 4 patients who underwent parathyroidectomy, mean calcium was 11.2 mg/dL (range 11.1-11.4), and mean parathyroid hormone was 272 pg/mL (range 108-622). Three patients were localized on preoperative imaging, 2 of whom underwent unilateral exploration with cure, with 1 experiencing recurrence at 31 months. The remaining patient who localized preoperatively underwent bilateral exploration and had 2 ipsilateral glands resected and persistence. The patient who did not localize preoperatively underwent bilateral exploration with 3 gland resection and cure.

CONCLUSIONS

Screening for primary hyperparathyroidism and referral for parathyroidectomy are underutilized in United States veterans undergoing chronic long-term lithium therapy. Institutional protocols to standardize screening, surveillance, and referrals to endocrinology/endocrine surgery could benefit this population at increased risk for primary hyperparathyroidism.

Social vulnerability and time to surgeon evaluation for primary hyperparathyroidism in a Massachusetts cohort

BACKGROUND

Identifying patients at risk for under-evaluation of primary hyperparathyroidism is essential to minimizing long-term sequelae, including osteoporosis, nephrolithiasis, and cardiovascular disease. This study assessed the impact of social vulnerability on time-to-surgery evaluation among patients with primary hyperparathyroidism in a Massachusetts cohort.

METHODS

This is a retrospective review of patients from an institutional database with the first incident of hypercalcemia between 2010 and 2018 and subsequent biochemical diagnosis of primary hyperparathyroidism. The overall social vulnerability index and social vulnerability index subthemes were merged with the institutional data via patient ZIP code. Patients were stratified into social vulnerability index quartiles, where quartile 4 represented the highest vulnerability. Baseline sociodemographic and clinical characteristics were compared, and Cox regression was used to assess the association between social vulnerability index and time to surgeon evaluation.

RESULTS

Of 1,082 patients included, those with a higher social vulnerability index were less likely to be evaluated by a surgeon (quartile 1 social vulnerability index: 31.1% vs. quartile 2 social vulnerability index: 31.41% vs. quartile 3 social vulnerability index: 25.93% vs. quartile 4 social vulnerability index: 21.92%, P = .03). On adjusted analysis, patients with the highest vulnerability had a 33% lower estimated rate of surgeon evaluation and were seen 67 days later compared with patients with the lowest vulnerability (hazard ratio: 0.67, confidence interval 0.47-0.97, P = .032). Differential rates of surgical evaluation by vulnerability persisted for the social vulnerability index subthemes for socioeconomic status, minority status and language, and housing type and transportation.

CONCLUSION

Among a Massachusetts cohort, highly vulnerable populations with primary hyperparathyroidism are at greater risk for under-evaluation by a surgeon, which may contribute to the development of long-term sequelae of their disease.

Older Patients With Asymptomatic Primary Hyperparathyroidism: Should Criteria for Surgery Be Expanded?

Context

Patients with primary hyperparathyroidism (PHPT) can present with variable signs, symptoms, and end-organ effects. Clinical practice guidelines influence referral for consideration of parathyroidectomy.

Objective

This study compared the demographic, biochemical, and symptom profile and examine indications for surgery in patients older than 50 years who underwent parathyroidectomy to determine how changes to current guidelines may affect recommendations for parathyroidectomy.

Methods

A retrospective review was conducted of patients age 50 years or older who underwent initial parathyroidectomy for sporadic PHPT from 2012 to 2020. Patients were classified by indications for surgery per guideline criteria (classic, asymptomatic, and no criteria met) and age group (AG): 50 to 59 years; 60 to 69 years; 70 years or older. Patients were treated at a high-volume tertiary medical center by endocrine surgeons.

Results

Of 1182 patients, 367 (31%) classic and 660 (56%) asymptomatic patients met the criteria for surgery. The most common indications for surgery were extent of hypercalcemia (51%), osteoporosis (28%), and nephrolithiasis (27%). Of the 155 (13%) patients who did not meet the criteria, neurocognitive symptoms (AG1: 88% vs AG2: 81% vs AG3: 70%; P = .14) and osteopenia (AG1: 53% vs AG2: 68% vs AG3: 68%; P = .43) were frequently observed regardless of patient age. If the age threshold of younger than 50 years was expanded to 60, 65, or 70 years, an additional 61 (5%), 99 (8%), and 124 (10%) patients in the entire cohort would have met the guideline criteria for surgery, respectively.

Conclusion

Expanding current guidelines for PHPT to include a broader age range, osteopenia, and neurocognitive symptoms may allow for earlier surgical referral and evaluation for definitive treatment.

Opportunistic CT Assessment of Parathyroid Glands: Utility of Radiologist-Recommended Biochemical Evaluation for Diagnosing Primary Hyperparathyroidism

BACKGROUND. Existing gaps in primary hyperparathyroidism (PHPT) diagnosis and treatment have prompted calls for systemic change in the approach to this disease. One proposed change is opportunistic assessment for enlarged parathyroid glands on routine CT examinations, to target biochemical testing to individuals most likely to have un-diagnosed PHPT. OBJECTIVE. The purpose of our study was to assess the utility of a radiologist recommendation for biochemical testing in patients with a suspected enlarged parathyroid gland on routine CT for identifying previously undiagnosed PHPT. METHODS. This retrospective study included patients without known or suspected PHPT who underwent routine CT (i.e., performed for reasons other than known or suspected parathyroid disease) between August 2019 and September 2021 in which the clinical CT report included a radiologist recommendation for biochemical testing to evaluate for possible PHPT because of a suspected enlarged parathyroid gland. Neuroradiologists at the study institution included this recommendation on the basis of individual judgment without formal criteria. The EHR was reviewed to identify patients who underwent subsequent laboratory evaluation for PHPT. An endocrine surgeon used available laboratory results and clinical data to classify patients as having PHPT, secondary hyper-parathyroidism, or no parathyroid disorder independent of the CT findings. RESULTS. The sample comprised 39 patients (median age, 68 years; 20 women, 19 men) who received the radiologist recommendation for biochemical evaluation. Of these patients, 13 (33.3%) received the recommended biochemical evaluation. Of the 13 tested patients, three (23.1%) were classified as having PHPT, four (30.8%) as having secondary hyperparathyroidism, and six (46.2%) as having no parathyroid disorder. Thus, the number of patients needing to receive a radiologist recommendation for biochemical testing per correct PHPT diagnosis was 13.0, and the number of patients needing to undergo laboratory testing per correct PHPT diagnosis was 4.3. One of the three patients classified as having PHPT underwent surgical resection of the lesion identified by CT, which was shown on histopathologic evaluation to represent hypercellular parathyroid tissue. CONCLUSION. Radiologist recommendations for biochemical testing in patients with suspected enlarged parathyroid glands on routine CT helped to identify individuals with undiagnosed PHPT. CLINICAL IMPACT. Opportunistic assessment for enlarged parathyroid glands on routine CT may facilitate PHPT diagnosis.

Estimated Effect of Parathyroidectomy on Long-Term Kidney Function in Adults With Primary Hyperparathyroidism

BACKGROUND

Multidisciplinary guidelines recommend parathyroidectomy to slow the progression of chronic kidney disease in patients with primary hyperparathyroidism (PHPT) and an estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2. Limited data address the effect of parathyroidectomy on long-term kidney function.

OBJECTIVE

To compare the incidence of a sustained decline in eGFR of at least 50% among patients with PHPT treated with parathyroidectomy versus nonoperative management.

DESIGN

Target trial emulation was done using observational data from adults with PHPT, using an extended Cox model with time-varying inverse probability weighting.

SETTING

Veterans Health Administration.

PATIENTS

Patients with a new biochemical diagnosis of PHPT in 2000 to 2019.

MEASUREMENTS

Sustained decline of at least 50% from pretreatment eGFR.

RESULTS

Among 43 697 patients with PHPT (mean age, 66.8 years), 2928 (6.7%) had a decline of at least 50% in eGFR over a median follow-up of 4.9 years. The weighted cumulative incidence of eGFR decline was 5.1% at 5 years and 10.8% at 10 years in patients managed with parathyroidectomy, compared with 5.1% and 12.0%, respectively, in those managed nonoperatively. The adjusted hazard of eGFR decline did not differ between parathyroidectomy and nonoperative management (hazard ratio [HR], 0.98 [95% CI, 0.82 to 1.16]). Subgroup analyses found no heterogeneity of treatment effect based on pretreatment kidney function. Parathyroidectomy was associated with a reduced hazard of the primary outcome among patients younger than 60 years (HR, 0.75 [CI, 0.59 to 0.93]) that was not evident among those aged 60 years or older (HR, 1.08 [CI, 0.87 to 1.34]).

LIMITATION

Analyses were done in a predominantly male cohort using observational data.

CONCLUSION

Parathyroidectomy had no effect on long-term kidney function in older adults with PHPT. Potential benefits related to kidney function should not be the primary consideration for PHPT treatment decisions.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Kidney Stone Events Following Parathyroidectomy vs Nonoperative Management for Primary Hyperparathyroidism

CONTEXT

Primary hyperparathyroidism (PHPT) is associated with an increased risk of kidney stones. Few studies account for PHPT severity or stone risk when comparing stone events after parathyroidectomy vs nonoperative management.

OBJECTIVE

Compare the incidence of kidney stone events in PHPT patients treated with parathyroidectomy vs nonoperative management.

DESIGN

Longitudinal cohort study with propensity score inverse probability weighting and multivariable Cox proportional hazards regression.

SETTING

Veterans Health Administration integrated health care system.

PATIENTS

A total of 44 978 patients with > 2 years follow-up after PHPT diagnosis (2000-2018); 5244 patients (11.7%) were treated with parathyroidectomy.

MAIN OUTCOMES MEASURE

Clinically significant kidney stone event.

RESULTS

The cohort had a mean age of 66.0 years, was 87.8% male, and 66.4% White. Patients treated with parathyroidectomy had higher mean serum calcium (11.2 vs 10.8mg/dL) and were more likely to have a history of kidney stone events. Among patients with baseline history of kidney stones, the unadjusted incidence of ≥ 1 kidney stone event was 30.5% in patients managed with parathyroidectomy (mean follow-up, 5.6 years) compared with 18.0% in those managed nonoperatively (mean follow-up, 5.0 years). Patients treated with parathyroidectomy had a higher adjusted hazard of recurrent kidney stone events (hazard ratio [HR], 1.98; 95% CI, 1.56-2.51); however, this association declined over time (parathyroidectomy × time: HR, 0.80; 95% CI, 0.73-0.87).

CONCLUSION

In this predominantly male cohort with PHPT, patients treated with parathyroidectomy continued to be at higher risk of kidney stone events in the immediate years after treatment than patients managed nonoperatively, although the adjusted risk of stone events declined with time, suggesting a benefit to surgical treatment.

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

BACKGROUND

Among patients with primary hyperparathyroidism, parathyroidectomy offers a chance of cure and mitigation of disease-related complications. The impact of race/ethnicity on referral and utilization of parathyroidectomy has not been fully explored.

METHODS

Population-based, retrospective cohort study using 100% Medicare claims from beneficiaries with primary hyperparathyroidism from 2006 to 2016. Associations of race/ethnicity with disease severity, surgeon evaluation, and subsequent parathyroidectomy were analyzed using adjusted multivariable logistic regression models.

RESULTS

Among 210,206 beneficiaries with primary hyperparathyroidism, 63,136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis. Black patients were more likely than other races/ethnicities to have stage 3 chronic kidney disease (10.8%) but had lower prevalence of osteoporosis and nephrolithiasis compared to White patients, Black and Hispanic patients were more likely to have been hospitalized for primary hyperparathyroidism-associated conditions (White 4.8%, Black 8.1%, Hispanic 5.8%; P < .001). Patients who were White and met operative criteria were more likely to undergo parathyroidectomy than Black, Hispanic, or Asian patients (White 30.5%, Black 23.0%, Hispanic 21.4%, Asian 18.7%; P < .001). Black and Hispanic patients had lower adjusted odds of being evaluated by a surgeon (odds ratios 0.71 [95% confidence interval 0.69-0.74], 0.68 [95% confidence interval 0.61-0.74], respectively) and undergoing parathyroidectomy if evaluated by a surgeon (odds ratios 0.72 [95% confidence interval 0.68-0.77], 0.82 [95% confidence interval 0.67-0.99]). Asian race was associated with lower adjusted odds of being evaluated by a surgeon (odds ratio 0.64 [95% confidence interval 0.57-0.71]), but no difference in odds of parathyroidectomy.

CONCLUSION

Racial/ethnic disparities exist in the management of primary hyperparathyroidism among older adults. Determining the factors that account for this disparity require urgent attention to achieve parity in the management of primary hyperparathyroidism.

Risk of Fracture Among Older Adults With Primary Hyperparathyroidism Receiving Parathyroidectomy vs Nonoperative Management

IMPORTANCE

Primary hyperparathyroidism (PHPT) contributes to the development and progression of osteoporosis in older adults. The effectiveness of parathyroidectomy for reducing fracture risk in older adults is unknown.

OBJECTIVE

To compare the incidence of clinical fracture among older adults with PHPT treated with parathyroidectomy vs nonoperative management.

DESIGN, SETTING, AND PARTICIPANTS

This was a population-based, longitudinal cohort study of all Medicare beneficiaries with PHPT from 2006 to 2017. Multivariable, inverse probability weighted Cox proportional hazards and Fine-Gray competing risk regression models were constructed to determine the association of parathyroidectomy vs nonoperative management with incident fracture. Data analysis was conducted from February 17, 2021, to September 14, 2021.

MAIN OUTCOMES AND MEASURES

The primary outcome was clinical fracture at any anatomic site not associated with major trauma during the follow-up period.

RESULTS

Among the 210 206 Medicare beneficiaries with PHPT (mean [SD] age, 75 [6.8] years; 165 637 [78.8%] women; 183 433 [87.3%] White individuals), 63 136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis, and 147 070 (70.0%) were managed nonoperatively. During a mean (SD) follow-up period of 58.5 (35.5) months, the unadjusted incidence of fracture was 10.2% in patients treated with parathyroidectomy. During a mean (SD) follow-up of 52.5 (33.8) months, the unadjusted incidence of fracture was 13.7% in patients observed nonoperatively. On multivariable analysis, parathyroidectomy was associated with lower adjusted rates of any fracture (hazard ratio [HR], 0.78; 95% CI, 0.76-0.80]) and hip fracture (HR, 0.76; 95% CI, 0.72-0.79). At 2, 5, and 10 years, parathyroidectomy was associated with adjusted absolute fracture risk reduction of 1.2% (95% CI, 1.0-1.4), 2.8% (95% CI, 2.5-3.1), and 5.1% (95% CI, 4.6-5.5), respectively, compared with nonoperative management. On subgroup analysis, there were no significant differences in the association of parathyroidectomy with fracture risk by age group, sex, frailty, history of osteoporosis, or meeting operative guidelines. Fine-Gray competing risk regression confirmed parathyroidectomy was associated with a lower probability of any fracture and hip fracture when accounting for the competing risk of death (HR, 0.84; 95% CI, 0.82-0.85; and HR, 0.83; 95% CI, 0.80-0.85, respectively).

CONCLUSIONS AND RELEVANCE

This longitudinal cohort study found that parathyroidectomy was associated with a lower risk of any fracture and hip fracture among older adults with PHPT, suggesting a clinically meaningful benefit of operative management in this population.

Underdiagnosis of primary hyperparathyroidism in patients with osteoarthritis undergoing arthroplasty

BACKGROUND

Primary hyperparathyroidism (HPT) is commonly underdiagnosed and undertreated. Joint pain is a nonspecific symptom associated with osteoarthritis or primary HPT. We hypothesize that patients treated for osteoarthritis are underdiagnosed with primary HPT.

METHODS

Adult patients diagnosed with hip/knee osteoarthritis at the Medical College of Wisconsin from January 2000 to October 2020 were queried. Patients with a calcium level drawn within 1 year of diagnosis of osteoarthritis were included. Patients who had undergone prior parathyroidectomy were excluded. Patients were stratified by serum calcium level, HPT diagnosis, and PTH level. Arthroplasty rates were compared between groups.

RESULTS

Of 54,788 patients, 9,967 patients (18.2%) had a high serum calcium level, of whom 1,089 (10.9%) had a diagnosis of HPT. Only 76 (7.0%) patients with HPT underwent parathyroidectomy, 208 (19.1%) underwent knee/hip arthroplasty, and 14 (1.3%) underwent both. Arthroplasty was performed in 1,793 patients without evaluation and/or definitive treatment for HPT. There were higher rates of arthroplasty performed in patients with a high serum calcium level compared with those without (21.2% vs 17.4%, P < .001).

CONCLUSION

Patients with high serum calcium levels were more likely to undergo arthroplasty than those with normocalcemia. Hypercalcemia in the setting of hip or knee osteoarthritis should prompt a full evaluation for primary HPT.

Parathyroidectomy for nephrolithiasis in primary hyperparathyroidism: Beneficial but not a panacea

BACKGROUND

Nephrolithiasis is a classic indication for parathyroidectomy in primary hyperparathyroidism patients; however, the effects of parathyroidectomy on nephrolithiasis recurrence are not well studied. The aim was to determine effect of parathyroidectomy on time to first nephrolithiasis recurrence and recurrence rate per patient-years.

METHODS

A retrospective cohort study of patients diagnosed with primary hyperparathyroidism and at least one episode of nephrolithiasis was performed. The patients were divided into observation, presurgery, and postsurgery groups. Endpoints were time to first recurrence of nephrolithiasis and average recurrence rate per patient-years.

RESULTS

The cohort was comprised of 1,252 patients. In addition, 334 (27%) patients underwent parathyroidectomy and 918 (73%) were observed. The surgical and nonsurgical groups differed significantly in age, sex, Charlson, calcium, and primary hyperparathyroidism level. Overall recurrence rate was 31.3%. The 5-, 10-, and 15-year recurrence-free survival rates were 74.4%, 56.3%, 49.5%, respectively (presurgery), 82.4%, 70.9%, 62.8%, respectively (postsurgery; P < .0001), and 86.3%, 77.7%, and 70.6%, respectively (observation). The presurgery group had an increased risk of first recurrence compared with the observation group (hazard ratio 1.89; 95% confidence interval, 1.44-2.47). The average recurrence rates among all surgical patients who recurred were 1 event per 4.3 patient-years presurgery versus 1 event per 6.7 patient-years postsurgery (P = .0001).

CONCLUSION

Recurrent nephrolithiasis is a significant problem in patients with primary hyperparathyroidism. Parathyroidectomy prolongs the time to first recurrence and decreases the number of re-recurrences over time but does not eliminate recurrences. Observation may also be a reasonable approach in selected patients.

Superior sensitivity of 18F-fluorocholine: PET localization in primary hyperparathyroidism

BACKGROUND

Preoperative parathyroid imaging guides surgeons during parathyroidectomy. This study evaluates the clinical impact of ¹⁸F-fluorocholine positron emission tomography for preoperative parathyroid localization on patients with primary hyperparathyroidism.

METHODS

Patients with primary hyperparathyroidism and indications for parathyroidectomy had simultaneous ¹⁸F-fluorocholine positron emission tomography imaging/magnetic resonance imaging. In patients who underwent subsequent parathyroidectomy, cure was based on lab values at least 6 months after surgery. Location-based sensitivity and specificity of ¹⁸F-fluorocholine positron emission tomography imaging was assessed using 3 anatomic locations (left neck, right neck, and mediastinum), with surgery as the gold standard.

RESULTS

In 101 patients, ¹⁸F-fluorocholine positron emission tomography localized at least 1 candidate lesion in 93% of patients overall and in 91% of patients with previously negative imaging, leading to a change in preoperative strategy in 60% of patients. Of 76 patients who underwent parathyroidectomy, 58 (77%) had laboratory data at least 6 months postoperatively, with 55/58 patients (95%) demonstrating cure. ¹⁸F-fluorocholine positron emission tomography successfully guided curative surgery in 48/58 (83%) patients, compared with 20/57 (35%) based on ultrasound and 13/55 (24%) based on sestamibi. In a location-based analysis, sensitivity of ¹⁸F-fluorocholine positron emission tomography (88.9%) outperformed both ultrasound (37.1%) and sestamibi (27.5%), as well as ultrasound and sestamibi combined (47.8%).

CONCLUSION

Long-term results in the first cohort in the United States to use ¹⁸F-fluorocholine positron emission tomography for parathyroid localization confirm its utility in a challenging cohort, with better sensitivity than ultrasound or sestamibi.

Use and disparities in parathyroidectomy for symptomatic primary hyperparathyroidism in the Medicare population

BACKGROUND

Few studies assess use of parathyroidectomy among older adults with symptomatic primary hyperparathyroidism. Our objective was to determine national usage and disparities in parathyroidectomy for symptomatic primary hyperparathyroidism among insured older adults.

METHODS

We identified older adult patients with symptomatic primary hyperparathyroidism using Medicare claims (2006-2017). Primary study variables were race/ethnicity, rurality, and zip-code socioeconomic status. We calculated cumulative incidence of parathyroidectomy and used multivariable Cox proportional hazards regression models to assess the adjusted association of our study variables with parathyroidectomy.

RESULTS

We included 94,803 patients. The median age at primary hyperparathyroidism diagnosis was 76 years (interquartile range 71-82). The majority of patients were female (72%), non-Hispanic White (82%), from metropolitan areas (82%), and had a Charlson Comorbidity score ≥3 (62%). Nine percent of patients (n = 8,251) underwent parathyroidectomy during follow-up. After adjustment, non-Hispanic Black patients, compared to non-Hispanic White (hazard ratio 0.80; 95% confidence interval 0.74, 0.87), and living in a low socioeconomic status neighborhood (low socioeconomic status vs highest socioeconomic status hazard ratio 0.89; 95% confidence interval 0.83, 0.95) were both associated with lower incidences of parathyroidectomy. Patients from non-metropolitan areas were more likely to undergo parathyroidectomy.

CONCLUSION

Parathyroidectomy is underused for symptomatic primary hyperparathyroidism in older adults. Quality improvement efforts, rooted in equitable care, should be undertaken to increase access to parathyroidectomy for this disease.

Advances in the diagnosis and the management of primary hyperparathyroidism

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.

Association of Parathyroidectomy With 5-Year Clinically Significant Kidney Stone Events in Patients With Primary Hyperparathyroidism

OBJECTIVE

Patients with primary hyperparathyroidism (PHPT) are at increased risk of kidney stones. Guidelines recommend parathyroidectomy in patients with PHPT with a history of stone disease. This study aimed to compare the 5-year incidence of clinically significant kidney stone events in patients with PHPT treated with parathyroidectomy versus nonoperative management.

METHODS

We performed a longitudinal cohort study of patients with PHPT in a national commercial insurance claims database (2006-2019). Propensity score inverse probability weighting-adjusted multivariable regression models were calculated.

RESULTS

We identified 7623 patients aged ≥35 years old with continuous enrollment >1 year before and >5 years after PHPT diagnosis. A total of 2933 patients (38.5%) were treated with parathyroidectomy. The cohort had a mean age of 66.5 years, 5953 (78.1%) were female, and 5520 (72.4%) were White. Over 5 years, the unadjusted incidence of ≥1 kidney stone event was higher in patients who were managed with parathyroidectomy compared with those who were managed nonoperatively overall (5.4% vs 4.1%, respectively) and among those with a history of kidney stones at PHPT diagnosis (17.9% vs 16.4%, respectively). On multivariable analysis, parathyroidectomy was associated with no statistically significant difference in the odds of a 5-year kidney stone event among patients with a history of kidney stones (odds ratio, 1.03; 95% CI, 0.71-1.50) or those without a history of kidney stones (odds ratio, 1.16; 95% CI, 0.84-1.60).

CONCLUSION

Based on this claim analysis, there was no difference in the odds of 5-year kidney stone events in patients with PHPT who were treated with parathyroidectomy versus nonoperative management. Time horizon for benefit should be considered when making treatment decisions for PHPT based on the risk of kidney stone events.

Risk of fractures in primary hyperparathyroidism: a systematic review and meta-analysis

An increased risk of fractures in primary hyperparathyroidism (PHPT) has been reported in a number of relatively small studies. Performing a systematic literature search, we identified available studies and calculated common estimates by pooling results from the individual studies in a meta-analysis. Searching EMBASE and PubMed, we identified published studies reporting the risk of fractures in PHPT compared to a control group. We calculated odds ratio (OR) with 95% confidence interval (CI). A total of 804 studies were identified of which 12 studies were included. Risk of any fracture was increased compared to controls (OR 2.01; 95% CI, 1.61-2.50; I² 46%, 5 studies). Analysis of fracture risk at specific sites showed an increased risk of fracture at the forearm (OR 2.36; 95% CI, 1.64-3.38; I² 0%, 4 studies) and spine (OR 3.00; 95% CI, 1.41, 6.37, I² 88%, 9 studies). Risk estimate for hip fractures was non-significantly increased (OR 1.27; 95% CI, 0.97-1.66; I² 0%, 3 studies). Risk of vertebral fractures (VFx) was also increased if analyses were restricted to only studies with a healthy control group (OR 5.76; 95% CI, 3.86-8.60; I² 29%, 6 studies), studies including patients with mild PHPT (OR 4.22; 95% CI, 2.20-8.12; I² 57%, 4 studies) or studies including postmenopausal women (OR 8.07; 95% CI, 4.79-13.59; I² 0%, 3 studies). PHPT is associated with an increased risk of fractures. Although a number of studies are limited-it seems that the risk is increased across different skeletal sites including patients with mild PHPT and postmenopausal women.