Systems-Level Opportunities in the Management of Primary Hyperparathyroidism: An Informatics-based Assessment.

CONTEXT: Primary hyperparathyroidism (PHPT), a leading cause of hypercalcemia and secondary osteoporosis, is underdiagnosed. OBJECTIVE: This work aims to establish a foundation for an electronic medical record-based intervention that would prompt serum parathyroid hormone (PTH) assessment in patients with persistent hypercalcemia and identify care gaps in their management. METHODS: A retrospective cohort study was conducted in a tertiary academic health system of outpatients with persistent hypercalcemia, who were categorized as having classic or normohormonal PHPT. Main outcome measures included the frequencies of serum PTH measurement in patients with persistent hypercalcemia, and their subsequent workup with bone mineral density (BMD) assessment, and ultimately, medical therapy or parathyroidectomy. RESULTS: Among 3151 patients with persistent hypercalcemia, 1526 (48%) had PTH measured, of whom 1377 (90%) were confirmed to have classic (49%) or normohormonal (41%) PHPT. PTH was measured in 65% of hypercalcemic patients with osteopenia or osteoporosis (P < .001). At median 2-year follow-up, bone density was assessed in 275 (20%) patients with either variant of PHPT (P = .003). Of women aged 50 years or older with classic PHPT, 95 (19%) underwent BMD assessment. Of patients with classic or normohormonal PHPT, 919 patients (67%) met consensus criteria for surgical intervention, though only 143 (15%) underwent parathyroidectomy. CONCLUSION: Within a large academic health system, more than half of patients with confirmed hypercalcemia were not assessed for PHPT, including many patients with preexisting bone disease. Care gaps in BMD assessment and medical or surgical therapy represent missed opportunities to avoid skeletal and other complications of PHPT.

Derivation of a cost-saving screening strategy for asymptomatic primary hyperparathyroidism.

BACKGROUND: Our study seeks to find a cost-saving screening strategy in a primary care population for diagnosing primary hyperparathyroidism based on peak serum total calcium level, age, and patient sex. METHODS: Laboratory data resulting from primary care office visits at our institution between January 2016 through December 2017 to evaluate patients who had at least 1 episode of hypercalcemia (≥10.5 mg/dL). For each serum calcium threshold, we calculated the percentage of patients who were found to have an increased parathyroid hormone level (≥65 pg/mL). We determined whether net cost savings could be achieved by screening hypercalcemic patients given their probability of primary hyperparathyroidism and expected cost savings from fracture risk reduction, given their sex and age. RESULTS: From 155,350 unique patients in the study period, a total of 2,271 had a minimum of 1 hypercalcemic lab value. After exclusion criteria, there were 1,326 patients of whom 27.5% had a parathyroid hormone level checked. Cost savings was established at a screening threshold of 10.5 for all patients until age 66 years for men and 69 years for women. For men aged 67-68 y and women aged 70-71 years, the optimal screening threshold was 10.8 mg/dl. CONCLUSION: Cost savings can be achieved by screening hypercalcemic patients with a life expectancy exceeding 16 years, with varying thresholds based on age and sex.

Parathyroidectomy for asymptomatic primary hyperparathyroidism: A revised cost-effectiveness analysis incorporating fracture risk reduction.

BACKGROUND: Recent data demonstrate decreased fracture risk after operation for asymptomatic primary hyperparathyroidism. We performed a revised cost-effectiveness analysis comparing parathyroidectomy versus observation while incorporating fracture risk reduction. METHODS: A Markov transition-state model was created comparing parathyroidectomy and guideline-based medical observation for a 60-year-old female patient with mild asymptomatic primary hyperparathyroidism. Costs were estimated using published Medicare reimbursement data. Treatment strategy outcomes, including risk of fracture, were identified by literature review. Quality adjustment factors were used to weight treatment outcomes. A threshold of $100,000/quality-adjusted life year was used to determine cost-effectiveness. Sensitivity analyses and Monte Carlo simulation were performed to examine the effect of uncertainty on the model. RESULTS: Parathyroidectomy was the dominant strategy (less costly and more effective) with an incremental cost savings of $1,721 and an incremental effectiveness of 0.185 quality-adjusted life years. Parathyroidectomy remained dominant when the relative risk reduction of fracture after operation was ≥14%, the cost of fracture was ≥$7,600, or the probability of recurrent laryngeal nerve injury was <12.5%. Monte Carlo simulation showed parathyroidectomy was cost-effective in 995/1,000 hypothetical patients. CONCLUSION: When fracture risk reduction is considered, parathyroidectomy for mild asymptomatic primary hyperparathyroidism is the dominant strategy when compared to observation.

How should age at diagnosis impact treatment strategy in asymptomatic primary hyperparathyroidism? A cost-effectiveness analysis.

BACKGROUND: The National Institutes of Health consensus conference on asymptomatic primary hyperparathyroidism (PHPT) recommended several criteria for parathyroidectomy (PTX), including age <50 years. We hypothesized that a cost-effectiveness analysis would show PTX to be the optimal strategy for asymptomatic patients >50 years of age. METHODS: A Markov model was constructed comparing operative, observational, and pharmacologic treatments. Costs were estimated from a third-party payer perspective. Outcomes were weighted with utility adjustment factors, yielding quality-adjusted life-years (QALYs). Future costs and QALYs were discounted at 3%. Threshold analysis identified the optimal strategy at life expectancies ranging from 6 months to 75 years. Multivariate sensitivity analysis was completed with Monte Carlo simulation. RESULTS: PTX was optimal when life expectancy reached 5 years for outpatient PTX and 6.5 years for inpatient PTX. Observation was the optimal strategy at all shorter life expectancies considered. The pharmacologic treatment strategy was not optimal at any life expectancy. CONCLUSION: PTX is the optimal strategy for many patients with asymptomatic PHPT who are >50 years of age. PTX is cost effective for patients with a predicted life expectancy of 5 years (outpatient) or 6.5 years (inpatient). For patients with a shorter life expectancy, observation is the most cost-effective strategy.

Surgery versus medical follow-up in patients with asymptomatic primary hyperparathyroidism: a decision analysis.

OBJECTIVES: To examine the cost-effectiveness of strategies for management of primary asymptomatic hyperparathyroidism: surgical strategies and medical follow-up versus surgery. DESIGN: We used a Markov state-transition decision-analytic model for an hypothetical cohort of 55-year-old women to compare with a lifetime horizon costs and effectiveness of bilateral neck exploration (BNE), unilateral neck exploration (UNE), video-assisted parathyroidectomy (VAP) and lifelong medical follow-up shifting for either BNE or UNE in case of disease progression. METHODS: Data on localization tests, complications and treatment efficacies were derived from a systematic review of the literature. Outcomes were expressed as quality-adjusted life years (QALY). Costs (2002 Euro) discounted at 3% yearly were estimated from the health care system perspective. RESULTS: In the base-case analysis, VAP strategy (VAPS) was the most effective and BNE strategy (BNES) was the least costly. UNE strategy (UNES) had an incremental cost-effectiveness ratio of 2688 Euro/QALY versus BNES and VAPS of 17,250 Euro/QALY in comparison with UNES. Surgical management was more effective than medical follow-up with acceptable incremental cost-effectiveness ratios. VAPS became less effective than UNES over 71 years. Differences between UNES and VAPS were sensitive to success and complication rates, quality-of-life weights and procedural costs. Medical follow-up strategies became the most effective if quality-of-life weight for this condition was higher than 0.99. CONCLUSIONS: Surgery is more effective than medical follow-up at a reasonable cost and can be preferred except in patients choosing medical follow-up. Minimally invasive surgery is cost-effective compared to the traditional surgical approach.