Rates and Outcomes of Parathyroidectomy for Secondary Hyperparathyroidism in the United States.

BACKGROUND AND OBJECTIVES: Secondary hyperparathyroidism is common among patients with ESRD. Although medical therapy for secondary hyperparathyroidism has changed dramatically over the last decade, rates of parathyroidectomy for secondary hyperparathyroidism across the United States population are unknown. We examined temporal trends in rates of parathyroidectomy, in-hospital mortality, length of hospital stay, and costs of hospitalization. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Using the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, a representative national database on hospital stay regardless of age and payer in the United States, we identified parathyroidectomies for secondary hyperparathyroidism from 2002 to 2011. Data from the US Renal Data System reports were used to calculate the rate of parathyroidectomy. RESULTS: We identified 32,971 parathyroidectomies for secondary hyperparathyroidism between 2002 and 2011. The overall rate of parathyroidectomy was approximately 5.4/1000 patients (95% confidence interval [95% CI], 5.0/1000 to 6.0/1000). The rate decreased from 2003 (7.9/1000 patients; 95% CI, 6.2/1000 to 9.6/1000), reached a nadir in 2005 (3.3/1000 patients; 95% CI, 2.6/1000 to 4.0/1000), increased again through 2006 (5.4/1000 patients; 95% CI, 4.4/1000 to 6.4/1000), and remained stable since that time. Rates of in-hospital mortality decreased from 1.7% (95% CI, 0.8% to 2.6%) in 2002 to 0.8% (95% CI, 0.1% to 1.6%) in 2011 (P for trend <0.001). In-hospital mortality rates were significantly higher in patients with heart failure (odds ratio [OR], 4.23; 95% CI, 2.59 to 6.91) and peripheral vascular disease (OR, 4.59; 95% CI, 2.75 to 7.65) and lower among patients with prior kidney transplantation (OR, 0.20; 95% CI, 0.06 to 0.65). CONCLUSIONS: Despite the use of multiple medical therapies, rates of parathyroidectomy of secondary hyperparathyroidism have not declined in recent years.

Trends in parathyroidectomy rates in US hemodialysis patients from 1992 to 2007.

BACKGROUND: Parathyroidectomy rates in hemodialysis patients increased from 1992 to 2002, when medication choices to manage secondary hyperparathyroidism expanded. STUDY DESIGN: Retrospective follow-up registry study. SETTING & PARTICIPANTS: We evaluated annual cohorts of point-prevalent US hemodialysis patients with Medicare as primary payer for 1992-2007 (n = 1,063,258 for 1992-1999; 757,207 for 2000-2003; 902,119 for 2004-2007). PREDICTOR: Comorbid conditions, vitamin D use, previous kidney transplant, and parathyroid hormone testing were assessed in the previous year. Available bone and mineral disorder treatment patterns were evaluated. OUTCOMES: We examined incidence rate trends and patient characteristics through 2007 to estimate the association between parathyroidectomy and patient factors. Follow-up was from January 1 of each study year to the earliest in the same year of parathyroidectomy, death, or December 31. MEASUREMENTS: We used χ(2) analysis to compare patient characteristics in 3 time frames. Unadjusted and adjusted parathyroidectomy rates were calculated. Cox regression was used to test the association of parathyroidectomy and covariates. RESULTS: Adjusted parathyroidectomy rates increased from 1998 (7.0/1,000 patient-years; 1,045 events), peaked in 2002 (12.8/1,000 patient-years; 2,229 events), decreased through 2005 (5.4/1,000 patient-years; 1,078 events), and increased in 2006 (8.6/1,000 patient-years; 1,743 events) and 2007 (8.8/1,000 patient-years; 1,832 events). Vitamin D use, virtually undetectable in 1991, subsequently steadily increased; >80% of patients received vitamin D in 2006. LIMITATIONS: The study was not designed to provide causal explanations for observed changes; oral medication use trend data were limited to one large dialysis provider and may not reflect use patterns in all dialysis facilities; because Medicare is not the primary payer for all US hemodialysis patients, results do not describe the entire US hemodialysis population; parathyroid hormone values are lacking in the database. CONCLUSIONS: Adjusted parathyroidectomy rates varied substantially from 1992 through 2007. Rates were highest in 1994 and 2002 and lowest in 1998 and 2005, likely influenced by changing medication use patterns and guideline publication.

Recent trends becoming standard of care yielding smaller, more successful operations at a lower cost.

Surgeons are now performing much smaller, more directed parathyroid operations in less time, and reported cure rates are the highest they have ever been. The ability to operate physiologically,and not just anatomically, has allowed a more directed and confident approach. This approach has subsequently led to minimal use of anesthesia and to immediate postoperative discharge,changes that have been embraced enthusiastically by referring endocrinologists. This article discusses the intraoperative monitoring used by the author and the pitfalls that can await the inexperienced surgeon.