Use of parathormone as a predictor of hypoparathyroidism after total thyroidectomy.

BACKGROUND: Post-operative hypoparathyroidism is the most frequent complication after total thyroidectomy. It represents one of the main causes of prolonged hospital-stay and is associated with a significant increase in health costs. The identification of patients with higher risk of suffering this complication allows early treatment, reduces clinical complications and adequate the use of health resources. Throughout history, several predictors have been used to stratify patients at risk. In recent years the use of parathormone parathyroid hormone (PTH) has taken particular interest. OBJECTIVE: To review the existing literature on the use of PTH as a predictor of hypocalcemia after thyroidectomy. METHOD: A medline search was performed. We reviewed the existing evidence on efficacy of PTH as a predictor of post-operative hypocalcemia, economic impact, optimal time for sampling and implementation mode. CONCLUSION: The use of PTH predicts with adequate sensitivity, specificity, negative and positive predictive value the risk for the patients to suffer post-operative hypocalcemia. Cut-off values and sampling number and time vary among authors; as a result, more data is needed to reach a conclusion about the standardization of use after a total thyroidectomy procedure. It use could be beneficial not only for patients but also for care providers as health cost might be diminished.

ANTECEDENTES: El hipoparatiroidismo posoperatorio constituye la complicación más frecuente de la tiroidectomía total. Se asocia, entre otras cosas, a internación prolongada y múltiples pruebas de laboratorio, y con ello a un incremento en los costos de salud. La identificación de pacientes con mayor riesgo de padecer esta complicación permite realizar un tratamiento precoz, disminuyendo el costo económico y evitando complicaciones asociadas a un retraso en la externación. Se han descrito diversos predictores para identificar tempranamente a los pacientes en riesgo; en los últimos años, ha tomado particular relevancia el uso de la parathormona (PTH). OBJETIVO: El objetivo del presente trabajo es revisar la literatura existente sobre la utilidad de la PTH como predictor de hipocalcemia postiroidectomía. MÉTODO: Se realizó una búsqueda en PubMed revisando la evidencia existente sobre eficacia de la PTH como predictor de hipocalcemia posoperatoria, su repercusión económica, el tiempo óptimo para la toma de muestra y el modo de implementación. CONCLUSIÓN: El uso de la PTH permite predecir con adecuada sensibilidad, especificidad, valor predictivo negativo y valor predictivo positivo los pacientes en riesgo de padecer hipocalcemia posoperatoria. Sin embargo, los valores de corte, los tiempos de toma de muestra y la cantidad de estas varían entre los autores, por lo que persisten algunos interrogantes acerca de la estandarización de su uso.

Association of Hypocalcemia and Magnesium Disorders With Thyroidectomy in Commercially Insured Patients.

Importance: Hypocalcemia is a common complication of total thyroidectomy. Objectives: To identify factors associated with hypocalcemia after total thyroidectomy and to explore the association between hypocalcemia, magnesium disorders, and costs of care. Design, Setting, and Participants: A retrospective cross-sectional analysis was performed using data from the MarketScan Commercial Claim and Encounters database on 126 766 commercially insured patients younger than 65 years undergoing total thyroidectomy between January 1, 2010, and December 31, 2012. Statistical analysis was performed from January 1, 2016, to May 30, 2019. Main Outcomes and Measures: Short- and long-term hypocalcemia and the costs of care were examined using multivariable regression modeling. Results: Among the 126 766 patients in the study (81.6% women; mean age, 46.5 years [range, 18-64 years]), postoperative hypocalcemia was present in 19.1% of patients in the initial 30-day postoperative period and in 4.4% of patients at 1 year. Magnesium disorders were present in 2.1% of patients at the time of surgery. Short- and long-term hypocalcemia were significantly more likely in women (short-term: odds ratio [OR], 1.39 [95% CI, 1.29-1.50]; long-term: OR, 1.69 [95% CI, 1.52-1.89]), those younger than 40 years (short-term: OR for ages 40-64 years, 0.83 [95% CI, 0.78-0.87]; long-term: OR for ages 40-64 years, 0.73 [95% CI, 0.67-0.79]), those with a diagnosis of thyroiditis (short-term: OR, 1.48 [95% CI, 1.16-1.89]; long-term: OR, 1.60 [95% CI, 1.13-2.26]) or cancer (short-term: OR, 1.32 [95% CI, 1.05-1.67]; long-term: OR, 1.17 [95% CI, 0.83-1.63]), vitamin D deficiency (short-term: OR, 1.96 [95% CI, 1.74-2.21]; long-term: OR, 3.72 [95% CI, 3.30-4.18]), concurrent lateral neck dissection (short-term: OR, 1.51 [95% CI, 1.37-1.66]; long-term: OR, 1.95 [95% CI, 1.69-2.26]), concurrent central neck dissection (short-term: OR, 1.15 [95% CI, 1.07-1.24]; long-term: OR, 1.25 [95% CI, 1.12-1.40]), intraoperative parathyroid (short-term: OR, 1.58 [95% CI, 1.46-1.71]; and long-term: OR, 2.05 [95% CI, 1.82-2.31]) or recurrent laryngeal nerve injury (short-term: OR, 1.49 [95% CI, 1.27-1.74]; long-term: OR, 2.04 [95% CI, 1.64-2.54]), and magnesium disorders (short-term: OR, 8.40 [95% CI, 7.21-9.79]; long-term: OR, 25.23 [95% CI, 19.80-32.17]). Compared with the initial postoperative period, the odds of hypocalcemia decreased by 90.0% (OR, 0.10 [95% CI, 0.09-0.11]) at 6 months and 93.0% (OR, 0.07 [95% CI, 0.06-0.08]) at 1 year. After controlling for all other variables, magnesium disorders were associated with the highest odds of short- and long-term postoperative hypocalcemia. Hypocalcemia ($3392) and magnesium disorders ($14 314) were associated with increased mean incremental 1-year costs of care. Conclusions and Relevance: Hypocalcemia is common after total thyroidectomy but resolves in most patients by 1 year. Magnesium disorders are significantly independently associated with short- and long-term hypocalcemia and are associated with greater costs of care. These data suggest a potentially modifiable target to reduce the incidence and cost of long-term hypocalcemia at patient and systemic levels.

A comparative cost-utility analysis of postoperative calcium supplementation strategies used in the current management of hypocalcemia.

BACKGROUND: Symptomatic hypocalcemia is a common complication of total thyroidectomy. Management strategies include responsive treatment initiation for symptoms or prevention by routine or parathyroid hormone-directed calcium supplementation. The comparative cost-effectiveness of even the most often utilized strategies is unclear. METHODS: A Markov cohort model was created to compare routine supplementation with calcium alone (RS), postoperative parathyroid hormone-based selective supplementation with calcium and calcitriol (SS), and no supplementation (NS) in asymptomatic patients. Patients could remain asymptomatic or develop symptomatic hypocalcemia, managed with outpatient oral supplementation or intravenous calcium infusion and administered either inpatient or outpatient. Effectiveness was measured in quality-adjusted life years. Sensitivity analyses were performed to test model parameter assumptions. RESULTS: RS was the preferred strategy, costing $329/patient and resulting in 0.497 quality-adjusted life years, which was only marginally better compared to SS ($373 for 0.495 quality-adjusted life years). NS was most costly at $4,955 for 0.491 quality-adjusted life years. Preference for RS over SS was sensitive to the probability of developing symptoms and the probability of symptom treatment with intravenous supplementation. On probabilistic sensitivity analysis, RS was preferred in 75.4% of scenarios. CONCLUSION: After total thyroidectomy, a preventative calcium supplementation strategy should be strongly considered. In this data-driven theoretical model, RS was the least costly option and resulted in an incremental gain in quality-adjusted life years.

An Evaluation of Postoperative Complications and Cost After Short-Stay Thyroid Operations.

BACKGROUND: Concern for postoperative complications causing airway compromise has limited widespread acceptance of ambulatory thyroid surgery. We evaluated differences in outcomes and hospital costs in those monitored for a short stay of 6 h (SS), inpatient observation of 6-23 h (IO), or inpatient admission of >23 h (IA). METHODS: We retrospectively reviewed all patients undergoing thyroidectomy from 2006 to 2012. The incidence of postoperative hemorrhage, nerve dysfunction, and hypocalcemia were evaluated, as well as cost data comparing the SS and IO groups. RESULTS: Of 1447 thyroidectomies, 880 (60.8 %) were performed as SS, 401 (27.7 %) as IO, and 166 (11.5 %) as IA. Fewer patients in the SS group (59 %) underwent total thyroidectomy than IO (73 %) and IA (71 %; p < 0.01), and SS patients had smaller thyroid weights (27.9 g) compared with IO and IA (47.2 and 98.9 g, respectively; p < 0.01). Ten (0.69 %) patients developed hematomas requiring reoperation, five of the ten patients received antiplatelet or anticoagulant therapy perioperatively. Only one patient in the IA group bled within the 6- to 23-h period, and no patients with bleeding who were discharged at 6 h would have benefitted from 23-h observation. Twenty-four (1.66 %) recurrent laryngeal nerve injuries were identified, 16 with temporary neuropraxias. In addition, 24 (1.66 %) patients had symptomatic hypocalcemia, which was transient in 17 individuals. Financial data showed higher payments and lower costs associated with SS compared with IO. CONCLUSIONS: Selective SS thyroidectomy can be safe and cost effective, with few overall complications in patients undergoing more complex operations involving larger thyroids who were admitted to hospital.

A stochastic estimate of the economic impact of oral calcium supplementation in postparturient dairy cows.

The objective was to develop stochastic models to estimate the economic impact in the first 30 d in milk of oral calcium supplementation to multiparous postparturient dairy cows using 4 different strategies: (1) supplementation of cows with a high previous lactation mature-equivalent milk yield, (2) supplementation of lame cows, (3) supplementation of both cows that have a high previous lactation mature-equivalent milk yield and cows that are lame, and (4) supplementation of all cows. Data from current literature were used to model input variables associated with the costs and risks related to milk production, postparturient disease, and culling. The mean net herd impact per 1,000 calvings for each of the 4 supplementation strategies was $4,425, $5,812, $8,313, and $3,065, respectively. Postpartum supplementation of multiparous lame cows had the highest return on investment at 6.5 to 1, followed by supplementation of multiparous high milk yield and lame cows, multiparous high milk yield cows only, and supplementation of all multiparous postpartum cows with returns of 1.8 to 1, 1.1 to 1, and 0.3 to 1, respectively. A herd's average milk yield at first test had the highest influence on the net impact of oral calcium supplementation to all multiparous cows and accounted for 30% of the variation, followed by the decrease in risk of health events in lame cows given oral calcium at 22%, a herd's prevalence of lameness at calving at 13%, and the price of milk at 10%. Each of the remaining stochastic variables contributed to less than 5% of the variation in net herd financial impact of oral calcium administration. Whereas supplementation of all postpartum multiparous cows returned a positive net herd impact approximately 80% of the time, if a herd was willing to devote time to mature-equivalent milk yield calculations and locomotion scoring, supplementation of this subpopulation of postpartum cows with oral calcium was estimated to have a positive economic impact in all iterations. Depending on the supplementation strategy chosen and baseline milk yield and immediate postpartum lameness prevalence in a herd, a herd with 1,000 calvings per year can expect to see an average net impact ranging from approximately $3,000 to $8,000 after postpartum supplementation of oral calcium in multiparous animals.

Safety, efficacy, and cost savings of single parathyroid hormone measurement for risk stratification after total thyroidectomy.

The management of hypocalcemia (HC) after total thyroidectomy (TTx) is a challenge as TTx is transitioned into a same-day surgery. Measurement of parathyroid hormone (PTH) level after TTx may allow for prediction of postoperative HC and lead to shorter hospital stays. A prospective database was queried between January 2010 and June 2012 with 95 patients who had undergone TTx identified. Patient demographics; preoperative diagnosis; laboratory values and cost; complications; intravenous calcium supplementation; and length of stay (LOS) were analyzed. A PTH-based algorithm was retrospectively applied and theoretical cost savings were analyzed in terms of laboratory cost, LOS, and total cost. Ninety-five patients underwent TTx: 37 patients (38.9%) had cancer, whereas 27 (28.4%) had Graves' disease and the remaining 31 (32.6%) had a benign multinodular goiter. Postoperative PTH was recorded in 72 patients (74.4%); 46 (63.8%) had PTH greater than 10 pg/mL and 26 (36.9%) had PTH less than 10 pg/mL. Transient HC occurred in 10 patients (38.4%) with PTH less than 10 pg/mL (relative risk, 17.69; P = 0.0001). Patients with PTH less than 10 pg/mL incurred a 14.9 per cent higher hospital cost compared with those with PTH greater than 10 pg/mL. With retrospective implementation of the algorithm, there is a potential 46.4 per cent cost savings for the PTH less than 10 pg/mL group, 67.3 per cent savings for the PTH greater than 10 pg/mL group, and 46.7 per cent savings when taken altogether. Algorithmic risk stratification based on postoperative PTH less than 10 pg/mL serves as both a sensitive (100%) and specific (76.7%) predictor of postoperative HC. Such risk stratification may allow for same-day discharge in a number of patients, and even in patients requiring an overnight stay, result in cost savings as a result of a reduction in laboratory expenditures.

Questionable safety of thyroid surgery with same day discharge.

INTRODUCTION: Over the last two decades increasing numbers of surgical procedures have been performed on an outpatient basis. In 2000 the National Health Service in England set the target of performing 75% or more of all elective surgical procedures as day cases and in 2001 the British Association of Day Surgery added thyroidectomy to the list of day case procedures. However, same day discharge following thyroidectomies has been adopted by only a very small number of UK centres. The aim of this review was to establish the evidence base surrounding same day discharge thyroid surgery. METHODS: The British Association of Endocrine and Thyroid Surgeons commissioned the authors to perform a review of the best available evidence regarding day case thyroid surgery as a part of a consensus position to be adopted by the organisation. A MEDLINE(®)review of the English medical literature was performed and the relevant articles were collated and reviewed. RESULTS: There are limited comparative data on day case thyroid surgery. It is feasible and may save individual hospitals the cost of inpatient stay. However, the risk of airway compromising and life threatening post-operative bleeding remains a major concern since it is not possible to positively identify those patients most and least at risk of bleeding after thyroidectomy. It is estimated that half of all post-thyroidectomy bleeds would occur outside of the hospital environment if patients were discharged six hours after surgery. CONCLUSIONS: Same day discharge in a UK setting cannot be endorsed. Any financial benefits may be outweighed by the exposure of patients to an increased risk of an adverse outcome. Consequently, 23-hour surgery is recommended.

Cost-effectiveness analysis regarding postoperative administration of vitamin-D and calcium after thyroidectomy to prevent hypocalcaemia / Análisis de costo-efectividad de la administración postoperatoria de Vitamina D y calcio después de tiroidectomía para la prevención de la hipo calcemia

Objective Hypocalcaemia is a frequently arising complication following total thyroidectomy. Routine postoperative prophylactic administration of vitamin D or metabolites and calcium reduce the incidence of symptomatic hypocalcaemia; this article reports evaluating its cost-effectiveness in Colombia. Methods Meta-analysis was used for comparing the administration of vitamin D or metabolites to oral calcium or no treatment at all in patients following total thyroidectomy and a cost-effectiveness analysis was designed based on a decision-tree model with local costs. Results The OR value for the comparison between calcitriol and calcium compared to no treatment and to exclusive calcium treatment groups was 0.32 (0.13-0.79 95 %CI) and 0.31 (0.14-0.70 95 %CI), respectively. The most cost-effective strategy was vitamin D or metabolites and calcium administration, having a US $0.05 incremental cost-effectiveness ratio. Conclusion Prophylactic treatment of hypocalcaemia with vitamin D or metabolites + calcium or calcium alone is a cost-effective strategy.

Objetivos La hipo calcemia es la complicación más frecuente después de tiroidectomía. La administración profiláctica de vitamina D o metabolitos y calcio reduce la incidencia de hipocalcémia sintomática. Se evalúa su costo-efectividad en Colombia. Materiales y métodos Utilizamos la información de un meta-análisis que comparó la administración de vitamina D o metabolitos contra calcio no tratamiento en pacientes llevados a tiroidectomía total y diseñamos un análisis de costo-efectividad basados en un modelos de decisiones con costos locales. Resultados El valor del OR para la comparación entre calcitriol y calcio comparado con no tratamiento o calcio exclusivo fue de 0.32 (95 % IC, 0.13- 0.79) y 0.31 (95 % IC, 0.14-0.70), respectivamente. La estrategia más costo-efectiva fue la administración de vitamina D o metabolitos y calcio, con una relación de costo-efectividad incremental de US $0.05. Conclusiones El tratamiento profiláctico de la hipo calcemia con vitamina D o metabolitos y calcio o calcio exclusivo después de tiroidectomía total es una estrategia costo-efectiva.

Cost-effectiveness analysis regarding postoperative administration of vitamin-D and calcium after thyroidectomy to prevent hypocalcaemia.

OBJECTIVE: Hypocalcaemia is a frequently arising complication following total thyroidectomy. Routine postoperative prophylactic administration of vitamin D or metabolites and calcium reduce the incidence of symptomatic hypocalcaemia; this article reports evaluating its cost-effectiveness in Colombia. METHODS: Meta-analysis was used for comparing the administration of vitamin D or metabolites to oral calcium or no treatment at all in patients following total thyroidectomy and a cost-effectiveness analysis was designed based on a decision-tree model with local costs. RESULTS: The OR value for the comparison between calcitriol and calcium compared to no treatment and to exclusive calcium treatment groups was 0.32 (0.13-0.79 95 %CI) and 0.31 (0.14-0.70 95 %CI), respectively. The most cost-effective strategy was vitamin D or metabolites and calcium administration, having a US $0.05 incremental cost-effectiveness ratio. CONCLUSION: Prophylactic treatment of hypocalcaemia with vitamin D or metabolites + calcium or calcium alone is a cost-effective strategy.

Cost savings associated with post-thyroidectomy parathyroid hormone levels.

OBJECTIVES: A 1-hour post-thyroidectomy parathyroid hormone (PTH) level of < or =8 ng/L is predictive of patients who will develop hypocalcemia and guides early supplementation with calcium and vitamin D. However, most hypocalcemic patients fail to meet this criterion. The goal of this study was to determine whether PTH < or = 15 ng/L could be used as a better predictor of hypocalcemia. STUDY DESIGN, SUBJECTS, AND METHODS: This retrospective study involved 270 thyroidectomy patients (2004-2006). PTH and calcium levels, length of admission, supplementation, and rates of hypocalcemia were recorded. RESULTS: Forty-three percent (26/60) of patients developing hypocalcemia met the PTH < or = 8 ng/L cut-off. In contrast, 80% (48/60) of patients developing hypocalcemia had a PTH < or = 15 ng/L. Two point two percent of patients had a 1-hour PTH < or = 15 ng/L and failed to develop hypocalcemia, for a specificity of 97%. CONCLUSIONS: A 1-hour PTH cut-off of < or =15 ng/L for prophylactic supplementation should allow the prevention of the majority of cases of hypocalcemia, leading to significant cost savings by shortening hospital stays.

Clinical and economic impact of falsely decreased calcium values caused by gadoversetamide interference.

OBJECTIVE: Gadolinium is administered as a contrast agent in MRI procedures. Two gadolinium-based contrast agents, gadodiamide and gadoversetamide, interfere with colorimetric total serum calcium methods. The purpose of this prospective observational study was to examine the incidence of calcium interference after gadoversetamide procedures, associated clinical outcomes, and costs 20 months after implementation of quality assurance and physician education programs. MATERIALS AND METHODS: Records of patients who received gadoversetamide from June 24, 2006, to October 7, 2006, were reviewed to determine if a routine calcium test had been performed after the injection. Calcium values were repeated with an alternate method that is less susceptible to gadoversetamide interference. If the difference was > or = 2.0 mg/dL or if the initial test value was < or = 7.0 mg/dL, patient charts were reviewed for any related treatment. Costs associated with this algorithm were tracked. RESULTS: The initial calcium test was performed after gadoversetamide in 766 of 3,439 instances. The alternate test was performed in 633 of 766. One hundred twenty-five of 633 (20%) showed a difference in calcium values that was > or = 0.7 mg/dL, with 16 showing differences of > or = 1.6 mg/dL. Chart review for 56 instances revealed that calcium supplements were administered in 22 of 56 around the time of gadoversetamide injection. However, none appeared to be related to the spurious hypocalcemia. The total additional cost (reagent and technologist) for following this algorithm for just over 3 months was $6,807. CONCLUSION: Approximately 20% of patients receiving gadoversetamide exhibited spurious hypocalcemia. No patients were identified who received inappropriate calcium because of this interference. This may be attributable to the quality assurance and physician education programs.

Benefits resulting from 1- and 6-hour parathyroid hormone and calcium levels after thyroidectomy.

OBJECTIVE: Previous studies have established the efficacy of post-thyroidectomy hypocalcemia monitoring using parathyroid hormone (PTH) and corrected calcium levels at 1 and 6 hours. The goal of this study was to measure the impact of managing patients based on the above findings with respect to: duration of hospital stays, rates of transient hypocalcemia, number of blood tests, cost savings, and discharge from the hospital as early as 8 hours post-thyroidectomy without compromising safety. STUDY DESIGN AND SETTING: This is a prospective study involving 95 total thyroidectomy patients using historical data as controls. The previous protocol was modified in that all blood tests ceased for patients meeting the 6-hour critical level of PTH > or = 28 ng/L and simultaneous corrected calcium > or = 2.14 mmol/L (8.56 mg/dL). Furthermore, patients with 1-hour PTH levels < or = 8 ng/L were prophylactically treated with calcium and vitamin D supplementation. RESULTS: This study demonstrates lower rates of transient hypocalcemia from 28% to 9% (OR = 4.13, P = 0.016), a 10-hour reduction in mean hospital stay, and fewer blood tests (23 vs 15) for patients undergoing total thyroidectomy since the implementation of the new protocol. Furthermore, the experimental protocol resulted in an average cost savings of 766 Canadian dollars per patient. CONCLUSIONS: The new algorithm resulting from PTH and corrected calcium monitoring at 1 and 6 hours post-thyroidectomy has led to significant cost savings for our institution. It has also translated into greater patient satisfaction as a result of fewer blood tests, a lower incidence of transient hypocalcemia, and significantly shorter hospital stays.

Early hospital readmission was less likely for hemodialysis patients from facilities with longer median length of stay in the DOPPS study.

The length of hospital stay is considered to influence hospital readmission in general. The Dialysis Outcomes and Practice Patterns Study (DOPPS), an international prospective observational study undertaken to establish a relationship between facility practices and dialysis outcomes, started in 1996. Results suggest that the duration of hospital stay is significantly correlated with the probability of early readmission in dialysis patients. Thus, early hospital readmission was observed to be less likely for hemodialysis patients from facilities with longer median length of stay. The lengths of hospital stay for hemodialysis patients differed in the three continents studied. Although socioeconomic pressures may drive the lengths of hospital stay, the duration of hospitalization should be determined keeping in mind the safety of clinical course for each disease. In this forum, a 47-year-old female hemodialysis patient with severe secondary hyperparathyroidism, who had been treated with hemodialysis for 21 years, was hospitalized with severe clinical symptoms. Although the clinical symptoms disappeared 10 days after total parathyroidectomy with autotransplantation, severe hypocalcemia persisted despite large amounts of intravenous calcium gluconate. This patient was hospitalized for a long duration owing to the large calcium deficit in her body. Had the length of her hospital stay been shortened, either she could have needed rehospitalization or her condition could have worsened.