Most older adults with primary hyperparathyroidism (PHPT) did not receive definitive treatment with parathyroidectomy, instead receiving non-operative management, researchers reported.
According to a population-based cohort study, older age, frailty, and multimorbidity had inverse associations with parathyroidectomy — and guideline recommendations had minimal impact on treatment decisions, “especially among frail patients with a high comorbidity burden,” wrote Carolyn D. Seib, MD, MAS, Department of Surgery, Stanford University School of Medicine, Stanford, California, and colleagues in JAMA Surgery.
PHPT is a common endocrine disorder that has tripled in prevalence over the past two decades, Seib and colleagues explained. It primarily affects older adults and is associated with an increased risk of osteoporotic fractures, nephrolithiasis, and chronic kidney disease, as well as neurocognitive impairment and cardiovascular disease.
The only definitive treatment for PHPT is parathyroidectomy. “However, despite more inclusive surgical guidelines and evidence that operative cure results in benefits across multiple dimensions, including a reduced risk of fractures, and symptomatic nephrolithiasis and improved quality of life, rates of parathyroidectomy for the management of PHPT are low and have been declining over time,” Seib and colleagues noted.
In addition, small studies found that no matter how severe the disease is, or whether consensus guidelines are met, older age is associated with delays in surgical referral and decreased likelihood of parathyroidectomy. This is particularly problematic for older patients, the authors added, since they are at greater risk of fracture, nephrolithiasis, and chronic kidney disease and are more likely to benefit from parathyroidectomy.
Therefore, in this study, Seib and colleagues wanted to assess the factors influencing treatment decisions for older adults with PHPT by conducting a population-based, retrospective cohort study, using 100% Medicare claims from beneficiaries with an initial diagnosis of PHPT from Jan. 1, 2006, to Dec. 31, 2016.
The primary outcome was management with parathyroidectomy within 1 year of diagnosis.
The authors identified 210,206 diagnosed with PHPT during the period of the study (mean age of 75.3 years, 78% women, and 87.3% white). Among these individuals, 63,136 (30%) underwent parathyroidectomy within 1 year of diagnosis. They were more likely to be younger, white, prefrail or robust, and have a lower comorbidity burden than those who didn’t undergo parathyroidectomy.
About two-thirds (62.7%) of patients met at least 1 guideline criteria for surgical management, 29.6% of whom were treated with parathyroidectomy within 1 year of diagnosis.
Seib and colleagues found that on multivariable analysis, increasing age had a strong inverse association with parathyroidectomy among patients aged 76-85 (unadjusted rate, 25.9%; odds ratio [OR], 0.68 [95% CI, 0.67-0.70]) and older than 85 (unadjusted rate, 11.2%; OR, 0.27 [95% CI, 0.26-0.29]) compared with those aged 66 -75 (unadjusted rate, 35.6%).
The same held true for patients with moderate to severe frailty (unadjusted rate, 18.9%; OR, 0.60 [95% CI, 0.56-0.64]) compared with robust patients (unadjusted rate, 36.1%), as well as those with a Charlson Comorbidity Index score of 2 or greater (unadjusted rate, 25.9%; OR, 0.77 [95% CI, 0.75-0.79]) compared with a Charlson Comorbidity Index score of 0 (unadjusted rate, 37.0%).
In addition, patients living in the most disadvantaged neighborhoods and rural areas were more likely to be treated with parathyroidectomy.
As for guidelines consensus criteria, Seib and colleagues found that while a history of nephrolithiasis increased the odds of parathyroidectomy (OR, 1.43 [95% CI, 1.39-1.47]), a history of stage 3 chronic kidney disease decreased the odds of parathyroidectomy (OR, 0.71 [95% CI, 0.68-0.74]). A history of osteoporosis had no association with parathyroidectomy (OR, 1.01 [95% CI, 0.99-1.03]).
These results, wrote Seib and colleagues, resemble those from smaller regional, single-center, and Veterans Affairs studies and “confirm that poor adherence to guidelines is national in scope, preferentially affecting older adults.”
“Further research is needed to identify barriers to surgical care and develop tools to target parathyroidectomy to older adults most likely to benefit,” the authors concluded.
In a commentary accompanying the study, Martin Almquist, MD, PhD, and Martin Nilsson, MD, both of the Department of Surgery, Skåne University Hospital, Lund University, Lund, Sweden, asked why just 30% of patients fulfilling consensus criteria for surgery underwent parathyroidectomy. It could be, they suggested, that the fact that neither PHPT nor osteoporosis are associated with severe symptoms, and that older women are generally not vocal or outspoken about the disease, may account for this state of affairs.
In the case of hyperparathyroidism, Seib and colleagues “have done an excellent job in finding an area where the medical community can improve,” Almquist and Nilsson wrote. “Seib et al clearly show that PHPT is undertreated and barriers to treatment need to be identified to start treating patients with PHPT according to guidelines.”
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Most older patients with hyperparathyroidism do no undergo definitive treatment with parathyroidectomy.
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This suggests that many patients with hyperthyroidism are being treatment with minimal consideration of consensus guidelines.
Michael Bassett, Contributing Writer, BreakingMED™
Seib reported consulting for Virtual Incision Corporation.
Almquist reported grants from Ipsen and Medtronic outside the submitted work.
Cat ID: 110
Topic ID: 76,110,730,110,187,127,192,925,159
