Systems-Level Opportunities in the Management of Primary Hyperparathyroidism: an Informatics-Based Assessment

Abstract

Context Primary hyperparathyroidism (PHPT), a leading cause of hypercalcemia and secondary osteoporosis, is underdiagnosed. Objective 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. Design Retrospective cohort study. Setting Tertiary academic health system. Patients Outpatients with persistent hypercalcemia, who were then categorized as having classic or normohormonal PHPT. Main Outcome Measures The frequencies of serum parathyroid hormone (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, from whom 1377 (90%) were confirmed to have classic (49%) or normohormonal (41%) primary hyperparathyroidism (PHPT). PTH was measured in 65% of hypercalcemic patients with osteopenia or osteoporosis (p<0.001). Upon median two year follow-up, bone density was assessed in 275 (20%) patients with either variant of PHPT (p=0.003). Of women ≥ 50 years of age 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. Conclusions Within a large academic health system, over 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 opportunities to avoid skeletal and other complications of PHPT.

Hypercalcemia from primary hyperparathyroidism

“…PHPT has been increasing for decades since the advent of adding calcium measurement to routine metabolic panel testing ( 3 - 5 ). PHPT goes largely unrecognized and untreated in contemporary practice which complicates the measurement of its impact upon vasculopathy ( 6 - 8 ). To make matters worse, the incidence of atypical or borderline pHPT is increasing which complicates pHPT diagnosis and decisions regarding subsequent intervention ( 9 , 10 ).…”

“…The authors’ primary interest and focus is upon the latter at present. The challenge, after identifying the known populations of hypercalcemics in the Electronic Medical Record (EMR) that are never evaluated further ( 6 - 8 ), is to match elevated calcium values to other laboratory studies and/or validated elements within a data phenotype to risk stratify individuals for the diagnosis of pHPT and notify their physicians to make appropriate referrals.…”