Expert panel develops quality indicators for diagnosis and treatment of primary hyperparathyroidism

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By Megan Brooks

NEW YORK (Reuters Health) - An expert panel has developed quality indicators (QIs) for the diagnosis and management for primary hyperparathyroidism (pHPT), which they hope will help optimize quality and cost-effectiveness of care for patients.

"To our knowledge, these are the first pHPT QIs developed through a robust evidence and consensus-based methodology," write Dr. Jesse Pasternak of the University of Toronto and colleagues in JAMA Otolaryngology - Head & Neck Surgery.

pHPT is a common endocrine disorder causing dysregulation of calcium homeostasis. Diagnosing and treating the disorder can be challenging. Despite high-quality guidelines, care is variable, and there is low adherence to evidence-based treatment pathways.

Research has shown that patients are "under treated for parathyroid disease, and those that are treated may not be getting the optimal management," Dr. Pasternak told Reuters Health by email.

"We brought representative stakeholders from the health system to delineate a practical approach and guide to diagnosis and management for those with parathyroid disease to optimize patient outcomes," Dr. Pasternak said.

The "top" QIs proposed by the panel include:

- Diagnosis of pHPT should be made on biochemical grounds, and biochemical evaluation of suspected pHPT should include adequate calcium measurement (total calcium, corrected calcium, ionized calcium as appropriate), PTH, creatinine, and 25-hydroxyvitamin D levels.

- Parathyroidectomy is indicated, and is the preferred treatment, for all patients with symptomatic pHPT.

- Parathyroidectomy is indicated regardless of whether objective symptoms are present or absent when there is objective evidence of kidney involvement, including silent nephrolithiasis on kidney imaging, nephrocalcinosis, hypercalciuria with increased stone risk, or impaired kidney function.

- 24-hour urinary calcium and vitamin D serum levels should be measured in patients with pHPT, specifically those at risk for familial hypocalciuric hypercalcemia.

- Parathyroidectomy is indicated regardless of whether objective symptoms are present or absent when the serum calcium level is >1 mg/dL (0.25 mmol/L) above normal.

- Parathyroidectomy is indicated regardless of whether objective symptoms are present or absent in patients with osteoporosis, fragility fracture, or evidence of vertebral compression fracture on spine imaging.

- If the patient meets an indication for parathyroidectomy, negative imaging results should not preclude parathyroidectomy.

- Patients should not receive medical therapy (cinacalcet) for definitive management.

- Appropriate surgical strategies for parathyroidectomy include limited parathyroid exploration with use of intraoperative PTH or four-gland parathyroid exploration.

- Patients undergoing surgery for pHPT should have a cure rate approaching 98%.

- Preoperative imaging should start with the performance of cervical ultrasonography combined with sestamibi or 4-dimensional computed tomography.

"Health system clinician leaders can use these relatively brief QI tools to find areas of improvement and create metrics for benchmarking in how they find and treat patients with parathyroid disease," Dr. Pasternak told Reuters Health.

"Ultimately, if clinicians including surgeons, internists and primary care doctors can use this paper as part of their common-sense approach in guiding a more standardized and evidence-based management of parathyroid disease, patients who are affected will be better served," Dr. Pasternak added.

SOURCE: https://bit.ly/3r8pBt0 JAMA Otolaryngology - Head & Neck Surgery, online January 6, 2022.

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