Undertreatment of primary hyperparathyroidism in a privately insured US population: Decreasing utilization of parathyroidectomy despite expanding surgical guidelines.
Undertreatment of primary hyperparathyroidism in a privately insured US population: Decreasing utilization of parathyroidectomy despite expanding surgical guidelines.
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DOI：
10.1016/j.surg.2020.04.066
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发表时间：
2021-01
期刊：
影响因子：
3.8
通讯作者：
Kebebew E
中科院分区：
文献类型：
--
作者：
Seib CD;Meng T;Suh I;Cisco RM;Lin DT;Morris AM;Trickey AW;Kebebew E
原发性甲状旁腺功能亢进症(PHPT)与骨质疏松症、肾结石和慢性肾脏疾病(CKD)的发病率有关。甲状旁腺切除术(PTX)可以预防这些后遗症，但在许多实践中应用较少。我们使用国家Optom去识别的Clinformatics®数据集市数据库进行了一项回溯性队列研究。我们确定了2004年至2016年首次观察到的≥诊断为35岁的患者。多变量Logistic回归用于确定与PTX相关的患者/提供者特征。在26,522名PHPT患者中，10,101名(38.1%)接受了PTX。在14,896名有手术指征的患者中，5,791名(38.9%)接受了PTX。随着时间的推移，PTX的发生率总体上呈下降趋势(2004年：54.4%，2016年：32.4%，P<；.001)，在有和没有手术指征的组中都有下降趋势。多变量分析显示，年龄和合并症的增加与PTX显著负相关(年龄75-84，OR0.50[95%可信区间0.45-0.55]；年龄≥85，OR 0.21[95%可信区间0.17-0.26]对年龄35-49；Charlson共病指数≥2vs0或0.62[95%可信区间0.58-0.66])。大多数美国私人保险的PHPT患者不接受PTX治疗。有手术指征仅略微增加PTX的可能性。需要进一步的研究来解决治疗障碍和PHPT指南与临床护理之间的差距。使用Optom去识别的Clinformatics数据集市数据库，我们发现大多数患者没有接受甲状旁腺切除术，满足手术的普遍标准只略微增加了最终手术治疗的可能性。这些结果很重要，因为它们表明，需要有重点的努力来教育提供者关于管理原发性甲状旁腺功能亢进症的适当的、基于证据的指南，并确定手术转诊和使用甲状旁腺切除术的障碍。
Primary hyperparathyroidism (PHPT) is associated with substantial morbidity, including osteoporosis, nephrolithiasis, and chronic kidney disease (CKD). Parathyroidectomy (PTX) can prevent these sequelae but is poorly utilized in many practice settings. We performed a retrospective cohort study using the national Optum de-identified Clinformatics® Data Mart Database. We identified patients aged ≥35 with a first observed PHPT diagnosis from 2004–2016. Multivariable logistic regression was used to determine patient/provider characteristics associated with PTX. Of 26,522 patients with PHPT, 10,101 (38.1%) underwent PTX. Of the 14,896 patients with any operative indication, 5,791 (38.9%) underwent PTX. Over time, there was a decreasing trend in the rate of PTX overall (2004: 54.4% to 2016: 32.4% p<.001) and among groups with and without an operative indication. On multivariable analysis, increasing age and comorbidities were strongly, inversely associated with PTX (age 75–84, OR 0.50[95%CI 0.45–0.55]; age ≥85, OR 0.21[95%CI 0.17–0.26] versus age 35–49; Charlson Comorbidity Index ≥2 vs 0 OR 0.62[95%CI 0.58–0.66]). The majority of U.S., privately insured patients with PHPT are not treated with PTX. Having an operative indication only modestly increases the likelihood of PTX. Further research is needed to address barriers to treatment and the gap between guidelines and clinical care in PHPT. Using the Optum de-identified Clinformatics Data Mart Database, we found that the majority of patients are not treated with parathyroidectomy and meeting the consensus criteria for surgery only modestly increases the likelihood of definitive surgical management. These results are important, because they suggest that focused efforts are needed to educate providers about appropriate, evidence-based guidelines for management of primary hyperparathyroidism and to identify barriers to surgical referral and utilization of parathyroidectomy.
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