Understanding Reasons for Underdiagnosis and Undertreatment of Primary Hyperparathyroidism in the VA

背景：原发性甲状旁腺功能亢进症(PHPT)是一种常见的内分泌疾病，其发病率 随着时间的推移一直在增加。未经治疗的PHPT可导致许多可预防的并发症(肾结石、 骨质疏松症和病理性骨折、神经精神和认知障碍)，并显著降低 生活质量。我们使用退伍军人事务部(VA)公司数据中的国家数据进行的初步工作 仓库(CDW)发现高血钙症患者对PHPT的认识明显不足， 在退伍军人保健系统中，适应症甲状旁腺切除术未得到充分利用。要设计出有效的 干预措施，我们首先需要用来自个人病历的数据来验证数据库得出的结果 审查，并探讨如此严重偏离循证准则的原因。我们也 需要发现临床医生在知识方面可能存在的误解和差距，可能的系统障碍 PHPT患者的管理，以及征求临床医生对可能的干预措施的意见。 创新：这是第一个用混合方法在粒度水平上探索原因的研究 在退伍军人事务部和其他医疗保健系统中都可以观察到PHPT的认识不足和治疗不足。 我们预计，这项试点工作将作为基于卫生信息学的干预措施的基础，这将 成为首批解决外科疾病的研究之一，从而为其他外科病理学提供了一个模型 在未来。该提案旨在解决退伍军人事务部HSR&D的两个重点领域：信息系统以 提高护理的可获得性和及时性(信息学有助于诊断和管理常见的 内分泌疾病)和卫生服务研究的创新(拓宽研究重点的新方法 在整个退伍军人管理局的外科疾病管理中的健康信息学)。 具体目标：(1)评估患者诊断和治疗不足的潜在原因 PHPT在VA中的应用；(2)探讨VA临床医生对本病诊断和治疗的认识。 高钙血症和PHPT，包括他们对可能的改善干预措施的态度。 方法：在这一探索性试点项目中，我们将对200名患者进行深入的病历审查 无甲状旁腺激素检测(诊断不足)的高钙血症退伍军人和200例PHPT患者 未行甲状旁腺切除术(治疗不足)以探讨漏诊的可能原因和 PHPT处理不足。 我们还将对30名退伍军人管理局临床医生进行半结构化访谈，以了解他们的知识和 对高钙血症和PHPT管理的看法，影响遵守指南的外部障碍 以及他们对可能的干预的态度。我们的目标是揭示错误的概念，知识的差距， 退伍军人事务部PHPT患者管理的系统性限制，以及从 建议的干预措施的提供者。 下一步：结果将为改进干预措施的设计提供信息，这将在当地进行试验 在退伍军人事务部更广泛地传播执行情况之前，应先在这一级别开展工作。

Background: Primary hyperparathyroidism (pHPT) is a common endocrine disorder, whose incidence has been increasing over time. Untreated pHPT can lead to many preventable complications (nephrolithiasis, osteoporosis and pathologic fractures, neuropsychiatric and cognitive disorders) and significantly decrease the quality of life. Our preliminary work with national data from the Veterans Affairs (VA) Corporate Data Warehouse (CDW) has identified significant under-recognition of pHPT among hypercalcemic patients and underutilization of indicated parathyroidectomy across the VA healthcare system. To design effective interventions, we first need to validate the database-derived results with data from individual medical record review, and to explore the reasons for such a significant deviation from evidence-based guidelines. We also need to uncover possible misconceptions and gaps in knowledge among clinicians, possible system barriers in the management of patients with pHPT, as well as to elicit input from clinicians about possible interventions. Innovation: This is the first study to explore at a granular level with a mixed methods approach the reasons for the under-recognition and undertreatment of pHPT observed both in the VA and in other healthcare systems. We anticipate that this pilot work will serve as the basis for health-informatics-based interventions, which will be some of the first ones addressing surgical diseases, and thus provide a model for other surgical pathologies in the future. The proposal intends to address two VA HSR&D areas of emphasis: Information systems to enhance access and timeliness to care (informatics to facilitate diagnosis and management of a common endocrine disease) and Innovation in Health Services Research (novel approach of broadening the focus of Health Informatics in the management of surgical diseases across the VA system). Specific aims: (1) To evaluate the underlying reasons for underdiagnosis and undertreatment of patients with pHPT in the VA; (2) To explore VA clinician perceptions related to diagnosis and management of hypercalcemia and pHPT, including their attitudes towards potential interventions for improvement. Methodology: In this exploratory pilot project, we will conduct an in-depth medical record review of 200 hypercalcemic Veterans without parathyroid hormone testing (underdiagnosis) and of 200 patients with pHPT without parathyroidectomy (undertreatment) to explore possible reasons for underdiagnosis and undertreatment of pHPT. We will also conduct semi-structured interviews with 30 VA clinicians to explore their knowledge and perceptions on hypercalcemia and pHPT management, external barriers affecting compliance with guidelines and their attitude towards possible interventions. Our goal is to reveal misconceptions, gaps in knowledge, systemic limitations in the management of patients with pHPT in the VA, as well as to elicit input from the providers on proposed interventions. Next steps: The results will inform the design of improvement interventions, which will be trialed at a local level before disseminating implementation more broadly in the VA.