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（pHPT）是一种常见的内分泌疾病

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.