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，其发病率有 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），并显着降低 生活质量我们对退伍军人事务部（VA）企业数据的国家数据的初步工作 Warehouse（CDW）已经发现高钙血症患者对pHPT的认识严重不足， VA医疗保健系统中适用的甲状旁腺切除术的利用不足。设计有效 干预措施，我们首先需要验证数据库派生的结果与数据，从个人病历 审查，并探讨这种重大偏离循证指南的原因。我们也 需要发现临床医生之间可能存在的误解和知识差距， pHPT患者的管理，以及从临床医生那里获得关于可能的干预措施的输入。 创新：这是第一项研究，探讨在一个颗粒级的混合方法的原因， 在VA和其他医疗保健系统中观察到的对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， 是第一批解决外科疾病的方法之一，从而为其他外科病理学提供了模型 在未来该提案旨在解决VA HSR&D的两个重点领域： 提高获得护理的机会和及时性（信息化，以促进诊断和管理常见的 内分泌疾病）和卫生服务研究创新（扩大重点的新方法， VA系统外科疾病管理中的健康信息学）。 具体目的：（1）评估对患者诊断不足和治疗不足的根本原因， （2）探讨VA临床医生对VA的诊断和管理相关的看法， 高钙血症和pHPT，包括他们对潜在干预措施的态度。 方法：在本探索性试点项目中，我们将对200例患者进行深入的病历审查， 未进行甲状旁腺激素检测（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），以探讨诊断不足的可能原因， pHPT处理不足。 我们还将与30名VA临床医生进行半结构化访谈，以探索他们的知识， 对高钙血症和pHPT管理的看法，影响指南依从性的外部障碍 以及他们对可能的干预的态度。我们的目标是揭示误解，知识的差距， VA中pHPT患者管理的系统局限性，以及从 供应商提出的干预措施。 下一步：结果将为改进干预措施的设计提供信息，这些干预措施将在当地的一个实验室进行试验。 在VA中更广泛地传播实施之前，

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.