Underutilization of parathyroidectomy in elderly patients with primary hyperparathyroidism

Abstract

Context: Primary hyperparathyroidism (PHPT) disproportionately affects older patients, who may face higher thresholds for surgical intervention compared to young patients.

Objective: The aim was to examine for differences in the utilization of parathyroidectomy attributable to age.

Design: We conducted a retrospective cohort study.

Participants: Patients with biochemically diagnosed PHPT during the years 1995-2008 were identified within an integrated health care delivery system in Southern California encompassing approximately 3 million individuals.

Main outcome measures: The outcome measures were parathyroidectomy (PTx) and time interval to surgery.

Results: We found 3388 patients with PHPT, 964 (28%) of whom underwent PTx. Patients aged 60+ yr comprised 60% of the study cohort. The likelihood of PTx decreased linearly among patients aged 60+ when compared to patients aged 50-59, an effect that persisted in multivariate analysis: odds ratio 0.68 for ages 60-69 (P < 0.05); 0.41 for ages 70-79 (P < 0.0001), and 0.11 for age 80+ (P < 0.0001). The PTx rate for patients aged 70+ was 14%. Among patients meeting 2002 consensus criteria for surgical treatment, 45% of those aged 60-69 and 24% of those aged 70+ underwent PTx. A Cox proportional hazards model showed that patients aged 60+ experienced significantly longer delays from diagnosis to surgery compared to young patients (P < 0.0001).

Conclusions: PHPT is undertreated in the elderly. We observed a progressive age-related decline in PTx rate that renders patients aged 70+ unlikely to have definitive treatment, irrespective of comorbidity and eligibility for surgery.

Figure 1

A, Proportion of all patients with PHPT undergoing PTx according to age group (P < 0.0001). B, Proportion of patients meeting consensus criteria undergoing PTx according to age group (P < 0.0001).

Figure 2

Cox proportional hazards model of time interval to PTx according to age group. The proportion of patients managed without surgery is shown on the vertical axis (P < 0.0001).