Failure to Diagnose Hyperparathyroidism in 10,432 Patients With Hypercalcemia: Opportunities for System-level Intervention to Increase Surgical Referrals and Cure

Abstract

Objective: To determine whether a significant number of patients with hyperparathyroidism remain undiagnosed and untreated.

Background: Failure to diagnose primary hyperparathyroidism and refer patients to surgeons leads to impaired quality of life and increased costs. We hypothesized that many patients with hyperparathyroidism would be untreated due to not considering the diagnosis, inadequate evaluation of hypercalcemia, and under-referral to surgeons.

Methods: We reviewed administrative data on 682,704 patients from a tertiary referral center between 2011 and 2015, and identified hypercalcemia (>10.5 mg/dL) in 10,432 patients. We evaluated whether hypercalcemic patients underwent measurement of parathyroid hormone (PTH), had documentation of hypercalcemia/hyperparathyroidism, or were referred to surgeons.

Results: The mean age of our cohort was 54 years, with 61% females, and 56% whites. Only 3200 (31%) hypercalcemic patients had PTH levels measured, 2914 (28%) had a documented diagnosis of hypercalcemia, and 880 (8%) had a diagnosis of hyperparathyroidism in the medical record. Only 592 (22%) out of 2666 patients with classic hyperparathyroidism (abnormal calcium and PTH) were referred to surgeons.

Conclusions: A significant proportion of patients with hyperparathyroidism do not undergo appropriate evaluation and surgical referral. System-level interventions which prompt further evaluation of hypercalcemia and raise physician awareness about hyperparathyroidism could improve outcomes and produce long-term cost savings.

Figure 1.

Most patients with hypercalcemia do not receive appropriate evaluation of parathyroid hormone (PTH levels) or referral to surgeons for discussion of treatment options.

Figure 2.

Odds of having parathyroid hormone (PTH) levels evaluated after hypercalcemia vary with age, gender, insurance status, co-morbidity, and calcium level. Odds ratios and 95% confidence intervals shown on the left, with numeric value of odds ratio shown on the right. Results adjusted for type of visit (inpatient, outpatient, emergency room), year of initial calcium, and Elixhauser co-morbidities.

Figure 3.

Odds of being referred to surgery after hypercalcemia & evaluation of PTH vary with age, gender, co-morbidity, and calcium level. Odds ratios and 95% confidence intervals shown on the left, with numeric value of odds ratio shown on the right. Results adjusted for type of visit (inpatient, outpatient, emergency room), year of initial calcium, and Elixhauser co-morbidities.

Figure 4.

Odds of being referred to endocrinology after hypercalcemia & evaluation of PTH vary with gender but not age, co-morbidity, or calcium level. Odds ratios and 95% confidence intervals shown on the left, with numeric value of odds ratio shown on the right. Results adjusted for type of visit (inpatient, outpatient, emergency room), year of initial calcium, and Elixhauser co-morbidities.