Surgery Skipped for Most Older Adults With Primary Hyperparathyroidism

Treatment decisions for older adults with primary hyperparathyroidism are often influenced by age, multimorbidity, and frailty, rather than being guided by consensus guidelines, according to research published in JAMA Surgery.

In order to understand what factors influence treatment decision in this patient population, researchers conducted a retrospective cohort study of a population of Medicare beneficiaries between 2006 and 2016. Potential participants were identified through outpatient, carrier, and Medicaid claims. The primary outcome of interest was parathyroidectomy within 1 year of diagnosis.

The cohort included 210,206 Medicare beneficiaries diagnosed with primary hyperparathyroidism during the study period (mean age, 75.4±6.8 years; 78.8% women; 87.3% White). Within this group, 30% underwent parathyroidectomy within 1 year of diagnosis; these patients were younger (mean age, 73.5±5.7 years) and more likely to be White (90.1%), as well as more likely to be robust or prefrail and to have a lower comorbidity burden. In total, 62.7% met at least 1 consensus guideline criteria for the surgical management of hyperparathyroidism.

Differences in rates of parathyroidectomy were more pronounced by age group, comorbidity status, and frailty status than by criteria laid out via consensus guidelines. Although surgical procedure rates decreased with increasing age, Charlson Comorbidity Index score, and frailty status, investigators did not find a “clinically meaningful difference” in surgical intervention rates based on these domains.

Results of a multivariable analysis indicated that increasing age was inversely associated with parathyroidectomy in patients between 76 and 85 years of age and patients 86 years and older (unadjusted rate, 25.9% and 11.2%; odds ratios [ORs] 0.68 and 0.27, respectively) and those between 66 and 75 years (unadjusted rate, 35.9%). Those living in the most disadvantaged neighborhoods and in rural areas were more likely to be treated with parathyroidectomy (OR, 1.66 and 1.18, respectively).

Researchers reported no qualitative differences in results in planned sensitivity analyses that limited cohort enrollment to patients older than 67 years or that defined the primary outcome as parathyroidectomy at any time during follow-up. An inconsistent but overall decreasing trend in parathyroidectomy rates in both patients diagnosed during the study period and patients who met at least 1 consensus guideline criteria was noted.

Study limitations include those inherent to research using administrative claims data, the absence of clinical data like calcium and parathyroid hormone levels, and the retrospective nature of the analysis.

“These findings suggest that most ost older adults with [primary hyperparathyroidism] in the US do not receive definitive treatment with parathyroidectomy, and older age, frailty, and comorbidity are significantly associated with treatment decisions,” the researchers concluded. “Further research is needed to identify barriers to appropriate surgical care and develop tools to target parathyroidectomy to older adults most likely to benefit.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Seib CD, Suh I, Meng T, et al. Patient factors associated with parathyroidectomy in older adults with primary hyperparathyroidism. Published online January 6, 2021. JAMA Surg. doi: 10.1001/jamasurg.2020.6175