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Failure to Diagnose Hyperparathyroidism in 10,432 Patients with Hypercalcemia: Opportunities for System-Level Intervention to Increase Surgical Referrals and Cure
Courtney Balentine, Rongbing Xie, James J Kirklin, Herbert Chen
University of Alabama at Birmingham, Birmingham, AL

OBJECTIVE(S): Failure to diagnose primary hyperparathyroidism and refer patients for surgical management leads to impaired quality of life and increased healthcare costs. We hypothesized that many patients with hyperparathyroidism remain undiagnosed and untreated due to lack of consideration of the diagnosis, inadequate evaluation of hypercalcemia, and under-referral for surgical treatment.
METHODS: We used administrative data to review 682,704 consecutive patients from a tertiary referral center between 2011 and 2015, and identified hypercalcemia (>10.5mg/dl) in 10,432. We evaluated whether hypercalcemic patients underwent measurement of parathyroid hormone, had documentation of hypercalcemia/hyperparathyroidism in the medical record, or were referred for surgical evaluation.
RESULTS: The median age of our study population was 59 years, with 61% females, and 56% Caucasians. Only 3,200 (31%) of patients with hypercalcemia received appropriate biochemical workup with evaluation of parathyroid hormone level. Among patients with elevated serum calcium, 2,914 (28%) had a documented diagnosis of hypercalcemia and 880 (8%) had a diagnosis of hyperparathyroidism in the medical record. Additionally, only 592 (22%) out of 2,666 patients with classic hyperparathyroidism (both calcium and parathyroid hormone abnormal) were referred for surgical evaluation. Older patients were less likely to be referred to surgeons (OR 0.11, 95% CI 0.05-0.26 for ≥85 vs <65 years) while race and insurance status did not affect referral.
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 substantially improve patient outcomes and produce long-term cost savings.

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