Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford University School of Medicine, Stanford, California.
Department of Surgery, Stanford University School of Medicine, Stanford, California.
JAMA Surg. 2021 Apr 1;156(4):334-342. doi: 10.1001/jamasurg.2020.6175.
Parathyroidectomy provides definitive management for primary hyperparathyroidism (PHPT), reducing the risk of subsequent fracture, nephrolithiasis, and chronic kidney disease (CKD), but its use among older adults in the US is unknown.
To identify patient characteristics associated with the use of parathyroidectomy for the management of PHPT in older adults.
DESIGN, SETTING, AND PARTICIPANTS: This population-based, retrospective cohort study used 100% Medicare claims from beneficiaries with an initial diagnosis of PHPT from January 1, 2006, to December 31, 2016. Patients were considered to meet consensus guideline criteria for parathyroidectomy based on diagnosis codes indicating osteoporosis, nephrolithiasis, or stage 3 CKD. Multivariable logistic regression was used to identify patient characteristics associated with parathyroidectomy. Data were analyzed from February 11, 2020, to October 8, 2020.
The primary outcome was parathyroidectomy within 1 year of diagnosis.
Among 210 206 beneficiaries with an incident diagnosis of PHPT (78.8% women; mean [SD] age, 75.3 [6.8] years), 63 136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis. Among the subset of patients who met consensus guideline criteria for operative management (n = 131 723), 38 983 (29.6%) were treated with parathyroidectomy. Patients treated operatively were younger (mean [SD] age, 73.5 [5.7] vs 76.0 [7.1] years) and more likely to be White (90.1% vs 86.0%), to be robust or prefrail (92.1% vs 85.7%), and to have fewer comorbidities (Charlson Comorbidity Index score of 0 or 1, 54.6% vs 44.1%), in addition to being more likely to live in socioeconomically disadvantaged (46.9% vs 40.3%) and rural (18.1% vs 13.6%) areas (all P < .001). On multivariable analysis, increasing age had a strong inverse association with parathyroidectomy among patients aged 76 to 85 years (unadjusted rate, 25.9%; odds ratio [OR], 0.68 [95% CI, 0.67-0.70]) and older than 85 years (unadjusted rate, 11.2%; OR, 0.27 [95% CI, 0.26-0.29]) compared with those aged 66 to 75 years (unadjusted rate, 35.6%), as did patients with moderate to severe frailty (unadjusted rate, 18.9%; OR, 0.60 [95% CI, 0.56-0.64]) compared with robust patients (unadjusted rate, 36.1%) and those with a Charlson Comorbidity Index score of 2 or greater (unadjusted rate, 25.9%; OR, 0.77 [95% CI, 0.75-0.79]) compared with a Charlson Comorbidity Index score of 0 (unadjusted rate, 37.0%). With regard to operative guidelines, a history of nephrolithiasis increased the odds of parathyroidectomy (OR, 1.43 [95% CI, 1.39-1.47]); stage 3 CKD decreased the odds of parathyroidectomy (OR, 0.71 [95% CI, 0.68-0.74]); and osteoporosis showed no association (OR, 1.01 [95% CI, 0.99-1.03]).
In this cohort study, most older adults with PHPT did not receive definitive treatment with parathyroidectomy. Older age, frailty, and multimorbidity were associated with nonoperative management, and guideline recommendations had minimal effect on treatment decisions. Further research is needed to identify barriers to surgical care and develop tools to target parathyroidectomy to older adults most likely to benefit.
甲状旁腺切除术为原发性甲状旁腺功能亢进症（PHPT）提供了明确的治疗方法，可降低随后发生骨折、肾结石和慢性肾脏病（CKD）的风险，但在美国，老年人对此种治疗方法的应用情况尚不清楚。
确定与老年人甲状旁腺切除术用于 PHPT 管理相关的患者特征。
设计、设置和参与者：本研究基于人群的回顾性队列研究使用了 2006 年 1 月 1 日至 2016 年 12 月 31 日期间接受初始 PHPT 诊断的 100% 医疗保险受益人的数据。根据诊断代码指示骨质疏松症、肾结石或 CKD 3 期，患者被认为符合甲状旁腺切除术共识指南标准。多变量逻辑回归用于确定与甲状旁腺切除术相关的患者特征。数据于 2020 年 2 月 11 日至 2020 年 10 月 8 日进行分析。
主要结局为诊断后 1 年内甲状旁腺切除术。
在 210206 名患有原发性甲状旁腺功能亢进症的患者中（78.8%为女性；平均[SD]年龄为 75.3[6.8]岁），有 63136 名患者（30.0%）在诊断后 1 年内接受了甲状旁腺切除术。在符合手术治疗共识指南标准的患者亚组（n=131723）中，有 38983 名患者（29.6%）接受了甲状旁腺切除术。接受手术治疗的患者年龄更小（平均[SD]年龄为 73.5[5.7]岁 vs 76.0[7.1]岁），更有可能是白人（90.1% vs 86.0%），身体状况更好或处于虚弱前期（92.1% vs 85.7%），且合并症更少（Charlson 合并症指数评分为 0 或 1 的患者比例为 54.6% vs 44.1%），此外，他们更有可能居住在社会经济条件较差的地区（46.9% vs 40.3%）和农村地区（18.1% vs 13.6%）（所有 P<0.001）。多变量分析显示，在 76 岁至 85 岁（未调整率为 25.9%；比值比[OR]，0.68[95%CI，0.67-0.70]）和年龄大于 85 岁（未调整率为 11.2%；OR，0.27[95%CI，0.26-0.29]）的患者中，年龄与甲状旁腺切除术之间存在很强的反比关系，与 66 岁至 75 岁的患者相比（未调整率为 35.6%）；中度至重度虚弱的患者（未调整率为 18.9%；OR，0.60[95%CI，0.56-0.64]）与身体状况良好的患者相比（未调整率为 36.1%）和 Charlson 合并症指数评分为 2 或更高（未调整率为 25.9%；OR，0.77[95%CI，0.75-0.79]）与评分为 0（未调整率为 37.0%）的患者相比，也是如此。关于手术指南，肾结石病史增加了甲状旁腺切除术的几率（OR，1.43[95%CI，1.39-1.47]）；CKD 3 期降低了甲状旁腺切除术的几率（OR，0.71[95%CI，0.68-0.74]）；而骨质疏松症与甲状旁腺切除术无关（OR，1.01[95%CI，0.99-1.03]）。
在这项队列研究中，大多数老年 PHPT 患者并未接受甲状旁腺切除术的明确治疗。年龄较大、虚弱和合并症与非手术治疗相关，而指南建议对治疗决策的影响很小。需要进一步研究以确定手术护理的障碍，并开发针对最有可能受益的老年人的甲状旁腺切除术工具。
