Despite Guidelines Recommendations, Parathyroidectomy Carried Out in Few Patients of Primary Hyperparathyroidism: JAMA
USA: A large national cohort study has found that only a small proportion of patients with primary hyperparathyroidism (PHPT) and guideline-based indications for surgery due to end-organ damage underwent parathyroidectomy, highlighting a significant gap between recommended care and real-world clinical practice.
The findings, published in JAMA Surgery, come from a study led by Lia D. Delaney of the Stanford–Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, California, and colleagues.
Primary hyperparathyroidism (PHPT) is a common endocrine disorder that can cause skeletal and kidney complications due to excess parathyroid hormone. Although parathyroidectomy is the recommended treatment for patients with end-organ damage, many are managed without surgery. Researchers therefore assessed the frequency, timing, and surgical management of PHPT-related complications in routine clinical practice.
The population-based cohort study analyzed national electronic health record and claims data collected between 2010 and 2023, with follow-up through 2023. Adults with a new biochemical diagnosis of PHPT were identified based on elevated parathyroid hormone levels following repeated elevated calcium measurements. The primary outcomes included osteoporosis, atraumatic fractures, kidney stones, and stage 3 or worse chronic kidney disease, along with the timing and frequency of parathyroidectomy.
The analysis included 43,399 adults with PHPT. Participants had a mean age of 67.9 years, and 78% were women.
Key findings from the study include:
- At the time of diagnosis, 22,279 patients (51%) already had evidence of PHPT-related end-organ damage.
- Among 21,120 patients without end-organ damage at diagnosis, 6,762 (32%) developed skeletal or kidney complications during follow-up, with a median time of 516 days.
- Overall, approximately 67% of patients had end-organ damage either at diagnosis or during follow-up.
- Despite guideline-based indications for surgery, fewer than one in five patients with end-organ damage underwent parathyroidectomy.
- Only 19.9% of patients with end-organ damage present at diagnosis received parathyroidectomy, while 19.9% of those who developed complications later underwent surgery, typically 154 days after end-organ damage was identified.
The researchers noted several limitations, including the observational design, which precludes establishing causality between PHPT and skeletal or kidney complications. The inclusion of chronic kidney disease may have overestimated kidney-related morbidity, while clinically detected outcomes may have underestimated the true burden of end-organ damage. Some healthcare encounters outside participating health systems may also have been missed.
The authors concluded that although two-thirds of patients with PHPT had or developed end-organ damage, fewer than 20% underwent parathyroidectomy. The findings highlight a substantial gap between guideline recommendations and clinical practice, underscoring the need for earlier identification and referral of eligible patients to prevent PHPT-related complications.
Reference:
Delaney LD, Day HS, Arnow KD, et al. End-Organ Damage Associated With Primary Hyperparathyroidism. JAMA Surg. Published online July 29, 2026. doi:10.1001/jamasurg.2026.3051
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