Maintenance of Certification Screening for Primary Hyperparathyroidism

Introduction

This healthcare improvement educational activity is part of the Baylor College of Medicine Precision Medicine series to improve quality while personalizing care. These activities simplify participation in quality activities for MOC credit (and also provide a variety of opportunities for additional CME credit) by lessening burdens for clinicians who can focus on care improvements and receive credit for the work that they do. This project on Screening for Hyperparathyroidism is a high priority for Baylor Medicine clinics.

Credit Issuance for Continuing Certification

  • Family Medicine (ABFM) - One Improvement in Medical Practice Module
  • Internal Medicine (ABIM) - 30 Practice Assessment Points

For more participant information on credit please visit the Baylor QIPS website.

Clinical Background on Screening for Primary Hyperparathyroidism

  • Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia in the outpatient setting (Press, 2011).
  • PHPT can be associated with fractures, nephrolithiasis, nephrocalcinosis, abdominal pain, changes in mental status, myopathy, hypertension, and cardiovascular disease (Bilezikian, 2022).
  • Prevalence of PHPT in the general population is estimated at 0.86%; however, in patients with mild hypercalcemia is may be as high as 43% (Press, 2011).
  • Current screening rates suggest that screening for hyperparathyroidism may be infrequently conducted in the population of patients with chronic hypercalcemia. For example, in a recent study in the Veterans Affairs Health Care System examining a population of over 371,000 patients with chronic hypercalcemia, only 23.4% received follow-up evaluation with parathyroid hormone levels (Alore, 2019).
  • Incidence increases with age and is 2 to 3 times higher in women (Wilhelm, 2016).

Smart Aims

1.

2.

3.

System Integrated MOC Hypercalcemia Workflow

Tools:

  • Physician dashboards provide data and calculated metrics for review.
  • Best Practice Advisory (BPA) alerts in the EMR for identifying patients meeting screening criteria.
  • SmartSets accompanied by Point-of-Care CME credit to facilitate ordering/interpretation.
  • Brief online modules for the clinical introduction of PA with CME credit.

Activity Steps for Obtaining MOC points and PI-CME AMA PRA Category 1 credits:

  1. Stage A: Baseline measurement and intervention planning
    1. Umbrella Goal: Review Smart Aim for the QI Project.
    2. Review baseline measurement and plan intervention.
      1. Potential steps to be taken by clinician and clinical team:
        1. Reaction to baseline data compared to umbrella goal and planned intervention?
        2. Potential barriers anticipated for clinical and patients?
      2. You will be asked to check those that apply and describe (as indicated) for your intervention planning:
        1. Analyze baseline data, baseline screening, referral rate and summarize trends documented in dashboard.
        2. Plan to use BPAs as needed.
        3. Plan to use SmartSet as needed.
        4. Plan to use the Point-of-Care CME algorithm and/or quick reference guide and/or prescribe mineralocorticoids as needed.
        5. Plan to review relevant online modules for clinical background.
        6. If you plan to do so, describe how you will engage your clinical team.
        7. Describe how you will support your patients and engage them in the importance of screening.
        8. Other plans
  2. Stage B: Intervention implementation. Examine data and trends at least once, e.g., mid-way, and share observations and/or need for assistance.
    1. Briefly describe what, if any, trends in the dashboard data you have observed since project initiation.
    2. Which steps are you using? & What did you observe?
    3. What problems and/or unexpected observations have you experienced?
    4. What additional actions do you plan to implement?
    5. Did you need assistance (If yes, please describe)?
  3. Stage C: For MOC and PI-CME credit, please analyze your results and compare them to your predictions. Compare screening rates to what you predicted.
    1. Reflect on what you have learned, what worked well, what did not.
    2. If you were successful (at the level of Baylor Medicine or in your own screening, how will you sustain this? If you were not, what modifications could be employed to adapt or adopt if you plan to continue. If not, please describe why briefly. Have you worked previously on improvement projects? Did it take more time or less time to use this process for improvement? Did the steps and support increase the ease of your being able to engage in this improvement process as part of your daily work? (If yes, please describe.)

Additional Benefits for Clinicians

  • Maintenance of Certification (MOC) Points for the learning accompanying participation in the healthcare improvement project. (This activity has been approved for MOC Part IV points for the following specialty boards: American Board of Internal Medicine and the American Board of Family Medicine.)
  • CME credit for the learning that you will do for the project (e.g., participating in grand rounds or using online modules) and for work in the project (e.g., Process-Improvement [PI-CME]).
  • Point-of-Care CME credit in reviewing easy-to-read decision-assisting materials during or surrounding the encounter.
  • Potential productivity assistance as participation may assist in meeting the requirements for Coding Level 4 Office Visits by identifying established patients with unstable chronic illness, e.g., resistant hypertension. (Millette 2021 for guidance).
CME CreditPoint-of-Care CME CreditClinician DashboardConnect with a QI CoachEnrollee Forms

References

  1. Padmanabhan H. Outpatient management of primary hyperparathyroidism. Am J Med. 2011;124(10):911-4. doi: 10.1016/j.amjmed.2010.12.028. Epub 2011 Aug 3. PMID: 21816381
  2. Press DM, Siperstein AE, Berber E, et al. The prevalence of undiagnosed and unrecognized primary hyperparathyroidism: A population-based analysis from the electronic medical record. Surgery. 2013;154(6):1232-1238. doi:10.1016/j.surg.2013.06.051
  3. Wilhelm SM, Wang TS, Ruan DT, et al. The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism. JAMA Surg. 2016;151(10):959. doi:10.1001/jamasurg.2016.2310
  4. El-Hajj Fuleihan, et al. Classical and Nonclassical Manifestations of Primary Hyperparathyroidism. J Bone Miner Res. 2022;37: 2330-2350. https://doi.org/10.1002/jbmr.4679
  5. Alore, E. A., Suliburk, J. W., Ramsey, D. J., Massarweh, N. N., Balentine, C. J., Singh, H., Awad, S. S., & Makris, K. I. (2019). Diagnosis and Management of Primary Hyperparathyroidism Across the Veterans Affairs Health Care System. JAMA Internal Medicine, 179(9), 1220. https://doi.org/10.1001/jamainternmed.2019.1747