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MOC Part 4 - QI Activity: Improving Primary Care Clinician Screening for Primary Hyperparathyroidism in Patients with Hypercalcemia

PROGRAM INFO

Program Info | Activity Timeline | Participant Workflow


>> View/Download: Detailed Program Info (pdf) <<


Clinical Background

Screening for Primary Hyperparathyroidism

The prevalence of primary hyperparathyroidism (PHPT) in the general population has varied with the onset of automated clinical chemistry measurements with a recent estimate of 0.84 - 0.86%. [1, 2] However, in patients with chronic, mild hypercalcemia, it may be as high as 43% and can have an incidence rate of two to three times higher in women. [1, 3]

PHPT is one of the most common causes of lifelong asymptomatic hypercalcemia in the outpatient setting. [4] Patients with PHPT may have higher rates of myocardial infarction, hypertension, stroke, congestive heart failure, diabetes, fractures, nephrolithiasis, abdominal pain, changes in mental status, myopathy, and mortality. [3, 5]


Quality Gap

Data has suggested that parathyroid hormone (PTH) measurement is infrequent in hypercalcemic patients, pointing to the gap between current medical screening practices [1] and specialty board recommendations. Recommendations for biochemical screening in hypercalcemic patients include using the corrected total serum calcium, intact PTH, creatinine, and 25-hydroxyvitamin D (25OHD) levels. [3, 5]

There is no definitive medical treatment for primary hyperparathyroidism, although options do exist. A benign single-gland adenoma is the most common abnormality (85% of cases), and less often by multiple gland involvement with hyperplasia and less frequently adenomas (15%) and rarely by parathyroid carcinoma (<1%). Sporadic parathyroid adenomas can be cured by identification and resection of the single offending gland. Additional options and approaches including use of advanced imaging modalities may be used in multigland disease, although bilateral neck explorations have reported success rates of 95%. [5]


Activity Goal

The overall goal of this QI activity is to increase the number of primary hyperparathyroidism (PHPT) screening by primary care clinicians in patients with hypercalcemia, with referrals to endocrinology or surgery.


Aim Statement

The rate of primary hyperparathyroidism (PHPT) screening^ by primary care clinicians in patients with hypercalcemia* will be increased by 100% from its baseline measure (approximately 7% screening rate†)** over a 6-month period across the aggregated total of eligible patients seen in Baylor Medicine primary care clinics in the areas of General Internal Medicine and Family and Community Medicine.


^PHPT screening requires that patients are tested for repeat corrected calcium levels and for intact parathyroid hormone (PTH), 25-hydroxy vitamin D, and creatinine levels.

*Hypercalcemia is indicated by a corrected calcium level > 10.5 mg/dL.

†Screening rate represents the number of patients meeting screening criteria who received the 4 screening blood tests divided by the total number of patients meeting screening criteria, expressed as a percentage.

**Approximate baseline screening rate noted above; actual baseline screening rate to be reported by each participating clinician.


Detailed Program Information

Refer to the Detailed Program Info (pdf) document for more information about the QI activity, including screening criteria and available improvement tools and resources.


References

1. 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

2. Wermers R. Incidence of Primary Hyperparathyroidism in the Current Era: Have We Finally Reached a Steady State? Journal of Clinical Endocrinology. 2023;108(12):e1749-e1750. doi:10.1210/clinem/dgad267

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. 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.

5. Bilezikian JP, et al. Evaluation and Management of Primary Hyperparathyroidism: Summary Statement and Guidelines from the Fifth International Workshop. J of Bone & Mineral Res. 2022;37(11):2293-2314.


For questions or assistance, contact: BCM MOC Program

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