Improvement in patient-reported physical and mental health after parathyroidectomy for primary hyperparathyroidism

doi:10.1016/j.surg.2015.03.054

Surgery

Volume 158, Issue 3, September 2015, Pages 837-845

Presented at the 10th Annual Academic Surgical Congress in Las Vegas, NV, February 3–5, 2015.

https://doi.org/10.1016/j.surg.2015.03.054 Get rights and content

Background

The majority of patients with primary hyperparathyroidism (PHPT) are diagnosed without the classic signs of renal or osseous complications. Vague and subjective symptoms have been attributed to PHPT but have been difficult to measure during the medical encounter. The Patient-Reported Outcomes Measurement Information System (PROMIS) of the National Institutes of Health contains validated measures of physical and mental health that can be administered by the use of computer-adaptive testing (CAT). The objective of this study was to evaluate the feasibility of PROMIS assessment in the clinical setting to measure changes in patient-reported health before and after parathyroidectomy. We hypothesized that patients undergoing parathyroidectomy for PHPT would report greater improvement in mental and physical health compared with control patients.

Methods

Adult PHPT patients scheduled for parathyroidectomy and control patients requiring diagnostic thyroid operation were enrolled prospectively during a 6-month period. Patients were administered clinically relevant PROMIS health domains via CAT at a preoperative visit and 3 weeks after operation. A change in score of 5 or greater for each PROMIS instrument was defined as clinically important. Statistical significance of pre/post-surgery changes in scores was determined using paired t tests.

Results

A total of 35 patients with PHPT and 9 control patients completed the study. The mean number of PROMIS items answered during an assessment was 67 (range 51–121, SD 15.4). Median completion time was 8.2 minutes (range 3.4–38.4, SD 4.7). Clinically important improvement after parathyroidectomy in the PHPT group was greater than in the control group in 5 PROMIS domains. The score improvement experienced by PHPT patients was 8.8 in Fatigue, 6.7 in Sleep-Related Impairment, 5.0 in Anxiety, 7.0 in Applied Cognition, and 6.2 in Depression (all P < .05).

Conclusion

PROMIS is an efficient clinical assessment platform for measuring patient-reported outcomes in PHPT via CAT. Several domains of physical and mental health in patients with PHPT show statistically and clinically important improvement after parathyroidectomy.

Section snippets

Study population

Approval from the Northwestern University Institutional Review Board was obtained for this prospective study. Participant enrollment occurred during a 6-month period from September 1, 2012 to February 28, 2013. Patients older than the age of 18 who were evaluated in the Northwestern Memorial Faculty Foundation Endocrine Surgery Clinic and had a biochemical diagnosis of PHPT (serum calcium exceeding 10.5 mg/dL with a serum parathyroid hormone [PTH] level at or exceeding 50 pg/mL) were eligible

Study flow and participant data

Fig 1, Fig 2 show the complete study flow of the patients in the PHPT and control groups, respectively. Fifty-three patients with PHPT and 13 control patients were approached for participation. After nonenrollment and exclusions, 85% of patients with PHPT and 77% of control patients completed a preoperative PROMIS assessment. All patients were able to complete the assessments without assistance after a brief tutorial. Table I displays the demographic characteristics and preoperative laboratory

Discussion

This study demonstrates that several domains of physical and mental health in patients with PHPT are improved after parathyroidectomy. The findings also suggest that these domains improve in “asymptomatic” PHPT patients who do not meet consensus criteria for parathyroidectomy to the same extent as PHPT patients who do meet the criteria. Furthermore, given a median completion time of less than 10 minutes for the assessment of 12 domains, computer-delivered PROMIS instruments have the practical

References (26)

R.E. Burney et al.
Health status improvement after surgical correction of primary hyperparathyroidism in patients with high and low preoperative calcium levels
Surgery
(1999)
K. Zanocco et al.
How should age at diagnosis impact treatment strategy in asymptomatic primary hyperparathyroidism? A cost-effectiveness analysis
Surgery
(2008)
D. Cella et al.
The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005-2008
J Clin Epidemiol
(2010)
K.J. Yost et al.
Minimally important differences were estimated for six Patient-Reported Outcomes Measurement Information System-Cancer scales in advanced-stage cancer patients
J Clin Epidemiol
(2011)
J.L. Pasieka et al.
The long-term benefit of parathyroidectomy in primary hyperparathyroidism: a 10-year prospective surgical outcome study
Surgery
(2009)
J.A. Sosa et al.
The parathyroid glands
J.P. Bilezikian et al.
Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop
J Clin Endocrinol Metab
(2014)
K. Zanocco et al.
Cost-effectiveness analysis of parathyroidectomy for asymptomatic primary hyperparathyroidism
Surgery
(2006)
M.S. Eigelberger et al.
The NIH criteria for parathyroidectomy in asymptomatic primary hyperparathyroidism: are they too limited?
Ann Surg
(2004)
S.J. Silverberg et al.
A 10-year prospective study of primary hyperparathyroidism with or without parathyroid surgery
N Engl J Med
(1999)

J.P. Bilezikian et al.

Third International Workshop on the Management of Asymptomatic Primary H. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the third international workshop

J Clin Endocrinol Metab

(2009)

D.P. Macfarlane et al.

Should 'mild primary hyperparathyroidism' be reclassified as 'insidious': is it time to reconsider?

Clin Endocrinol

(2011)

S.A. Roman et al.

Parathyroidectomy improves neurocognitive deficits in patients with primary hyperparathyroidism

Surgery

(2005)

Cited by (35)

The underrecognized impact of parathyroidectomy for primary hyperparathyroidism
2024, American Journal of Surgery
Objectively measured cognitive dysfunction in patients with primary hyperparathyroidism improves after parathyroidectomy
2024, Surgery (United States)
A relationship between primary hyperparathyroidism (PHPT) and decreased quality of life has been shown using patient-reported outcome measures, including Pasieka’s Parathyroid Assessment of Symptoms, SF-36, and PROMIS. Despite this, there remains a paucity of objectively measured data demonstrating cognitive dysfunction in patients with PHPT. We assessed whether parathyroidectomy resulted in quantifiable cognitive improvement.
We examined 59 consecutive patients with PHPT who underwent parathyroidectomy at a single institution between 2019 and 2021. We used BrainCheck, a clinically validated objective measure of neurocognition, to assess pre- and postoperative neurocognitive changes and evaluated associations between BrainCheck scores and parathyroidectomy using the Wilcoxon signed-rank test.
Of the 59 patients with PHPT who underwent parathyroidectomy and rapid cognitive assessment with BrainCheck, 72.9% were female, 49.2% were White, and 30.5% were African American. A total of 44.1% of patients preoperatively showed neurocognitive dysfunction relative to the general population compared to 22% postoperatively, representing an improvement in 53% of the cohort. Postoperative scores for the entire cohort were significantly higher than preoperative scores (Z =2.85, P = .004). This association remained significant when the cohort was stratified by sex, as both males (Z =2.02, P = .044) and females (Z =2.09, P = .037) had a significant increase in scores. Domain sub-analysis demonstrated a significant association between parathyroidectomy and improved executive function (P < .01).
Patients with PHPT experience objectively measurable cognitive changes associated with PHPT that can be reversed by parathyroidectomy, with improvements observed as early as 2 weeks after surgery. Further research with a larger cohort is needed to corroborate our findings.
Social Determinants of Health and Quality of Life in Endocrine Surgery Patients
2023, Journal of Surgical Research
Quality of life (QoL) of endocrine surgery patients is an important patient outcome but the role of social determinants of health (SDH) on preoperative QoL is understudied.
This study used preoperative data of 233 endocrine surgery patients participating in a longitudinal QoL study to examine the influence of SDH (patient-level and environmental) on preoperative QoL. Patient-level SDH was assessed with structured survey questions and environmental SDH with the Social Vulnerability Index. Multiple domains of QoL were assessed with the Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29).
The average age of the sample was 52.9 y and 76.8% were female, 10% were Hispanic, 55.8% were White, 32.6% were Black, 6.9% were Other, and 4.7% were Asian. Patients with patient-level SDH were more likely to have worse preoperative QoL in multiple PROMIS domains. Patients who lived in the most socially vulnerable areas had the same or better QoL scores in the PROMIS-29 domains than those living in less vulnerable areas. Minority race patients were more likely to have patient-level SDH and to live in the most vulnerable areas.
This study is the first to our knowledge to examine the role of patient-level and environmental SDH on preoperative QoL among endocrine surgery patients. The results identified specific patient-level factors that could be used as the basis for interventions aimed to improve patients’ QoL. Future studies that evaluate the role of preoperative SDH on long-term QoL and clinical outcomes would further enhance our understanding of the impact of SDH on patient wellbeing.
Improved sexual function after parathyroidectomy in women with primary hyperparathyroidism
2023, American Journal of Surgery
The study aimed to evaluate whether women with primary hyperparathyroidism (PHPT) experience improvement in their sexual function after parathyroidectomy.
Women with PHPT or benign thyroid nodules (controls) undergoing surgery were administered the validated Parathyroidectomy Assessment Score (PAS), Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) and Female Sexual Function Index (FSFI) pre-operatively, at 3 months and 6 months postoperatively.
Of the 26 PHPT and 18 control patients, PHPT patients were older (53.1 vs 45.3 years, p = 0.008). Post-operatively, both PHPT (pre-op 2.4 vs 3-month 3.0 vs 6-month 2.4, p = 0.022) and control patients (pre-operative 2.4 vs 3-month 3.3 vs 6-month 3.6, p = 0.032) reported increased desire for sexual activities. In addition, PHPT patients experienced increased arousal (pre-operative 2.7 vs 3-month 3.9 vs 6-month 3.6, p = 0.047) and satisfaction (pre-operative 3.0 vs 3-month 4.8 vs 6-month 4.0, p = 0.006).
The current study indicates that women with PHPT may experience improved sexual function after parathyroidectomy.
Pilot Cross-Sectional Quality of Life Study of a Diverse Endocrine Surgery Patient Population
2022, Journal of Surgical Research
Citation Excerpt :
On one hand, thyroid cancer survivors may have worse postoperative QOL as compared to their preoperative QOL, in part related to worse mental health QOL and financial difficulties.8-12 On the other hand, patients with primary hyperparathyroidism (PHPT) and primary hyperaldosteronism or other adrenal conditions may have better postoperative QOL as compared to their preoperative QOL, where postoperative hormone normalization was associated with an improved physical and mental function.13-15 Furthermore, our knowledge of PROs of QOL has multiple potential benefits; it may allow us to better identify and support patients at a high risk of having lower QOL, and if results show the QOL benefits of endocrine surgery, it may promote the rates of surgical referrals in conditions such as hyperparathyroidism where referral rates are low.8,9,12,14,16-18
Quality of life (QOL) studies of endocrine surgery patients have lacked diverse patient representation, long-term follow-up, or the use of validated questionnaires. This cross-sectional pilot study explored the need for prospective QOL studies in diverse endocrine surgery patients who were ≥6 mo postoperative.
In 2019, we mailed anonymous questionnaires to 671 adult patients cared for by an endocrine surgery division between 2018 and 2019. Patients were ≥6 mo postoperative and had undergone thyroidectomy, parathyroidectomy, or adrenalectomy. Patients mailed back responses to two validated questionnaires, the Patient-Reported Outcomes Measurement Information System–29 (PROMIS-29), and the Voice Handicap Index–10 (VHI-10). We compared responses across race.
Of 135 respondents (20.1% response rate), 27.4% were 60-69 y and 69.6% were female. Race and ethnicity frequencies include 60.0% White patients, 27.4% Black patients, 4.4% Asian patients, and 5.2% Hispanic/LatinX patients. For surgery, 57.8% underwent thyroidectomy, 28.2% parathyroidectomy, 9.6% both, 4.4% adrenalectomy, and 32.6% surgery for cancer. Regarding PROMIS-29 results for patients who underwent thyroidectomy, significant differences were observed in the domains of physical function, depression, sleep disturbances, social roles, and global pain across race (P < 0.05). However, few differences were seen after completion of post hoc pairwise comparisons. We did not observe differences in PROMIS scores across race among patients who underwent parathyroidectomy and adrenalectomy or in VHI-10 for all surgical groups.
These results suggest long-term QOL differences across race and surgery type and support the need for prospective studies among diverse endocrine surgery patients.
The impact of patient age on practice patterns and outcomes for primary hyperparathyroidism
2022, American Journal of Surgery
Management of asymptomatic primary hyperparathyroidism (PHPT) in older patients (age >50) is controversial. The 4th International Workshop on the Management of Asymptomatic PHPT recommends surveillance for older patients who lack objective signs of disease, whereas The American Association of Endocrine Surgeons (AAES) guidelines recommend consideration of parathyroidectomy for patients of any age with subjective constitutional, neuropsychiatric, or cognitive symptoms. Therefore, the primary objective of this study was to evaluate the association between patient age and both practice patterns and outcomes in the management of patients with sporadic PHPT.
The Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) database was queried for all adults (age ≥18) who underwent an index parathyroidectomy for sporadic primary hyperparathyroidism between 2014 and 2020. Associations between patient age (≤50 years vs. >50 years) and both practice patterns and outcomes were evaluated separately using adjusted multivariable logistic and multinomial regression models.
Of 9,938 patients who underwent parathyroidectomy, 8,080 (81.3%) were >50 years old and 1,858 (18.7%) were ≤50. Of this cohort, 17% of older patients and 26% of younger patients presented with only subjective symptoms. Compared to younger patients, older patients were more likely to have an objective indication for parathyroidectomy (aOR = 1.8, 95%CI: 1.6–2.0, p < 0.001). They were also more likely to undergo ≥2 imaging studies pre-operatively (aOR = 1.2, 95%CI: 1.1–1.3, p = 0.003), to undergo bilateral neck exploration (aOR = 1.4, 95%CI: 1.3–1.6, p < 0.001), and to have multi-gland disease (aOR = 1.6, 95%CI: 1.4–1.8, p < 0.001). There was no difference between age groups and parathyroidectomy-related complications including hypocalcemia, vocal cord dysfunction, hematoma requiring evacuation, or reintubation, however, older patients were less likely to have any peri-operative morbidity (aOR = 0.7, 95%CI: 0.6–0.9, p = 0.011).
Older patients were more likely to meet objective criteria prior to undergoing parathyroidectomy by CESQIP participating high-volume endocrine surgeons, however they were less likely to have peri-operative complications compared to younger patients. Given the growing evidence demonstrating improvement of both objective and subjective symptoms after parathyroidectomy for PHPT, additional studies are still needed to fully understand the benefit of surgical referral in older adults for less objective indications.

View all citing articles on Scopus

: Kyle Zanocco's participation in this study was supported in part by the Northwestern University Feinberg School of Medicine Center for Healthcare Studies under an institutional award from the Agency for Healthcare Research and Quality, T-32 HS 000078 (PI: Jane L. Holl, MD, MPH).

View full text

EndocrineImprovement in patient-reported physical and mental health after parathyroidectomy for primary hyperparathyroidism

Background

Methods

Results

Conclusion

Section snippets

Study population

Study flow and participant data

Discussion

Surgery

Surgery

J Clin Epidemiol

J Clin Epidemiol

Surgery

The parathyroid glands

Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop

J Clin Endocrinol Metab

Cost-effectiveness analysis of parathyroidectomy for asymptomatic primary hyperparathyroidism

Surgery

The NIH criteria for parathyroidectomy in asymptomatic primary hyperparathyroidism: are they too limited?

Ann Surg

A 10-year prospective study of primary hyperparathyroidism with or without parathyroid surgery

N Engl J Med

Third International Workshop on the Management of Asymptomatic Primary H. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the third international workshop

J Clin Endocrinol Metab

Should 'mild primary hyperparathyroidism' be reclassified as 'insidious': is it time to reconsider?

Clin Endocrinol

Parathyroidectomy improves neurocognitive deficits in patients with primary hyperparathyroidism

Surgery

Endocrine
Improvement in patient-reported physical and mental health after parathyroidectomy for primary hyperparathyroidism