Toward a 21st-century health care system: Recommendations for health care reform

The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care to substantially changing the organization and delivery of care. The FRESH-Thinking Project (www.fresh-thinking.org) held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others who represent diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform: 1. Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment. 2. Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions. 3. Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions. 4. Develop a health information technology infrastructure with national standards of interoperability to promote data exchange. 5. Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make de-identified information from this database on clinical interventions, patient outcomes, and costs available to researchers. 6. Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans. 7. Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees' coverage. 8. Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges

Presentation and Outcomes After Surgery for Primary Hyperparathyroidism During an 18-Year Period.

The objective of this study is to analyze whether the trend towards operating on patients with less severe primary hyperparathyroidism (pHPT) than earlier is reflected in a change of preoperative presentation and surgical outcome

Surgery for patients with primary hyperparathyroidism and negative sestamibi scintigraphy--a feasibility study

BACKGROUND: We report the surgical treatment of a consecutive series of scan negative patients with the intention of unilateral parathyroid exploration with the aid of intraoperative quick PTH (qPTH).MATERIALS AND METHODS: The study included 35 consecutive sestamibi scan negative patients (27 women, eight men) with sporadic pHPT subjected to first time surgery. Median age was 70 years and median preoperative calcium level 2.8 mmol/L.RESULTS: Thirty-three patients had a histological diagnosis of a parathyroid adenoma (median weight 0.48 g [range 0.12 g-2.5 g]). Nineteen patients were explored bilaterally and 16 patients (46%) were operated unilaterally. The median operation time was 40 min in the unilateral group and 95 min in the bilateral group (p < 0.001). Three patients were treated for postoperative hypocalcemia after bilateral exploration versus none in the unilateral group (p = 0.23). With a minimum of 12 months of follow-up, 33 patients (94.3%) were cured. One case of recurrent HPT presented after bilateral exploration with visualization of four glands. One case of persistent HPT was observed after unilateral exploration. qPTH was predictive of operative failure in both patients.CONCLUSION: Forty-six percent of the patients in our study could be operated unilaterally with a total cure rate of 94%. Patients in the unilateral group had a significant shorter operation time and a lower incidence of postoperative hypocalcemia. In conclusion our investigation shows that limited parathyroid exploration can safely be performed on patients with negative sestamibi scintigraphy by the aid of qPTH

Predictors of multiglandular disease in primary hyperparathyroidism

Background: Primary hyperparathyroidism (pHPT) is caused by single- or multiglandular disease (MGD). Patients with MGD have an increased risk of complications at surgery and for persistence and recurrence after surgery. The study evaluated whether preoperative clinical and biochemical characteristics could predict MGD in patients with pHPT. Methods: We retrospectively evaluated patients operated 1989–2013 for first-time, non-hereditary pHPT. MGD was defined in patients with more than one pathological gland excised at surgery or with persistent hypercalcemia after the excision of a single pathological parathyroid gland, confirmed by histopathology. Clinical and biochemical variables were compared in patients with single- and multiglandular disease. Logistic regression was used to identify variables predicting MGD, yielding odds ratios (OR) with 95% confidence intervals (CI). Results: There were 707 patients, of which 79 (11%) had MGD. Patients with MGD were more likely to have negative sestamibi scintigraphy than patients with single-gland disease, 15 of 49 (31%) vs. 70 of 402 (17%; p = 0.03), to suffer from diabetes (12 of 74, 16%) vs. 45 out of 626 patients (7.2%; p < 0.01) and had lower preoperative levels of urinary calcium (3.80 vs. 4.44 mmol/L; p = 0.04). Multivariable analysis identified negative scintigraphy (OR 2.42; 95% CI 1.18 to 4.79), diabetes (OR 2.75; 95% CI 1.31 to 4.97) and elevated levels of osteocalcin (OR 3.79, 95% CI: 1.75 to 8.21) as predictors of MGD. Conclusion: Negative sestamibi scintigraphy, diabetes and elevated osteocalcin levels were predictors of MGD

Results of a Fifteen-Year Follow-up Program in Patients Operated with Unilateral Neck Exploration for Primary Hyperparathyroidism.

Since the introduction of unilateral parathyroidectomy for primary hyperparathyroidism (pHPT) it has been debated wherever this approach is associated with greater long-term risk for recurrence compared to bilateral neck exploration

Changing biochemical presentation of primary hyperparathyroidism.

PURPOSE: Patients with primary hyperparathyroidism, pHPT, present with milder symptoms than previously. Some, but not all studies, suggest that this change in clinical pattern also implies lower preoperative parathyroid hormone (PTH) and/or calcium levels and smaller adenomas. This is important since reports indicate that smaller adenomas are more difficult to detect on preoperative imaging, possibly increasing the risk of surgical failure. METHODS: There were 640 patients with histologically confirmed single-gland pHPT identified in a prospectively collected database. Median values of preoperative calcium, PTH, as well as adenoma weight were compared in three different time periods: 1990-1995, 1996-2000, and 2000-2007. Correlation between the preoperative levels of calcium and PTH and adenoma weight was calculated. RESULTS: Preoperative ionized calcium decreased significantly over time (p < 0.001). There was a positive correlation between preoperative PTH and adenoma weight (r = 0.32, p < 0.001). The magnitude of this correlation decreased over time. In women, adenoma weight decreased significantly over time (p = 0.03). Median (25th-75th percentile) adenoma weight in women was 750 (400-1,380) mg, 650 (350-1,205) mg, and 520 (305-1,065) mg in the first, second, and third period, respectively. CONCLUSION: From 1990 to 2007, there was a significant trend to operate pHPT patients with lower preoperative serum ionized calcium levels. In women, the adenoma weight decreased. This trend could potentially lead to decreased sensitivity in preoperative localization procedures

Vitamin D Status in Patients Operated for Primary Hyperparathyroidism: Comparison of Patients from Southern and Northern Europe

Aim. The interaction between vitamin D deficiency and primary hyperparathyroidism (PHPT) is not fully understood. The aim of this study was to investigate whether patients with PHPT from Spain and Sweden differed in vitamin D status and PHPT disease activity before and after surgery. Methods. We compared two cohorts of postmenopausal women from Spain (n=126) and Sweden (n=128) that had first-time surgery for sporadic, uniglandular PHPT. Biochemical variables reflecting bone metabolism and disease activity, including levels of 25-hydroxy vitamin D3 (25(OH)D) and bone mineral density, BMD, were measured pre- and one year postoperatively. Results. Median preoperative 25(OH)D levels were lower, and adenoma weight, PTH, and urinary calcium levels were higher in the Spanish cohort. The Spanish patients had higher preoperative levels of PTH (13.5 versus 11.0 pmol/L, P<0.001), urinary calcium (7.3 versus 4.1 mmol/L, P<0.001), and heavier adenomas (620 versus 500 g, P<0.001). The mean increase in BMD was higher in patients from Spain and in patients with vitamin D deficiency one year after surgery. Conclusion. Postmenopasual women with PHPT from Spain had a more advanced disease and lower vitamin 25(OH)D levels. Improvement in bone density one year after surgery was higher in patients with preoperative vitamin D deficiency

Reduced fracture incidence in patients having surgery for primary hyperparathyroidism

Objective: The indication of surgery in primary hyperparathyroidism has been controversial, as many patients experience mild disease. The primary aim was to evaluate fracture incidence in a contemporary population-based cohort of patients having surgery for primary hyperparathyroidism. The secondary aim was to investigate whether preoperative serum calcium, adenoma weight or multiglandular disease influence fracture incidence. Design: A retrospective cohort study with population controls. Primary outcomes, defined by discharge diagnoses and prescriptions, were any fracture and fragility fracture, secondary outcomes were multiple fractures anytime and osteoporosis. Subjects were followed 10 years pre- and up to 10 years postoperatively (or 31 December 2015). Multiple events per subject were allowed. Fracture incidence rate ratios (IRRs) for patients pre- and postoperatively were tabulated and evaluated with mixed-effects Poisson regression. Secondary outcomes were evaluated using conditional logistic regression. Patients: A Swedish nationwide cohort of patients having surgery for primary hyperparathyroidism (n = 5009) from the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery between 2003 and 2013 was matched with population controls (n = 14,983). Data were cross-linked with Statistics Sweden and the National Board of Health and Welfare. Measurements: Preoperative serum calcium and adenoma weight at pathological examination. Results: Patients had an increased incidence rate of any fracture preoperatively, IRR 1.27 (95% confidence interval: 1.11–1.46), highest in the last year before surgery. Fracture incidence was not increased postoperatively. Serum calcium, adenoma weight and multiglandular disease were not associated with fracture incidence. Conclusions: Fracture incidence is higher in patients with primary hyperparathyroidism but is normalized after surgery