Utilization of Outcome Patient Based Instruments

In the past, the vague, nonspecific nature of these nonclassic symptoms in HPT limited the ability of clinicians and investigators to quantitate these symptoms with validated outcome tools. Today, patient-based outcome instruments are utilized to provide a better understanding of the impact of a disease on a patient's well-being and of the effectiveness of intervention on a disease process.29"31 Several authors have demonstrated an improvement in the ability to concentrate, in cognitive function, and in some of the psychiatric symptoms such as depression following parathyroidectomy by utilizing generic neuropsychiatric assessment tools.19,23'25'26 Others have attempted to illustrate the effect that 1° HPT has on the patient's functional health status and well-being as well as demonstrate the impact of surgical intervention on these parameters utilizing a generic QOL instrument, the SF-36 form.21,32"34 The SF-36 form defines eight domains of health status: general health, physical function, physical and emotional role limitations, social function, mental health, bodily pain, and energy or fatigue.

Burney and colleagues were the first to utilize the SF-36 form and demonstrate that 1° HPT patients had a marked impairment in their health status and QOL scoring significantly lower in seven of the eight measured domains compared with population norms before parathyroidectomy.33 34 Sustained improvement in six of the eight domains was demonstrated following parathyroidectomy. Talpos and coworkers randomly assigned 53 asymptomatic patients to surgery versus observation alone.32 The authors demonstrated a statistically significant improvement in two of the eight domains of the SF-36 health survey, those of social functioning and emotional role limitations, in the surgically treated group. These studies give insight into the impact of the nonclassic symptoms of HPT on a patient's well-being and how parathyroidectomy can affect the patient's overall health. Although these observations are important, the generic nature of the SF-36 outcome tool makes it less responsive to clinical changes that may have occurred after parathyroidectomy.30 A disease-specific outcome measurement tool would be more responsive to the subtle clinical changes that have been observed retrospectively by patients and their surgeons.30

A disease-specific outcome tool for HPT has been validated. This instrument, including both the classic and nonclassic symptoms, has been utilized at the University of Calgary as well as in a multicenter trial studying the impact of parathyroidectomy on patients with HPT.1617,35 Parathyroidectomy Assessment of Symptoms (PAS) scores were obtained for 13 disease-specific items preoperatively, 7 to 10 days postoperatively, at 3 months, and at 1 year. The higher the PAS score, the higher the patients ranked their experience of the symptom. We found that the 1° HPT patients were more symptomatic preoperatively than the thyroid comparison group. Following surgical intervention, the HPT patients experienced a significant decrease in their PAS scores in the first study period and this decreasing trend continued out to 1 year.16,17 35 In contrast, the thyroid comparison group demonstrated no change in their PAS scores throughout the study (Fig. 44-1).

In a further subset analysis of the University of Calgary's patients, Sywak and coworkers found that 22 of 117 patients with 1° HPT who underwent successful parathyroidectomy had none of the NIH criteria for parathyroidectomy and by definition were free of all classic symptoms.22 The preoperative PAS scores were equally high in both the 22 patients without NIH criteria for surgery and the 95 patients in whom at least one of the NIH criteria was present. More important, both of these 1° HPT groups were significantly more symptomatic preoperatively than the nontoxic thyroid comparison group. All 1° HPT patients reported a significant improvement in their symptom scores after parathyroidectomy (Fig. 44-2). Looking specifically at the nonclassic symptoms of fatigue, depression, irritability, mood swings, and forgetfulness, we found that all of these symptoms improved at 1-year follow-up in the 1° HPT patients, in contrast to no change demonstrated in these symptoms in the thyroid comparison group (Fig. 44-A and B). We concluded that the so-called asymptomatic patients were indeed suffering from reversible, nonspecific manifestations of the disease and felt the guidelines for parathyroidectomy should be broadened to include the nonclassical manifestations of 10 HPT.

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