Developing a framework to individualize surgical decision-making for older adults with primary hyperparathyroidism

PROJECT SUMMARY/ABSTRACT This K76 Career Development award will address the large unmet need for patient-specific decision support tools for surgical interventions in older adults and provide a platform for the applicant to become a leader in geriatric surgery. Primary hyperparathyroidism (PHPT) is a common endocrine disorder in older adults that is associated with serious long-term morbidity, including osteoporotic fractures, kidney stones, and chronic kidney disease (CKD). Parathyroidectomy can prevent these morbid sequelae. However, increased surgical risk associated with advanced age and frailty, in addition to the competing risk of death prior to achieving benefit from surgical intervention, raises the question of whether the short-term risks of parathyroidectomy outweigh long-term risk reduction in this group. Identifying older adults likely to benefit from surgical interventions, such as parathyroidectomy, while preventing overuse of surgery in this vulnerable group, is critical to improve patient-centered care. Currently, there is no standardized methodology for developing surgical decision support for older adults that incorporates individualized risk prediction and stakeholder input to facilitate informed, patient-centered decision-making. Therefore, this coordinated research and training proposal aims to: 1) compare the effects of parathyroidectomy vs. medical management on the incidence of fractures, symptomatic kidney stones, and CKD in older adults with PHPT; 2) develop and validate predictive models for the perioperative risks of parathyroidectomy and long-term risks of fractures, kidney stones, and CKD specific to older adults with PHPT; and 3) design and test with stakeholder feedback a PHPT decision support tool that describes the tradeoffs of parathyroidectomy vs. non-operative management. To accomplish these aims, Dr. Seib will obtain training in comparative effectiveness and predictive modeling, qualitative and mixed methods research to develop decision support, and implementation science. Upon completion of this research, Dr. Seib will have a user-tested risk/benefit calculator that will form the basis of a decision support tool to improve individualized, patient-centered treatment recommendations for older adults with PHPT. In addition, this research will establish a framework for developing patient-centered decision support that can be applied to other conditions to promote appropriate surgical management of older adults. This proposal is significant because it directly addresses the gap in decision support tools for PHPT and other surgically managed conditions in older adults. This project is innovative because it proposes a paradigm shift to incorporate geriatric principles to individualize treatment decisions in older adults with PHPT to optimize clinical outcomes. At the end of the proposed research, Dr. Seib will have the data and skills necessary to successfully pursue R01 funding for a hybrid type 1 effectiveness-implementation trial to test this decision support tool and apply this methodology to other conditions with surgical treatment options that affect older adults.