Opportunity

Primary hyperparathyroidism (PHPT) is a disorder resulting from overactive parathyroid glands that can cause calcium-related health issues if left untreated. Estimates suggest that PHPT occurs in 1 percent of the United States population, with patients who are older, female, or Black at higher risk. However, 75 percent of affected individuals are not screened for PHPT. At Penn Medicine, this translates to around 2,000 primary care patients with undiagnosed PHPT.

Intervention

With support from the Nudge Unit, a team of researchers at the University of Pennsylvania has developed an automated method for identifying and treating PHPT.   

• First, our tool identifies patients by scanning the electronic health record (EHR) for lab abnormalities indicative of hyperparathyroidism.  
• We tested two nudge approaches to prompt PHPT screening if the criteria are met. With the standard approach, the patient’s primary care clinician receives an alert through the EHR's Storyboard – a sidebar summarizing essential patient details, including a "Care Gaps" section where this screening alert appears – recommending they order the lab tests needed for PHPT diagnosis. The second intervention automatically pends the screening order for an upcoming primary care appointment (using technology developed for LiveAware, a liver cancer screening program), which clinicians may cancel if appropriate. 
• After screening is complete, the tool interprets the lab results and provides clinicians with diagnostic guidance. 

Impact

We piloted these interventions over about two months in separate primary care clinics. The automated method yielded dramatically higher PHPT screening rates: Compared to the 12 percent screening rate observed without our tool (“usual care”), the screening rate was 12 times higher (75 percent) with the pended order nudge and four times higher (49 percent) with the standard alert nudge.  

We also found that, among patients who completed labs, PHPT was a new diagnosis for more patients in the intervention groups – 71 percent in the pended order group and 36 percent for the standard approach group, compared to 19 percent for the usual care group. 

In future work, we plan to evaluate the automated screening tool in a randomized control trial and scale the most effective nudge.