Revisiting Age Criterion for Surgery in Asymptomatic Primary Hyperparathyroidism

Gilad Horowitz*, Moshe Leshno, Elena Izkhakov, Daniel Halpern, Nidal Muhanna, Yona Greenman, Omer J. Ungar, Narin N. Carmel-Neidermann, Liyona Kampel, Anton Warshavsky

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Objective: To revisit the current age criterion (50 years) for surgical candidacy in patients diagnosed with asymptomatic primary hyperparathyroidism (PHPT). Study Design: A predictive model relying on past publications using the electronic databases “PubMed,” “Embase,” “Medline,” and “Google Scholar.”. Setting: Hypothetical large cohort. Methods: A Markov model was constructed, based on relevant literature, to compare 2 potential treatment algorithms for asymptomatic PHPT patients, parathyroidectomy (PTX), and observation. The various potential health states were characterized for the 2 treatment options and included potential surgical complications, end-organ deterioration, and death. A 1-way sensitivity analysis was performed to calculate the quality-adjusted life year (QALY) gains of both strategies. A Monte-Carlo simulation for 30,000 subjects was performed and cycled per annum. Results: On the basis of the model's assumptions, the QALY value for the PTX strategy was 19.17 versus 17.82 for the observation strategy. The incremental QALY gains for various ages according to the sensitivity analyses for PTX in comparison to observation were: 2.84 QALY for 40-year-old patients, 2.2 QALY for 50-year-old patients, 1.81 QALY for 55-year-old patients, 1.35 QALY for 60-year-old patients, and 0.86 QALY for 65-year-old patients. The incremental QALY is below 0.5 after the age of 75 years. Conclusion: This study found PTX to be advantageous for asymptomatic PHPT patients older than the current age criterion of 50 years. The calculated QALY gains support a surgical approach for medically fit patients in their 50s. The current guidelines for the surgical treatment of young asymptomatic PHPT patients should be revisited by the next steering committee.

Original languageEnglish
Pages (from-to)309-316
Number of pages8
JournalOtolaryngology - Head and Neck Surgery
Issue number2
StatePublished - Aug 2023


  • Markov model
  • age
  • hyperparathyroidism
  • observation
  • parathyroidectomy


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