Evaluation of a Best-Practice Advisory for Primary Aldosteronism Screening

Abstract

ImportancePrimary aldosteronism (PA) is a common cause of secondary hypertension and an independent risk factor for cardiovascular morbidity and mortality. Fewer than 2% to 4% of patients at risk are evaluated for PA.ObjectiveTo develop and evaluate an electronic health record best-practice advisory (BPA) that assists with PA screening.Design, Setting, and ParticipantsThis prospective quality improvement study was conducted at academic center outpatient clinics. Data analysis was performed between February and June 2023 and included adults with hypertension and at least 1 of the following: 4 or more current antihypertensive medications; hypokalemia; age younger than 35 years; or adrenal nodule(s). Patients previously tested for PA were excluded.ExposureA noninterruptive BPA was developed to trigger for PA screening candidates seen in outpatient setting by clinicians who treat hypertension. The BPA included an order set for PA screening and a link to results interpretation guidance.Main Outcomes and Measures(1) The number of PA screening candidates identified by the BPA between October 1, 2021, and December 31, 2022; (2) the rates of PA screening; and (3) the BPA use patterns, stratified by physician specialty were assessed.ResultsOver 15 months, the BPA identified 14 603 unique candidates (mean [SD] age, 65.5 [16.9] years; 7300 women [49.9%]; 371 [2.5%] Asian, 2383 [16.3%] Black, and 11 225 [76.9%] White individuals) for PA screening, including 7028 (48.1%) with treatment-resistant hypertension, 6351 (43.5%) with hypokalemia, 1537 (10.5%) younger than 35 years, and 445 (3.1%) with adrenal nodule(s). In total, 2040 patients (14.0%) received orders for PA screening. Of these, 1439 patients (70.5%) completed the recommended screening within the system, and 250 (17.4%) had positive screening results. Most screening orders were placed by internists (40.0%) and family medicine physicians (28.1%). Family practitioners (80.3%) and internists (68.9%) placed most orders via the embedded order set, while specialists placed most orders (83.0%-95.4%) outside the BPA. Patients who received screening were younger and included more women and Black patients than those not screened. The likelihood of screening was higher among patients with obesity and dyslipidemia and lower in those with chronic kidney disease and established cardiovascular complications.Conclusions and RelevanceThe study results suggest that noninterruptive BPAs are potentially promising PA screening-assistance tools, particularly among primary care physicians. Combined with artificial intelligence algorithms that optimize the detection yield, refined BPAs may contribute to personalized hypertension care.

Is Screening for Primary Aldosteronism Always the Best Option?

“…To the Editor Patients with hypertension and primary aldosteronism (PA) face a grim prognosis in the absence of specific therapy; they must be promptly identified and managed . Charoensri et al reported on an enhanced effective screening rate for this population, reaching up to 9.9%, through an artificial intelligence−based best practice advisories system that identifies patients who are at high-risk for PA for clinicians. Although this is an improvement compared with the commonly reported 2% to 4% rate, screening remained infrequent even in this study context, with 90.1% of patients who were identified as being at high risk not undergoing screening.…”

“…PA screening conducted through aldosterone renin ratio (ARR) measurement is recommended to confirm a PA diagnosis and is essential for proceeding to adrenal venous sampling and adrenalectomy when necessary. However, numerous challenges hinder the implementation of ARR measurement in routine care, as highlighted in this study and existing literature . These challenges include the need to discontinue interfering medications, adjusting patient regimens, standardizing blood sample methods, and dealing with high intraindividual variability, complicating the diagnosis …”

“…Given that the mean (SD) age of the study patients was 65.5 (16.9) years and the high prevalence of patients with 4 or more antihypertensive medications (48%) and/or cardiovascular or kidney comorbidities—hindering the interruption of interfering therapy (at the very least 30%)—the physicians may have preferred using MRA therapy as a screening test and empirical therapy over performing a PA screening. This approach, recently proposed by a leading expert in the field, could be an easier and more pragmatic option in numerous contexts.…”

“…It could be at least as effective as traditionally recommended screening given the current substantial prevalence of underdiagnosed and undertreated patients with PA. Thus, reporting in this study on how best practice advisories affected MRA prescriptions as recorded in the electronic health records would be crucial information for accurately evaluating the merit of this type of assistant.…”

Is Screening for Primary Aldosteronism Always the Best Option?—Reply

“…In Reply We appreciate the perspective from Boulestreau and Couffinhal on our recent initiative to enhance screening for primary aldosteronism (PA) by leveraging electronic health records capabilities. We designed and implemented an advisory that identifies PA screening candidates and assists clinicians with test ordering and interpretation . Boulestreau and Couffinhal suggest empirical use of mineralocorticoid receptor antagonists (MRA) to treat patients with possible PA as a more pragmatic alternative to PA screening.…”