Health Record Trigger Boosted Screening for Primary Aldosteronism

An electronic health record (EHR) best-practice advisory helped identify candidates for primary aldosteronism (PA) screening, a prospective quality improvement study found.

Out of a pool of 57,334 adults with hypertension seen at an outpatient clinic, 25.5% met at least one of the criteria for PA screening, Adina F. Turcu, MD, MS, of the University of Michigan in Ann Arbor, and colleagues reported in JAMA Internal Medicine.

Of those patients meeting the screening criteria suggested by the best-practice advisory, 14% received orders for PA screening by their provider. And among them, 70.5% completed the recommended screening within the system and 17.4% had positive screening results.

This is in stark contrast to the estimated 2% to 4% of eligible PA screening candidates tested in prior data referenced by Turcu’s group.

“Although we were hoping for broader uptake of this EHR-embedded best-practice advisory, we were delighted to see an increase in PA screening rates to 14% of identified candidates as compared to an average of less than 3% in retrospective studies of similar populations, including in our own institution prior to implementing this [best-practice advisory],” Turcu told MedPage Today.

“Targeted treatment for PA is readily available, and it mitigates the risk of cardiovascular and renal morbidity and mortality in these patients,” she pointed out. “Computerized health records leverage the development of healthcare support applications. We recognize that such applications must undergo continuous refinement and are no substitute for clinical judgment.”

“Nevertheless, considering that in the U.S. almost 1 in 2 adults has hypertension, such automatized tools become instrumental to the busy clinician, particularly those in primary care. Our results indicate a promising opportunity to meaningfully improve PA awareness and enhance its diagnosis,” said Turcu.

The best-practice advisory was built within the EHR. The PA screening suggestion was then triggered if the patient had hypertension plus was on four or more current antihypertensive medications, had hypokalemia, were younger than 35 years, and/or had adrenal nodules. When triggered, the advisory included a PA screen smart order set including plasma aldosterone, renin, and a basic metabolic panel, plus a link to results interpretation guidance.

Clinicians then had the option to either use, ignore, or decline the advisory by acknowledging one of the following: declined by patient, other secondary hypertension present, or screening deferred due to acute or chronic comorbidities.

Most orders for screening were placed by internists (40%) and family medicine physicians (28.1%). Family practitioners (80.3%) and internists (68.9%) placed most orders through the embedded order set, while specialists placed most orders (83-95.4%) outside the best-practice advisory.

There was a 15-month period from late 2021 through 2022 where PA screening candidates were identified from a targeted clinic. Of the PA screening candidates, the average age was 65.5 years, 49.9% were female, 76.9% were white patients, 16.3% were Black patients, and 2.5% were Asian patients.

Among them, 7,028 patients (48.1%) had treatment-resistant hypertension, 6,351 (43.5%) had hypertension and hypokalemia, 1,537 (10.5%) had early-onset hypertension, and 445 (3.1%) had hypertension and adrenal nodules. Fully 95% met one screening criterion, 5.16% met two criteria, and 0.02% met three screening criteria.

Those with treatment-resistant hypertension had the highest prevalence of chronic kidney disease (34.6%) and coronary artery disease (43.4%). On the other hand, those with adrenal nodules were more likely to have obesity (55.3%), and those with hypokalemia had the highest rates of atrial fibrillation (37.0%) and heart failure (43.4%).

Patients who received PA screening tended to be younger and included more women and Black patients than those not screened. Screening was also more common among patients with obesity and dyslipidemia and lower in those with chronic kidney disease and established cardiovascular complications.

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