Best practice advisory boosted primary aldosteronism screening
Noninterruptive best practice advisories are potentially promising as screening-assistance tools for primary aldosteronism, particularly for primary care physicians, according to the authors of a recent quality improvement study.
A best practice advisory could potentially improve the detection and personalized therapy of patients whose hypertension is due to primary aldosteronism, a study found.
Researchers conducted a prospective quality improvement study at academic outpatient clinics in 2023 among adults with hypertension who met one of the following conditions: four or more current antihypertensive medications; hypokalemia; age younger than 35 years; or adrenal nodule(s). The advisory included a screening smart order set (including plasma aldosterone, renin, and basic metabolic panel) and a link to guidance for interpreting results. Clinicians could use, ignore, or decline the advisory. The advisory was piloted within the endocrinology department, announced by email to all physicians in primary care departments, and then released to all university primary care clinics and to the secondary hypertension expertise units in cardiology, nephrology, and endocrinology. Results were published Jan. 8 by JAMA Internal Medicine.
Over 15 months, the best practice advisory identified 14,603 patients (mean age, 65.5 years; 49.9% women; 2.5% Asian, 16.3% Black, and 76.9% White) for primary aldosteronism screening, including 7,028 (48.1%) with treatment-resistant hypertension, 6,351 (43.5%) with hypokalemia, 1,537 (10.5%) younger than age 35 years, and 445 (3.1%) with adrenal nodule(s).
Among the 2,040 patients (14.0%) who received screening orders, 70.5% completed the recommended screening within the system, and 17.4% had positive screening results. Most screening orders were placed by internal medicine (40.0%) and family medicine physicians (28.1%). Family medicine (80.3%) and internal medicine (68.9%) physicians placed most orders via the embedded order set, while specialists placed most orders (83.0% to 95.4%) outside the best practice advisory.
Those 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.
“The use of EHR-delivered [best practice alerts] has been particularly effective among primary care physicians,” the study authors wrote. “This finding suggests an opportunity to implement innovative clinical decision supporting systems that may meaningfully improve [primary aldosteronism] awareness and enhance testing in high-risk patient populations.”