MON-503 - Enhancing Screening Practices and Addressing Underdiagnosis of Primary Aldosteronism

Background
Our quality improvement (QI) project was conducted at University of Pittsburgh Medical Center, Mercy where we targeted an underserved patient population with high pretest probability of primary aldosteronism (PA) and actively implemented measures to augment screening.

Methods
Our cohort comprised of 538 patients with high pretest probability of PA, including individuals with resistant hypertension and hypokalemia, obstructive sleep apnea, and family history of early-onset hypertension, stroke or primary aldosteronism per the 2016 guidelines. Screening, however, was implemented per the updated 2025 guidelines, for all hypertensive patients regardless of high risk features. Interventions included informational flyers, stickers on computers with reference QR code with testing instructions, weekly guideline review for faculty/ residents and EPIC EMR sticky note prompts with manually charted reminders for the selected patient cohort. The screening tests comprised of renin, aldosterone and basic metabolic panel. The first data analysis was conducted in two months following the interventions.

Results
Of the 538 patients, 431 patients were included in the study [excluding previously screened (88) and deceased patients (19)]. Among 431 eligible patients, 295 patients did not have office visits in two months since the intervention, while 136 patients were seen. Of the 136 patients, 53 patients (39%) were actively screened and 20 patients (38%) completed the tests. Of these, 3 tested positive (15%) and 17 tested negative. With our active screening measures, we were able to augment screening rates up to 39%, a substantial increase from preintervention rates of 16.4%. Universal screening also mediated capture of high-risk patients that were previously missed. 15% of the patients that screened positive exceeded the commonly accepted prevalence of 5-10%. Newly diagnosed patients were promptly referred to Endocrinology. Limitations for screening were identified to be low awareness, misconceptions about testing on antihypertensive therapy, limited patient follow-up, challenges correcting hypokalemia and repeat testing, and absence of standardized EMR prompts even for high-risk patients.

Conclusion
PA remains largely underdiagnosed due to poor screening rates with current evidence noting screening rates of often 1-2% and typically < 5% overall, thereby also underestimating its true prevalence. Our QI initiative strongly supports and concludes the necessity of the updated 2025 guidelines that now recommend screening for all hypertensive patients to improve identification and outcomes. Longitudinal follow-up is currently ongoing to complete cohort interventions and determine outcomes. Future directions include incorporating automatic EMR prompts and integration of PA screening into primary care practice guidelines to further reinforce screening practices.

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