Electronic Alert to Improve Testing For Primary Aldosteronism in Patients With Hypertension

Electronic Alert-Based Computerized Decision Support to Improve Testing For Primary Aldosteronism in Patients With Hypertension: ALERT-PA

Primary aldosteronism (PA) is common but rarely recognized cause of hypertension that carries excess cardiovascular and renal risk and has approved targeted treatments. Despite current clinical guidelines that recommend screening in a defined set of high-risk populations, less than 5% of eligible patients are ever screened for PA. This study aims to evaluate the impact of a computer decision support Best Practice Advisory (BPA) alert on rates of screening for PA in guideline-eligible patients, referral to specialist PA care, and treatment with mineralocorticoid receptor antagonists.

The study protocol is a single-center Quality Improvement initiative performed as a cluster-randomized controlled trial designed to evaluate the impact of an EPIC electronic health record Best Practice Advisory (BPA) alert on rates of screening for PA in guideline-eligible patients. 1600 patients meeting inclusion/exclusion criteria for Primary Aldosteronism (PA) screening will comprise the study population, with randomization of alert/no alert occurring at the level of their treating clinician (Attending Physician, Nurse Practitioner, or Physician Assistant) to minimize spillover/contamination effects of the BPA onto other patients treated by the same clinician. Treating clinicians within primary care and relevant specialties including endocrinology, nephrology, and cardiology will be randomized 1:1 to receive or not receive a BPA prompting screening for PA with laboratory testing of plasma aldosterone, plasma renin activity, and a basic metabolic panel, as well as an order for an e-consult to provide guidance on interpretation of results, for eligible patients. Outcomes will be ascertained by electronic health record review at 6 months.

Inclusion Criteria:

• Adults 18+

• Seen by clinician at one of the intervention practices at least once in the prior 2 years

• History of Hypertension (ICD Code) PLUS ≥1 of the below:

  • Outpatient BP >150/100 on 2 or more occasions
  • Three or more current antihypertensive medication prescriptions
  • Potassium level <3.5mEq/L or potassium supplement prescription in the last 5 years
  • History of Atrial Fibrillation or Atrial Flutter (ICD Code)

Exclusion Criteria:

• History of Primary Aldosteronism (ICD Code)
• Prescription for a Mineralocorticoid Receptor Antagonist (MRA) within the last 3 months