Massachusetts Chapter of the American College of Surgeons

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Impact of an Adrenal Incidentaloma Quality Improvement Initiative upon Primary Aldosteronism Screening
Alison P. Woods1,2, Timothy Feeney1, Marianna V. Papageorge1, Susanna W.L. de Geus1, Sing Chau Ng1, Jennifer F. Tseng1, David McAneny1, F. Thurston Drake1
1Boston University, School Of Medicine, Department Of Surgery, Boston, MA 2Johns Hopkins University School Of Medicine, Department Of Surgery, Division Of Surgical Oncology, Baltimore, MD

Background: Primary aldosteronism (PA) is a correctable cause of hypertension, but most patients meeting screening criteria do not undergo testing. We implemented a quality improvement (QI) program to improve adrenal incidentaloma (AI) evaluation and examined changes in PA screening among patients with both hypertension and AIs, a widely-accepted screening indication.
Methods: This systemwide QI initiative targeted primary care providers (PCPs) following detection of an AI. The intervention incorporated messages to PCPs, access to an evaluation algorithm, and radiology report templates specifying follow-up needs. Data were prospectively collected for patients with AIs from 1/1/2018 to 12/31/2019, and compared to a cohort diagnosed with AIs in 2016. The primary outcome was the proportion of patients ordered for screening laboratory tests for PA. Outcomes were assessed using Fisher’s exact test and logistic regression.
Results: The QI cohort included 349 patients, versus 251 in the historical cohort. Patients without hypertension, without a PCP in our system, or with life-limiting comorbidities were excluded. In the QI cohort, 22.6% (25/116) were screened for PA, compared to 5.9% (8/135) in the historical cohort (p=0.0003). After adjusting for insurance status and setting in which the study was ordered (e.g., inpatient, outpatient, emergency department), patients in the QI cohort had 3.80 higher odds (95% CI 1.5-10.7) of appropriate screening compared to those in the historical cohort.
Conclusion: Patients in whom hypertension and AI were identified during a QI initiative had higher odds of PCP-initiated screening for PA. Although screening tripled with this initiative, overall rates of screening remain low.


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