Presentation (CTI)

OBJECTIVES: Primary aldosteronism (PA) is an underdiagnosed cause of secondary hypertension (HTN), associated with increased cardiovascular morbidity and mortality. The updated Endocrine Society guideline recommends screening all HTN patients using the aldosterone-to-renin ratio (ARR). This study evaluated the cost-effectiveness of PA screening across multiple countries.
METHODS: A decision-analytic model combining a decision tree and a one-year cycle Markov model was developed to estimate the lifetime clinical and economic outcomes of chemiluminescence immunoassay-based and mass spectrometry-based PA screening versus no screening in HTN patients. The decision tree reflected the guideline-recommended diagnostic pathway, including ARR screening and, where indicated, confirmatory testing and PA subtyping to guide treatment. The Markov model estimated long-term coronary heart disease and stroke outcomes. Clinical inputs, including epidemiological data, diagnostic accuracy, transition probabilities, clinical efficacy, and utilities, were retrieved from published literature. The analysis was conducted from the healthcare system perspective in the United States, France, Germany, Italy, Spain, the United Kingdom (UK), and Australia. Direct healthcare costs, including PA-related screening and diagnosis, surgery and medical treatments, and coronary heart disease and stroke management, were sourced from country-specific sources. Deterministic and probabilistic sensitivity analyses (PSA and DSA) assessed parameter uncertainty.
RESULTS: PA screening yielded an incremental gain of nearly 0.1 quality-adjusted life years (QALYs) per patient across settings compared with no screening, through targeted PA treatment and consequent reduction of long-term cardiovascular events. Screening was dominant compared with no screening in all evaluated countries except the UK; for example, in Italy, reported per-patient savings were ~€250 (~€2k for each PA patient). In the UK, it remained cost-effective, with an incremental cost-effectiveness ratio of approximately £3k/QALY. PSA and DSA confirmed the robustness of results.
CONCLUSIONS: ARR-based PA screening can be considered cost-effective across multiple settings. These findings support broader implementation of PA screening in HTN.