The performance of marginal structural models for estimating risk differences and relative risks using weighted univariate generalized linear models
Austin PC. Stat Methods Med Res. 2024; Apr 24 [Epub ahead of print].
Primary aldosteronism is a common, yet highly underdiagnosed, cause of hypertension that leads to disproportionately high rates of cardiovascular disease. Hypertension plus hypokalemia is a guideline-recommended indication to screen for primary aldosteronism, yet the uptake of this recommendation at the population level remains unknown. We performed a population-based retrospective cohort study of adults ≥18 years old in Ontario, Canada, with hypertension plus hypokalemia (potassium <3.5 mEq/L) from 2009 to 2015 with follow-up through 2017. We measured the proportion of individuals who underwent primary aldosteronism screening via the aldosterone-to-renin ratio based upon hypokalemia frequency and severity along with concurrent antihypertensive medication use. We assessed clinical predictors associated with screening via Cox regression. The cohort included 26 533 adults of which only 422 (1.6%) underwent primary aldosteronism screening. When assessed by number of instances of hypokalemia over a 2-year time window, the proportion of eligible patients who were screened increased only modestly from 1.0% (158/15 983) with one instance to 4.8% (71/1494) with ≥5 instances. Among individuals with severe hypokalemia (potassium <3.0 mEq/L), only 3.9% (58/1422) were screened. Among older adults prescribed ≥4 antihypertensive medications, only 1.0% were screened. Subspecialty care with endocrinology (hazard ratio [HR], 1.52 [95% CI, 1.10-2.09]), nephrology (HR, 1.43 [95% CI, 1.07-1.91]), and cardiology (HR, 1.39 [95% CI, 1.14-1.70]) were associated with an increased likelihood of screening, whereas age (HR, 0.95 [95% CI, 0.94-0.96]) and diabetes (HR, 0.66 [95% CI, 0.50-0.89]) were inversely associated with screening. In conclusion, population-level uptake of guideline recommendations for primary aldosteronism screening is exceedingly low. Increased education and awareness are critical to bridge this gap.
Hundemer GL, Imsirovic H, Vaidya A, Yozamp N, Goupil R, Madore F, Agharazii M, Knoll G, Sood MM. Hypertension. 2022; 79(1):178-86. Epub 2021 Oct 18.
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