title: Cost-Effectiveness of Screening for Primary Aldosteronism and Subtype Diagnosis in the Resistant Hypertensive Patients.
abstract: BACKGROUND
  Primary aldosteronism (PA) is a common and underdiagnosed disease with significant morbidity potentially cured by surgery. We aim to assess if the long-term cardiovascular benefits of identifying and treating surgically correctable PA outweigh the upfront increased costs in patients at the time patients are diagnosed with resistant hypertension (RH).
  
  
  RESULTS
  A decision-analytic model compares aggregate costs and systolic blood pressure changes of 6 recommended or implemented diagnostic strategies for PA in a simulated population of at-risk RH patients. We also evaluate a 7th "treat all" strategy wherein all patients with RH are treated with a mineralocorticoid-receptor antagonist without further testing at RH diagnosis. Changes in systolic blood pressure are subsequently converted into gains in quality-adjusted life years (QALYs) by applying National Health and Nutrition Examination Survey data on concomitant risk factors to an existing cardiovascular disease simulation model. QALYs and lifetime costs were then used to calculate incremental cost-effectiveness ratios for the competing strategies. The incremental cost-effectiveness ratio for the strategy of computerized tomography (CT) followed by adrenal venous sampling (AVS) was $82,000/QALY compared with treat all. Incremental cost-effectiveness ratios for CT alone and AVS alone were $200,000/QALY and $492,000/QALY; the other strategies were more costly and less effective. Integrating differential patient-reported health-related quality of life adjustments for patients with PA, and incremental cost-effectiveness ratios for screening patients with CT followed by AVS, CT alone, and AVS alone were $52,000/QALY, $114,000/QALY, and $269,000/QALY gained.
  
  
  CONCLUSIONS
  CT scanning followed by AVS was a cost-effective strategy to screen for PA among patients with RH.
authors.affiliation: From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.). clubitz@partners.org.
authors.forename: Carrie C
authors.initials: CC
authors.lastname: Lubitz
authors.affiliation: From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.).
authors.forename: Konstantinos P
authors.initials: KP
authors.lastname: Economopoulos
authors.affiliation: From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.).
authors.forename: Stephen
authors.initials: S
authors.lastname: Sy
authors.affiliation: From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.).
authors.forename: Colden
authors.initials: C
authors.lastname: Johanson
authors.affiliation: From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.).
authors.forename: Heike E
authors.initials: HE
authors.lastname: Kunzel
authors.affiliation: From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.).
authors.forename: Martin
authors.initials: M
authors.lastname: Reincke
authors.affiliation: From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.).
authors.forename: G Scott
authors.initials: GS
authors.lastname: Gazelle
authors.affiliation: From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.).
authors.forename: Milton C
authors.initials: MC
authors.lastname: Weinstein
authors.affiliation: From the Departments of Surgery (C.C.L., K.P.E.) and Radiology (G.S.G.), Massachusetts General Hospital, Boston; Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (C.C.L., K.P.E., C.J., G.S.G.); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (S.S., G.S.G., M.C.W., T.A.G.); Schwerpunkt Endokrinologie, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, München, Germany (H.E.K., M.R.); and Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (T.A.G.).
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Gaziano
mesh_terms: D000315:Adrenalectomy / Q000191:economics; D000959:Antihypertensive Agents / Q000191:economics* / Q000627:therapeutic use; D001774:Blood Chemical Analysis / Q000191:economics*; D001794:Blood Pressure / Q000187:drug effects; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D016527:Drug Costs; D004351:Drug Resistance; D017048:Health Care Costs; D006801:Humans; D006929:Hyperaldosteronism / Q000150:complications / Q000175:diagnosis* / Q000191:economics* / Q000628:therapy; D006973:Hypertension / Q000175:diagnosis / Q000188:drug therapy / Q000191:economics* / Q000209:etiology / Q000503:physiopathology; D000451:Mineralocorticoid Receptor Antagonists / Q000191:economics / Q000627:therapeutic use; D018803:Models, Economic; D009749:Nutrition Surveys; D018579:Patient Selection; D011237:Predictive Value of Tests; D019057:Quality-Adjusted Life Years; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed / Q000191:economics*; D017211:Treatment Failure
chemical_list: D000959:Antihypertensive Agents; D000451:Mineralocorticoid Receptor Antagonists
keywords: blood pressure; cost-effectiveness; hyperaldosteronism; hypertension; mineralocorticoids