Clinician Decision-Making in Managing Primary Aldosteronism: A Qualitative Study

Rationale & Objectives Primary Aldosteronism (PA) is underdiagnosed in people living with hypertension, despite its considerable prevalence, association with poorer cardiovascular and kidney outcomes, and availability of effective treatment. The factors underlying such underdiagnosis and undertreatment remain uncertain. This study aimed to identify key factors influencing screening, diagnosis and treatment of PA from the clinician's perspective. Study Design Exploratory qualitative study. Setting and participants 38 clinicians were recruited from across Australia, including cardiologists (n=8), endocrinologists (n=10), general practitioners (GPs) (n=10) and nephrologists (n=10). Purposive sampling achieved diversity in practice location, setting and clinical experience. In-depth semi-structured interviews were conducted between May and November 2024. Analytical Approach Interview transcripts were analysed using both deductive content analysis aligned with the Consolidated Framework for Implementation Research (CFIR) and inductive reflexive thematic analysis. Results Four themes were developed to explain factors affecting clinician screening, diagnosis and treatment decisions: 1) Clinician experience, knowledge and perceptions 2) PA screening and diagnosis complexity and burden 3) Accessibility of services and information; and 4) Health systems, government and organisational factors. Common barriers across clinician groups included that PA is often considered in a narrow patient cohort, with older and co-morbid populations not considered candidates for screening; that the perceived complexity and burden associated with PA diagnosis inhibits initiation of the diagnostic process; that limited access to services is a barrier to screening or workup of PA, and; that lack of streamlined and local diagnostic services contributes to fragmented care and diagnostic delay. Key facilitators included access to specialised diagnostic units and cross-disciplinary and collegial decision-making in patient management. Limitations Generalizability may be limited due to Australian context. Conclusions These findings highlight key factors that influence clinicians' decision-making in PA detection and management, providing important guidance to the design of future clinician-targeted interventions to improve PA diagnosis and treatment. PLAIN LANGUAGE SUMMARY Primary aldosteronism (PA) is the most common hormonal cause of hypertension, however, it is vastly underdiagnosed, and often sub-optimally managed. The basis of this is poorly understood. To explore this, nephrologists, endocrinologists, cardiologists and general practitioners were interviewed to understand their decision-making in PA management. Major barriers included: often only narrow profiles of patients were considered candidates for PA screening; the diagnostic process was perceived as burdensome and therefore often not initiated, and; that limited diagnostic service access dictated clinical management and contributed to diagnostic delay. Conversely, specialized diagnostic units and professional networks promoted optimal patient management. These findings highlight key factors that can be leveraged in the design of future clinician-targeted interventions to improve PA care.