Evaluate or Ignore: National Variation in the Evaluation of Adrenal Lesions in Over 250,000 Patients

Background Adrenal lesions are commonly found on abdominal imaging obtained for unrelated indications. Available data on the incidence, evaluation, and management of adrenal incidentalomas are primarily based on single-institution retrospective studies that may not be nationally representative. Our aim was to evaluate national rates and predictors of guideline concordant adrenal lesion follow-up using a large, well-established national claims database (Merative MarketScan). Methods Using the MarketScan database, we identified a national cohort of patients >18 years old with adrenal lesions discovered on imaging. Outcomes of interest included biochemical workup, repeat imaging, and surgical intervention. We performed descriptive, comparative, and multivariable analyses to determine the rates and predictors of guideline concordant workup and assessed geographic trends. Results Among 251,705 patients with adrenal masses, only 3% received complete biochemical workup. Only 19% received any biochemical testing, 61% underwent follow-up imaging, and 2% ultimately underwent adrenalectomy. On multivariable analysis, hypertension, private insurance, and female sex were significant predictors of receiving adrenal biochemical workup. Older age and a prior cancer diagnosis were associated with lower rates of biochemical workup. Patients located in the Northeast and Western regions of the US were more likely to undergo biochemical workup. Conclusions National rates of guideline concordant evaluation for patients with adrenal incidentalomas are low. Patient comorbidities, region of residence, and insurance status influenced rates of follow-up. Targeted interventions for high-risk patients and efforts to address regional disparities may help improve national adherence to guideline-recommended evaluation.