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: Thirty-eight clinicians were recruited from across Australia, including cardiologists (n = 8), endocrinologists (n = 10), general practitioners (n = 10) and nephrologists (n = 10). Purposive sampling achieved diversity in practice location, setting, and clinical experience. In-depth semistructured interviews were conducted between May and November 2024. Analytical Approach: Interview transcripts were analyzed using both deductive content analysis aligned with the Consolidated Framework for Implementation Research 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 system, government, and organizational factors. Common barriers across clinician groups included that PA is often considered in a narrow patient cohort, with older and comorbid 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 specialized 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 suboptimally managed. The basis for 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.