Lower costs with ambulatory fludrocortisone suppression test vs. in-patient testing
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Ambulatory fludrocortisone suppression testing for primary aldosteronism has similar accuracy compared with in-patient fludrocortisone suppression testing but with significantly lower health care costs, according to study data.
“To the best of our knowledge, this is the first study to explore the safety and accuracy of fludrocortisone suppression tests performed in an ambulatory setting,” Ana Carasel, MD, of the department of endocrinology at Karolinska University Hospital in Stockholm, and colleagues wrote in a study published in Clinical Endocrinology. “In Stockholm, there is a long tradition of performing ambulatory fludrocortisone suppression testing, but this practice had not been evaluated systematically. We found that the ambulatory fludrocortisone suppression test is safe, accurate and can be performed with about 50% reduction in health costs compared to the in-patient fludrocortisone suppression testing.”
Researchers conducted a retrospective study of the medical records of adults screened for primary aldosteronism at four hospitals in the Stockholm region from 2005 to 2019. Researchers collected aldosterone to renin ratio, 24-hour urinary aldosterone, 24-hour urinary sodium, serum cortisol, incidence of hypokalemia during testing, episodes of arrhythmia, hospitalization due to testing complications, adherence to protocol, blood pressure and intolerance to medication. Accuracy was assessed by comparing the results of each test type with the combined results of initial laboratory screening, radiologic findings, confirmatory tests, adrenal vein sampling and histologic findings. Testing costs were calculated and reviewed by the financial departments of each hospital.
The study included 156 cases of ambulatory fludrocortisone suppression testing and 15 cases of in-patient fludrocortisone suppression testing. Median plasma potassium concentrations and 24-hour urinary sodium concentrations at day 5 were similar between the two tests. Serum cortisol concentrations were lower with ambulatory fludrocortisone suppression testing compared with in-patient fludrocortisone suppression testing. Plasma aldosterone concentrations as measured in a recumbent and seated posture was lower with ambulatory testing vs. in-person testing (333.5 pmol/L vs. 538 pmol/L; P = .018). The median increase in slow-release potassium chloride tablets was higher with in-patient fludrocortisone suppression testing compared with ambulatory fludrocortisone suppression testing (10.5 vs. 4; P = .001).
Adverse events were reported by five adults undergoing ambulatory fludrocortisone suppression testing and none in the in-patient fludrocortisone suppression testing group. Three participants in the ambulatory fludrocortisone suppression testing group had to repeat testing due to issues with medication intake. The mean cost for ambulatory fludrocortisone suppression tests was lower than in-patient fludrocortisone suppression testing ($2,400 vs. $5,200).
“The time needed for health professionals to complete the ambulatory fludrocortisone suppression test was only 2.5 hours of nurse time and 1 hour of physician time, respectively,” the researchers wrote. “This is a considerable reduction compared with the in-patient fludrocortisone suppression testing. Further, the total health care costs with the ambulatory fludrocortisone suppression test compared to the in-patient ambulatory fludrocortisone suppression test was significantly reduced by more than 50%. We are aware that the health costs will vary depending on the hospital and the country where fludrocortisone suppression test is performed. Nevertheless, we believe that our calculation gives a fair estimation of the cost reduction.”
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