P76. Fewer Pills, Lower Bills: Antihypertensive and Cost Outcomes of Adrenalectomy in Primary Aldosteronism

Primary aldosteronism (PA) can be treated surgically with adrenalectomy or medically with mineralocorticoid receptor antagonists depending on disease lateralization and surgical candidacy. While adrenalectomy has proven clinical efficacy compared with medical management, there is a dearth of data directly comparing antihypertensive medication (AHM) trajectories and costs between these two strategies.


Methods:

We performed a retrospective cohort study of patients with new PA diagnoses and adrenal vein sampling (AVS) to assess AHM outcomes and treatment costs using the national Optum Clinformatics® database (2004–22). Patients were stratified by receipt of adrenalectomy versus medical management alone. Index timepoint was defined as AVS for medically managed and adrenalectomy for surgically managed patients. Primary outcomes included number of AHM prescriptions from pre- to post-intervention and cost of therapy. Outcomes were assessed using regression models. Subcohort analysis compared outcomes in patients with resistant hypertension.


Results:

Of 911 patients with PA who underwent AVS, 472 (52%) underwent adrenalectomy and 439 (48%) medical therapy. Adrenalectomy patients were younger (median 55.0 vs. 57.0 years, p=0.003) with higher household income and median Elixhauser score. Surgically and medically managed patients did not differ in AHM use at index (2.9 vs. 2.8, p=0.636). One year post-index, adrenalectomy patients used fewer AHMs (1.5 ± 1.4) than medically managed patients (2.5 ± 1.5, p< 0.001). On regression, age (β=0.02, 95% CI 0.01–0.03, p=0.002), male sex (β=0.40, 95% CI 0.20–0.60, p< 0.001), and baseline AHMs (β=0.43, 95% CI 0.37–0.49, p< 0.001) were associated with higher AHM requirement at one year. Patients who underwent adrenalectomy were prescribed 1.11 fewer AHMs at one year (95% CI 0.91–1.31, p< 0.001). In patients with resistant hypertension, adrenalectomy reduced AHMs by 1.35 (95% CI 1.08–1.62, p< 0.001).

The median total cost of adrenalectomy was $26,805 (IQR $12,802–31,817). While AHM prescription costs at baseline did not differ significantly (p=0.744), surgically managed patients incurred lower median AHM prescription costs over one year ($161 vs. $830, p< 0.001). Adrenalectomy was associated with $908 lower total prescription costs on regression (95% CI $682–1135, p< 0.001).


Conclusions:

Patients with PA who undergo adrenalectomy demonstrate a significant reduction in AHMs compared with medically managed patients. While there is significant upfront cost to surgical intervention, reduced long-term prescription costs are realized.