New Tool Improves Hypertension Detection in Children

Nicola M. Parry, DVM

January 25, 2018

Incorporating a clinical decision support (CDS) tool into electronic health records (EHRs) improves recognition and management of hypertension in children and adolescents, a randomized trial published online today in Pediatrics shows.

"The CDS had a significant, beneficial effect on the recognition of hypertension, with a moderate increase in guideline-adherent management," write Elyse O. Kharbanda, MD, MPH, from the HealthPartners Institute, Minneapolis, Minnesota, and colleagues.

Hypertension often goes underrecognized in children and adolescents, even though blood pressure (BP) is routinely measured at outpatient visits. The authors note that although EHRs contain enough information to allow clinicians to diagnose hypertension among patients with multiple visits, the data may not be presented in a way that is useful for clinicians.

To improve on that situation, Dr Kharbanda and colleagues have developed and piloted a new EHR-linked pediatric BP CDS tool. In the current cluster-randomized trial, they tested whether the tool increases detection and management of hypertension in pediatric patients.

The study included 31,579 patients aged 10 to 17 years who were seen at 20 primary care clinics between April 15, 2014, and April 14, 2016. All the clinics were part of an integrated healthcare system and were randomly assigned to use the new CDS or to continue with usual care.

Overall, 522 (1.7%) patients had incident hypertension. Within 6 months of patients meeting the criteria for incident hypertension, clinicians recognized the condition in 54.9% of patients in CDS clinics compared with only 21.3% of those in usual care clinics (P ≤ .001).

Clinicians recognized hypertension most frequently through documentation of hypertension or elevated BP in discharge diagnoses, clinical notes, or patient discharge instructions. "Our CDS was innovative in its display of current and previous BPs along with medications and diagnoses that may affect BP, pooling clinically useful, patient-specific data on a single screen," the authors say.

Among those with incident hypertension, patients in the CDS clinics were more likely to be referred to dietitians or weight loss or exercise programs (17.1% vs 3.9%; P = .001).

Clinicians at CDS clinics also more commonly screened patients for lipid disorders. Among patients eligible for lipid screening, 14.4% at CDS clinics underwent screening compared with just 5.3% of those at usual care clinics (P = .03).

More patients at CDS clinics also had additional hypertension workup (9.4% vs 4.2%; P = .046).

Although the CDS tool improved guideline-adherent care for youth with incident hypertension, the authors acknowledge the need for further improvement. "Even in the intervention clinics, approximately half of the new hypertension cases were not recognized," they write.

"As we update our CDS tool to incorporate the 2017 hypertension guidelines, we are also planning strategies to increase adoption of and adherence to recommendations, such as a manual trigger to access the CDS at any time during the clinical encounter."

In an accompanying commentary, Ari H. Pollack, MD, MSIM, from the University of Washington in Seattle, and Joseph T. Flynn, MD, from Seattle Children's Hospital in Washington, describe the tool developed by Dr Kharbanda and colleagues as "the most comprehensive and well-integrated pediatric BP CDS described to date."

However, the commentators also highlight the substantial number of hypertension cases that still went unrecognized during the 2-year study period.

Stressing the need for additional strategies to further improve hypertension recognition, Dr Pollack and Dr Flynn suggest that CDS systems should also directly target patients and families. Clinicians should give patients and families summaries that include the BP readings from the clinic visit, their corresponding percentile, and a simple note of whether the BP was normal or high, they say.

This study was supported by the National Institutes of Health. The authors and editorialists have reported no financial conflicts of interest.

Pediatrics. Published online January 25, 2018. Article abstract, Commentary extract

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