September 2019, Volume XXXIII, No 6
Recognizing childhood and adolescent hypertension
A new clinical decision support tool
tarting at age three and continuing through adolescence, at least once per year it is recommended that children and adolescents have their blood pressure measured during a primary care visit. For those at increased risk for hypertension, based on family history, obesity, or presence of other medical conditions, blood pressure should be measured at every clinical encounter.
Updated definitions for hypertension in this age group have recently been published. In children 3–12 years of age, hypertension is defined as having blood pressure at or above the 95th percentile, based on their age, sex, and height at three separate clinical encounters. Mild elevations in blood pressure, at or above the 95th percentile, are classified as stage 1 hypertension, while blood pressures at or above the 95th percentile + 12 mmHG or above 140/90 mm Hg are classified as stage 2 hypertension. For adolescents 13–17 years of age, hypertension is defined as having blood pressure at or above 130/80 mm Hg at three separate visits and stage 2 hypertension is based on having blood pressures at or above 140/90 mm Hg at three separate visits. It is estimated that 1–3 percent of children and adolescents meet clinical criteria for hypertension, with a majority classified as stage 1.
Hypertension (HT) during childhood or adolescence is generally asymptomatic. Rarely, new hypertension in an older child or adolescent may be a sign of an underlying cardiac, renal, or endocrine disorder. However, for the most part, mild or stage 1 hypertension presenting in youth is idiopathic, also known as essential hypertension. Recognition is important as hypertension in adolescents has been found to be associated with increased stiffness of blood vessels and hypertrophy or thickening of the heart. Long-term risks associated with pediatric or adolescent hypertension include the persistence of hypertension into adulthood, along with future cardiovascular morbidity and mortality. The initial management of hypertension in children or adolescents is generally through lifestyle modifications, diet, and exercise. Antihypertensive medications may be considered if lifestyle changes are not effective, in cases where there is evidence of cardiac hypertrophy or other target organ damage, or when blood pressures are very elevated, consistent with stage 2 hypertension.
Updated definitions for hypertension in this age group have recently been published.
Barriers to hypertension recognition
In more than half of pediatric and adolescent patients with evidence of hypertension, based on blood pressures recorded at three or more primary care visits, their hypertension is not diagnosed or otherwise clinically recognized. Barriers to recognizing or diagnosing hypertension are numerous and include perceived complexities of the current hypertension definitions, which vary by age, and the need to review both current and previous blood pressure measurements to diagnose hypertension. For most pediatric and adolescent patients with an elevated blood pressure measurement, screening for hypertension is not the reason for their visit. With numerous competing demands or more urgent needs to attend to during the visit, providers may be challenged to find time to remeasure or further evaluate the blood pressure, especially when patients are seeking care for other health concerns. In addition, some providers may not be aware of or in agreement with the updated pediatric and adolescent hypertension guidelines.
As a final barrier, the provider’s behavior in response to an elevated blood pressure may be reinforced by his or her clinical experience. It is common for a single blood pressure measured in a pediatric primary care setting to be elevated—patients may be anxious about the visit, in pain, or there could be errors in measurement procedures leading to falsely elevated readings. Usually, when remeasured during the same visit, or at a subsequent visit, the next blood pressure will be normal. Thus, for most children and adolescents, when an elevated blood pressure is not clinically recognized, there is no immediate harm. Nevertheless, in a subset of patients, an elevated blood pressure recorded during a primary care visit is the first sign that the child or adolescent has developed hypertension. This is where health care organizations can leverage technology, by way of decision support that goes beyond simple prompts and reminders, to map trends over time and notify providers of these trends at the right time in the visit.
About the Peds & TeenBP Clinical Decision Support tool
The goals of our project were to improve recognition of elevated BP and hypertension, and to promote next steps in care consistent with pediatric hypertension guidelines. We aimed to achieve these goals targeting pediatric and adolescent patients presenting for primary care visits, integrating relevant clinical data within their electronic health record with clinical decision support (CDS) to provide tailored, patient-specific recommendations for nursing staff and medical providers. The Peds & TeenBP CDS was developed based on published guidelines and adapted for use within HealthPartners based on detailed evaluation of clinical workflow and input from leaders in pediatrics, family medicine, nursing, and informatics. Our goal was to design, develop, and implement CDS consistent with best practices, containing the right information, delivered to the right person, through the right channel, and at the right time during the clinical encounter to ensure use.
The Peds & TeenBP CDS incorporates prompts and reminders but also includes the following innovative features:
In order to understand its impact on care, starting in April 2014 we implemented the Peds & TeenBP CDS in 10 primary care clinics serving children and adolescents 10–17 years of age within HealthPartners Medical Group. We conducted in-person trainings at each of the 10 clinical sites at the beginning of the project to orient nurses and providers to the tool and to answer questions and gather feedback. Refresher training was conducted one year later to provide sites with use results and impact of the tool on the specific clinic as well as a general reminder of the what and why of the project to seasoned staff and to new staff. In addition, feedback regarding use of the CDS reports over the two-year project period was provided to leads at the Peds & TeenBP intervention clinics in the form of monthly use rates. The remaining comparison clinics did not have access to the Peds & TeenBP CDS and instead follow usual care. Among patients meeting clinical criteria for hypertension, our primary outcome was clinical recognition of hypertension. In addition, we evaluated specific next steps in care including lifestyle counseling, dietitian referrals, and additional diagnostic evaluations.
Barriers to recognizing or diagnosing hypertension are numerous.
Consistent with prior studies, hypertension was uncommon in our population. Only 1.5 percent of youth 10–17 years of age with at least one blood pressure recorded in their electronic health record over the two-year intervention period met clinical criteria for hypertension. Within six months of meeting criteria for new onset hypertension, 55 percent of Peds & TeenBP CDS patients versus 21 percent of patients at usual care clinics were recognized as having elevated blood pressure or hypertension (p<0.001). The most common form of recognition was having hypertension or elevated blood pressure as a discharge diagnosis at an outpatient encounter, documented in a clinical note, or described in the patient discharge instructions. Only 10 percent of patients at Peds & TeenBP CDS clinics and 5 percent of patients at the usual care sites had hypertension or elevated blood pressure added to their problem list.
Evaluations for secondary causes of hypertension or target organ damage were uncommon overall, but were more common in patients attending Peds & TeenBP intervention versus usual care clinics (9 percent versus 4 percent, p=.046). Of note, none of these patients undergoing additional work-up had a secondary cause for hypertension identified. Referrals to a dietitian, weight loss, or exercise program were also more common in patients at a Peds & TeenBP CDS intervention clinic (17 percent) versus patients at a usual care clinic (4 percent) (p=.001). Provision of antihypertensive medication within six months of meeting criteria occurred in <1 percent of patients overall and did not differ between intervention and usual care clinics.
Among 86 primary care providers at Peds & TeenBP intervention clinics, 71 (83 percent) completed a brief survey between March and June 2016. Eighty percent of respondents were physicians and 20 percent were advanced practice providers; 65 percent had over 10 years of experience in clinical practice. A majority of respondents (75 percent) recalled interacting with the Peds & TeenBP CDS. Of those who reported using the CDS, 92 percent thought it was useful in identifying patients with elevated BP or hypertension, 94 percent agreed that time using the Peds & TeenBP was “time well-spent,” and 95 percent agreed that Peds & TeenBP was useful for shared decision making.
The Peds & TeenBP CDS tool, developed and implemented in this study, significantly increased recognition of incident hypertension, promoted next steps in care consistent with pediatric hypertension guidelines, and was well accepted by the providers. Nevertheless, further work is needed to continue to increase hypertension recognition and to promote adoption of a healthy lifestyle in this population at risk for long-term cardiovascular morbidity. The Peds & TeenBP CDS has now been implemented system-wide across HealthPartners outpatient settings where blood pressure is routinely measured, including primary care, pediatric endocrine, and pediatric behavioral health departments. Although our formal research study has ended, we plan to continue to evaluate the impact of Peds and TeenBP CDS, now integrated as part of routine care. In addition, we plan to further promote cardiovascular health for children and adolescents through the dissemination of the Peds & TeenBP decision support tool in additional health systems in the region.
Elyse Kharbanda, MD MPH, is a senior research investigator and pediatrician at HealthPartners Institute. She is the principal investigator or co-investigator on several NIH- and CDC-funded studies covering a range of topics in maternal and child health, including two studies of clinical decision support for improving health outcomes in children and adolescents. The project described in this article was supported by the National Institutes of Health (R01 HL115082).
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Heidi Ekstrom, MA, is a principal project manager for Clinical Decision Support Applications at HealthPartners Institute. She is responsible for coordinating the development, implementation, and maintenance of several projects designed to test the effectiveness of sophisticated clinical decision support tools.