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Asowata O, Okekunle A, Akpa O, Fakunle A, Akinyemi J, Komolafe M, Sarfo F, Akpalu A, Obiako R, Wahab K, Osaigbovo G, Owolabi L, Jenkins C, Calys-Tagoe B, Arulogun O, Ogbole G, Ogah OS, Appiah L, Ibinaiye P, Adebayo P, Singh A, Adeniyi S, Mensah Y, Laryea R, Balogun O, Chukwuonye I, Akinyemi R, Ovbiagele B, Owolabi M. Risk Assessment Score and Chi-Square Automatic Interaction Detection Algorithm for Hypertension Among Africans: Models From the SIREN Study. Hypertension 2023; 80:2581-2590. [PMID: 37830199 PMCID: PMC10715722 DOI: 10.1161/hypertensionaha.122.20572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 09/13/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND This study aimed to develop a risk-scoring model for hypertension among Africans. METHODS In this study, 4413 stroke-free controls were used to develop the risk-scoring model for hypertension. Logistic regression models were applied to 13 risk factors. We randomly split the dataset into training and testing data at a ratio of 80:20. Constant and standardized weights were assigned to factors significantly associated with hypertension in the regression model to develop a probability risk score on a scale of 0 to 1 using a logistic regression model. The model accuracy was assessed to estimate the cutoff score for discriminating hypertensives. RESULTS Mean age was 59.9±13.3 years, 56.0% were hypertensives, and 8 factors, including diabetes, age ≥65 years, higher waist circumference, (BMI) ≥30 kg/m2, lack of formal education, living in urban residence, family history of cardiovascular diseases, and dyslipidemia use were associated with hypertension. Cohen κ was maximal at ≥0.28, and a total probability risk score of ≥0.60 was adopted for both statistical weighting for risk quantification of hypertension in both datasets. The probability risk score presented a good performance-receiver operating characteristic: 64% (95% CI, 61.0-68.0), a sensitivity of 55.1%, specificity of 71.5%, positive predicted value of 70.9%, and negative predicted value of 55.8%, in the test dataset. Similarly, decision tree had a predictive accuracy of 67.7% (95% CI, 66.1-69.3) for the training set and 64.6% (95% CI, 61.0-68.0) for the testing dataset. CONCLUSIONS The novel risk-scoring model discriminated hypertensives with good accuracy and will be helpful in the early identification of community-based Africans vulnerable to hypertension for its primary prevention.
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Affiliation(s)
| | - Akinkunmi Okekunle
- University of Ibadan, Ibadan, Nigeria
- Seoul National University, Seoul, Korea
| | | | - Adekunle Fakunle
- University of Ibadan, Ibadan, Nigeria
- College of Health Sciences, Osun State University, Osogbo, Nigeria
| | | | | | - Fred Sarfo
- Kwame Nkrumah University of Science and Technology, Ghana
| | | | | | | | | | | | | | | | | | | | | | - Lambert Appiah
- Kwame Nkrumah University of Science and Technology, Ghana
| | | | | | - Arti Singh
- Kwame Nkrumah University of Science and Technology, Ghana
| | | | - Yaw Mensah
- University of Ghana Medical School, Accra, Ghana
| | - Ruth Laryea
- University of Ghana Medical School, Accra, Ghana
| | | | | | - Rufus Akinyemi
- University of Ibadan, Ibadan, Nigeria
- Federal Medical Centre, Abeokuta, Nigeria
| | - Bruce Ovbiagele
- Weill Institute for Neurosciences, University of California San Francisco, USA
| | - Mayowa Owolabi
- University of Ibadan, Ibadan, Nigeria
- Lebanese American University, 1102 2801 Beirut, Lebanon
- University College Hospital, Ibadan, Nigeria
- Blossom Specialist Medical Center, Ibadan, Nigeria
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Benziger CP, Suess M, Allen CI, Freitag LA, Asche SE, Ekstrom HL, Essien IJ, Muthineni A, Thirumalai V, Vo PH, Kromrey KA, Ronkainen EA, Saman DM, O'Connor PJ, Kharbanda EO. Adapting a clinical decision support system to improve identification of pediatric hypertension in a rural health system: Design of a pragmatic trial. Contemp Clin Trials 2023; 132:107293. [PMID: 37454727 PMCID: PMC11027719 DOI: 10.1016/j.cct.2023.107293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/29/2023] [Accepted: 07/11/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Identifying hypertension (HTN) early is crucial in preventing and lowering the long-term risk of heart disease, yet HTN in children often goes undiagnosed. An electronic health record linked, web-based clinical decision support (CDS) called PedsBP can help address this care gap and has been previously shown to increase recognition of HTN by primary care clinicians. OBJECTIVES To adapt the PedsBP tool for use in a mostly rural health system and then to evaluate the effectiveness of PedsBP for repeat of hypertensive level blood pressure (BP) measurements and HTN recognition among youth 6-17 years of age in primary care settings, comparing low-intensity and high-intensity implementation approaches. METHODS AND DESIGN PedsBP was evaluated through a pragmatic, clinic-randomized trial. The tool was piloted in 2 primary care clinics and modified prior to the full trial. Forty community-based, primary care clinics (or clusters of clinics) were randomly allocated in a 1:1:1 ratio to usual care, low-intensity implementation (CDS only), or high-intensity implementation (CDS plus in-person training, monthly use reports, and ongoing communication between study staff and clinics). Accrual of eligible patients started on August 1, 2022 and will continue for 18 months. Primary outcomes include repeating hypertensive level BP measurements at office visits and clinical recognition of HTN. Secondary outcomes include lifestyle counseling, dietician referral, and BP at follow-up. CONCLUSION This report focuses on the design and feasibility of adapting and implementing PedsBP in a rural primary care setting. The trial and analysis are ongoing with main results expected in mid-2024.
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Affiliation(s)
- Catherine P Benziger
- Essentia Health Heart and Vascular Center, Duluth, MN, United States of America.
| | - Madison Suess
- University of Minnesota Medical School, Duluth Campus, Duluth, MN, United States of America
| | - Clayton I Allen
- Essentia Institute of Rural Health, Duluth, MN, United States of America
| | - Laura A Freitag
- Essentia Institute of Rural Health, Duluth, MN, United States of America
| | - Stephen E Asche
- HealthPartners Institute, Bloomington, MN, United States of America
| | - Heidi L Ekstrom
- HealthPartners Institute, Bloomington, MN, United States of America
| | - Inih J Essien
- HealthPartners Institute, Bloomington, MN, United States of America
| | | | | | - Phuong H Vo
- HealthPartners Institute, Bloomington, MN, United States of America
| | - Kay A Kromrey
- HealthPartners Institute, Bloomington, MN, United States of America
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Heider AK, Mang H. Effects of Non-monetary Incentives in Physician Groups-A Systematic Review. Am J Health Behav 2023; 47:458-470. [PMID: 37596755 DOI: 10.5993/ajhb.47.3.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
Objectives: Healthcare expenditures in western countries have been rising for many years. This leads many countries to develop and test new reimbursement systems. A systematic review about monetary incentives in group settings indicated that a sole focus on monetary aspects does not necessarily result in better care at lower costs. Hence, this systematic review aims to describe the effects of non- monetary incentives in physician groups. Methods: We searched the databases MEDLINE (PubMed), The Cochrane Library, CINAHL, PsycINFO, EconLit, and ISI Web of Science. Grey literature search, reference lists, and authors' personal collection provided additional sources. Results: Overall, we included 36 studies. We identified 4 categories of interventions related to non-monetary incentives. In particular, the category of decision support achieved promising results. However, design features vary among different decision support systems. To enable effective design, we provide an overview of the features applied by the studies included. Conclusions: Not every type of non-monetary incentive has a positive impact on quality of care in physician group settings. Thus, creating awareness among decision-makers regarding this matter and extending research on this topic can contribute to preventing implementation of ineffective incentives, and consequently, allocate resources towards tools that add value.
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Affiliation(s)
- Ann-Kathrin Heider
- Faculty of Medicine, Friedrich-Alexander-Universität, Erlangen-Nürnberg, Germany
| | - Harald Mang
- Master Program Medical Process Management, Universitätsklinikum Erlangen, Germany
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4
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Meisner JK, Yu S, Lowery R, Liang W, Schumacher KR, Burrows HL. Clinical Decision Support Tool for Elevated Pediatric Blood Pressures. Clin Pediatr (Phila) 2022; 61:428-439. [PMID: 35383471 DOI: 10.1177/00099228221087804] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Under-diagnosis of pediatric hypertension remains pervasive due to difficulty recognizing elevated systolic blood pressures (SBPs). We performed a retrospective review comparing recognition of and response to elevated SBPs ≥95th percentile before and after development of a clinical decision support tool (CDST) in an academic pediatric system. Of 44,351 encounters, 477 had elevated SBPs with documented recognition of an elevated SBP in 17.9% of encounters pre-CDST that increased to 33.7% post-CDST (P = .001). Post-CDST, 75.5% of elevated SBPs had repeat measurement, with 90.8% of initially elevated SBPs normalizing to <95th percentile. If repeat measurement was obtained and SBP remained elevated, documented recognition increased from 14.0 to 83.3% (P < .0001). These data support using the CDST is associated with increased identification of elevated SBPs in children with greatest improvements associated with repeat SBP measurement. This suggests targeted training and support systems at medical intake would be high yield for increasing recognition of elevated SBP.
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Affiliation(s)
- Joshua K Meisner
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Sunkyung Yu
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Ray Lowery
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Wen Liang
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Kurt R Schumacher
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Heather L Burrows
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
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Gold R, Larson AE, Sperl-Hillen JM, Boston D, Sheppler CR, Heintzman J, McMullen C, Middendorf M, Appana D, Thirumalai V, Romer A, Bava J, Davis JV, Yosuf N, Hauschildt J, Scott K, Moore S, O’Connor PJ. Effect of Clinical Decision Support at Community Health Centers on the Risk of Cardiovascular Disease: A Cluster Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2146519. [PMID: 35119463 PMCID: PMC8817199 DOI: 10.1001/jamanetworkopen.2021.46519] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
IMPORTANCE Management of cardiovascular disease (CVD) risk in socioeconomically vulnerable patients is suboptimal; better risk factor control could improve CVD outcomes. OBJECTIVE To evaluate the impact of a clinical decision support system (CDSS) targeting CVD risk in community health centers (CHCs). DESIGN, SETTING, AND PARTICIPANTS This cluster randomized clinical trial included 70 CHC clinics randomized to an intervention group (42 clinics; 8 organizations) or a control group that received no intervention (28 clinics; 7 organizations) from September 20, 2018, to March 15, 2020. Randomization was by CHC organization accounting for organization size. Patients aged 40 to 75 years with (1) diabetes or atherosclerotic CVD and at least 1 uncontrolled major risk factor for CVD or (2) total reversible CVD risk of at least 10% were the population targeted by the CDSS intervention. INTERVENTIONS A point-of-care CDSS displaying real-time CVD risk factor control data and personalized, prioritized evidence-based care recommendations. MAIN OUTCOMES AND MEASURES One-year change in total CVD risk and reversible CVD risk (ie, the reduction in 10-year CVD risk that was considered achievable if 6 key risk factors reached evidence-based levels of control). RESULTS Among the 18 578 eligible patients (9490 [51.1%] women; mean [SD] age, 58.7 [8.8] years), patients seen in control clinics (n = 7419) had higher mean (SD) baseline CVD risk (16.6% [12.8%]) than patients seen in intervention clinics (n = 11 159) (15.6% [12.3%]; P < .001); baseline reversible CVD risk was similarly higher among patients seen in control clinics. The CDSS was used at 19.8% of 91 988 eligible intervention clinic encounters. No population-level reduction in CVD risk was seen in patients in control or intervention clinics; mean reversible risk improved significantly more among patients in control (-0.1% [95% CI, -0.3% to -0.02%]) than intervention clinics (0.4% [95% CI, 0.3% to 0.5%]; P < .001). However, when the CDSS was used, both risk measures decreased more among patients with high baseline risk in intervention than control clinics; notably, mean reversible risk decreased by an absolute 4.4% (95% CI, -5.2% to -3.7%) among patients in intervention clinics compared with 2.7% (95% CI, -3.4% to -1.9%) among patients in control clinics (P = .001). CONCLUSIONS AND RELEVANCE The CDSS had low use rates and failed to improve CVD risk in the overall population but appeared to have a benefit on CVD risk when it was consistently used for patients with high baseline risk treated in CHCs. Despite some limitations, these results provide preliminary evidence that this technology has the potential to improve clinical care in socioeconomically vulnerable patients with high CVD risk. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03001713.
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Affiliation(s)
- Rachel Gold
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
- OCHIN Inc, Portland, Oregon
| | | | | | | | | | | | - Carmit McMullen
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | | | | | | | | | | | - James V. Davis
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Nadia Yosuf
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
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Solberg LI, Hooker SA, Rossom RC, Bergdall A, Crabtree BF. Clinician Perceptions About a Decision Support System to Identify and Manage Opioid Use Disorder. J Am Board Fam Med 2021; 34:1096-1102. [PMID: 34772765 PMCID: PMC8759280 DOI: 10.3122/jabfm.2021.06.210126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Addressing the opioid epidemic would benefit from primary care clinicians identifying and managing opioid use disorder (OUD) during routine clinical encounters, but current rates are low. Clinical decision support (CDS) systems are a promising way to facilitate such interactions, but will clinicians use them? METHODS We iteratively conducted semi-structured interviews with 8 purposively sampled primary care clinicians participating in a pilot OUD-CDS study to identify attitudes toward discussing OUD and preferences for support in doing so. Five of them had used a pilot version of the CDS for 6 months, while the others were in comparison clinics. Interviews were recorded, transcribed, and analyzed by a multi-disciplinary group of experienced researchers, using an editing organizing style where the analysts independently highlighted relevant text and then discussed to reach a consensus on themes. RESULTS We identified five themes: 1. Primary care is the right place to address OUD. 2. Both clinician-patient and clinician-clinician relationships affect how and whether clinicians address OUD in a particular patient encounter. 3. The main challenges are limited time and competing priorities for these complex patients. 4. Although a CDS for OUD could be very helpful, it must meet different needs for different clinicians and clinical situations and be simple to use. 5. For optimal benefit, the CDS needs to be complemented by supportive organizational policies and systems as well as local clinician encouragement. CONCLUSIONS With the right design and a supportive organization, these primary care clinicians believe a CDS could help them regularly identify and address OUD among their patients as long as it incorporates their concerns about relationships, competing priorities, patient complexity, and user simplicity.
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Affiliation(s)
- Leif I Solberg
- From the HealthPartners Institute, Minneapolis, MN (LIS, SAH, RCR, AB); Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (BFC).
| | - Stephanie A Hooker
- From the HealthPartners Institute, Minneapolis, MN (LIS, SAH, RCR, AB); Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (BFC)
| | - Rebecca C Rossom
- From the HealthPartners Institute, Minneapolis, MN (LIS, SAH, RCR, AB); Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (BFC)
| | - Anna Bergdall
- From the HealthPartners Institute, Minneapolis, MN (LIS, SAH, RCR, AB); Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (BFC)
| | - Benjamin F Crabtree
- From the HealthPartners Institute, Minneapolis, MN (LIS, SAH, RCR, AB); Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (BFC)
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Mastrianni A, Sarcevic A, Chung LS, Zakeri I, Alberto EC, Milestone ZP, Burd RS, Marsic I. Designing Interactive Alerts to Improve Recognition of Critical Events in Medical Emergencies. DIS. DESIGNING INTERACTIVE SYSTEMS (CONFERENCE) 2021; 2021:864-878. [PMID: 35330919 PMCID: PMC8941664 DOI: 10.1145/3461778.3462051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Vital sign values during medical emergencies can help clinicians recognize and treat patients with life-threatening injuries. Identifying abnormal vital signs, however, is frequently delayed and the values may not be documented at all. In this mixed-methods study, we designed and evaluated a two-phased visual alert approach for a digital checklist in trauma resuscitation that informs users about undocumented vital signs. Using an interrupted time series analysis, we compared documentation in the periods before (two years) and after (four months) the introduction of the alerts. We found that introducing alerts led to an increase in documentation throughout the post-intervention period, with clinicians documenting vital signs earlier. Interviews with users and video review of cases showed that alerts were ineffective when clinicians engaged less with the checklist or set the checklist down to perform another activity. From these findings, we discuss approaches to designing alerts for dynamic team-based settings.
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Determining pediatric hypertension criteria: concordance between observed physician methods and guideline-recommended methods. J Hypertens 2021; 39:1893-1900. [PMID: 33967240 DOI: 10.1097/hjh.0000000000002869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine and evaluate the accuracy of methods physicians use to detect diagnostic criteria for pediatric hypertension [hypertensive blood pressures (BPs) on three or more occasions] in electronic health records (EHRs). METHODS Methods used by pediatric-trained physicians (n = 12) to detect diagnostic criteria for hypertension in a simulation using a child's EHR data were directly observed, timed, and evaluated for accuracy. All physicians were given the same information regarding diagnostic criteria to eliminate knowledge gaps. Then, computer modeling and EHR data from 41 654 3-18-year-olds were used to simulate and compare the accuracy of detecting hypertension criteria using an observed-shorthand method vs. the guideline-recommended/gold-standard method. RESULTS No physician used the guideline-recommended method of determining multiple time-of-care hypertension thresholds for child age/height at the time of each BP measure. One physician estimated the child's BP diagnosis without computing thresholds; 11 of 12 physicians determined the child's hypertension threshold from age/height data at the time of a current visit and applied/imputed this threshold to BP measured at all visits (current-visit threshold used to assess historical-visit BPs) to detect three separate BP elevations. Physicians took 2.3 min (95% confidence interval, 1.5-3.0) to declare a diagnosis. Sensitivity was 83.1% when applying the current-visit threshold to detect the guideline-recommended-BP-threshold diagnosis using EHR data. Specificity and positive-predictive/negative-predictive values ranged from 98.5 to 99.9%. CONCLUSION Physicians applied a shorthand method to evaluate pediatric BPs. Computer-simulated comparison of the shorthand and guideline methods using clinical data suggest the shorthand method could yield an inaccurate impression of a child's BP history in 17% of pediatric ambulatory visits.
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Vuppala S, Turer CB. Clinical Decision Support for the Diagnosis and Management of Adult and Pediatric Hypertension. Curr Hypertens Rep 2020; 22:67. [PMID: 32852616 PMCID: PMC7450038 DOI: 10.1007/s11906-020-01083-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To review literature from 2016 to 2019 on clinical decision support (CDS) for diagnosis and management of hypertension in children and adults. RECENT FINDINGS Ten studies described hypertension CDS systems. Novel advances included the integration of patient-collected blood pressure data, automated information retrieval and management support, and use of CDS in low-resource/developing-world settings and in pediatrics. Findings suggest that CDS increases hypertension detection/control, yet many children and adults with hypertension remain undetected or undercontrolled. CDS challenges included poor usability (from lack of health record integration, excessive data entry requests, and wireless connectivity challenges) and lack of clinician trust in blood pressure measures. Hypertension CDS has improved but not closed gaps in the detection and control of hypertension in children and adults. The studies reviewed indicate that the usability of CDS and the system where CDS is deployed (e.g., commitment to high-quality blood pressure measurement/infrastructure) may impact CDS's ability to increase hypertension detection and control.
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Affiliation(s)
- Suchith Vuppala
- Department of Medicine, University of Texas Southwestern (UTSW) Medical School, Dallas, TX USA
| | - Christy B. Turer
- Departments of Pediatrics and Medicine, UTSW and Children’s Health, 5323 Harry Hines Blvd., Dallas, TX 75390-9063 USA
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Clinical Decision Support for Recognizing and Managing Hypertensive Blood Pressure in Youth: No Significant Impact on Medical Costs. Acad Pediatr 2020; 20:848-856. [PMID: 32004709 PMCID: PMC7872738 DOI: 10.1016/j.acap.2020.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 01/17/2020] [Accepted: 01/23/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate economic costs from the health system perspective of an electronic health record-based clinical decision support (CDS) tool, TeenBP, designed to assist in the recognition and management of hypertension in youth. METHODS Twenty primary care clinics within an integrated health system were randomized to the TeenBP CDS or usual care (UC), with patient enrollment from 4/15/14 to 4/14/16. The 12-month change in standardized medical care costs for insured patients aged 10 to 17 years without prior hypertension were calculated for each study arm. The primary analysis compared patients with ≥1 visit with blood pressure (BP) ≥95th percentile (isolated hypertensive BP), and secondary analyses compared patients with ≥3 visits within one year with BP ≥95th percentile (incident hypertension). Generalized estimating equation models estimated the difference-in-differences in costs between groups over time. RESULTS Among 925 insured patients with an isolated hypertensive BP, the pre-to-post change in overall costs averaged $22 more for TeenBP CDS versus UC patients over 12 months, but this difference was not statistically significant (P = .723). Among 159 insured patients with incident hypertension, the pre-to-post change in overall costs over 12 months was higher by $227 per person on average for TeenBP CDS versus UC patients, but this difference also was not statistically significant (P = .313). CONCLUSIONS The TeenBP CDS intervention was previously found to significantly improve identification and management of hypertensive BP in youth, and in this study, we find that this tool did not significantly increase care costs in its first 12 months of clinical use.
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Bismar N, Barlow SE, Brady TM, Turer CB. Pediatrician Communication About High Blood Pressure in Children With Overweight/Obesity During Well-Child Visits. Acad Pediatr 2020; 20:776-783. [PMID: 31783183 PMCID: PMC7247946 DOI: 10.1016/j.acap.2019.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/19/2019] [Accepted: 11/23/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Despite recognition that hypertension is associated with childhood obesity, data suggest that high blood pressure (BP) is infrequently diagnosed in children. This study sought to examine provider communication with overweight school-age children regarding BP measurements that were high at well-child visits. METHODS Cross-sectional mixed-methods analysis of audio-recorded communication from well-child visits with overweight 6-12-year-olds. Data from the subset of children with elevated BPs were used for this study. Three BP measures obtained at the audio-recorded visit were averaged, paired with historical BPs stored in the health record, and compared to contemporary/Fourth-Report thresholds to determine if children had elevated/hypertensive BPs only at the audio-recorded visit or met hypertension-diagnostic criteria (hypertension-level BP ≥3 separate visits). Two reviewers used visit transcripts to categorize communication about BP as "absent," "unclear," or "direct." Provider use of a billing diagnosis for elevated BP/hypertension in visits with direct-BP-communication was explored. RESULTS In 36 of 126 (29%) visit-audio-recordings, children had elevated/hypertensive BPs. Thirty-three of the 36 eligible (92%) had intelligible audio-recordings. Of these, 9 (25%) were overweight and 24 (75%) had obesity. Seventeen (52%) had elevated BPs, and 16 (48%) hypertensive BPs. Ten (30%) met criteria for hypertension diagnosis. BP communication was absent in 20 visits (61%), unclear in 8 (24%), and direct in 5 visits (15%). Billing diagnoses for elevated BP/hypertension were entered at 4 of 5 (80%) visits with direct-BP communication. CONCLUSIONS Most overweight children with elevated BPs did not receive communication that BP is high at well-child visits. Relevant billing diagnoses may indicate direct-BP communication.
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Affiliation(s)
- Nora Bismar
- School of Medicine (N Bismar), University of Texas Southwestern (UTSW), Dallas, Tex
| | - Sarah E Barlow
- Division of Pediatric Gastroenterology, Department of Pediatrics (SE Barlow, CB Turer), University of Texas Southwestern (UTSW), Dallas, Tex; Department of Population Health and Data Science (SE Barlow, CB Turner), UTSW Medical Center, Dallas, Tex; Children's Health (SE Barlow, CB Turer), Dallas, Tex
| | - Tammy M Brady
- Division of Pediatric Nephrology, Department of Pediatrics (TM Brady), Johns Hopkins University School of Medicine, Baltimore, Md
| | - Christy B Turer
- Division of Pediatric Gastroenterology, Department of Pediatrics (SE Barlow, CB Turer), University of Texas Southwestern (UTSW), Dallas, Tex; Department of Population Health and Data Science (SE Barlow, CB Turner), UTSW Medical Center, Dallas, Tex; Children's Health (SE Barlow, CB Turer), Dallas, Tex.
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12
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Kharbanda EO, Asche SE, Sinaiko A, Nordin JD, Ekstrom HL, Dehmer SP, Bredeson D, O'Connor PJ. Improving Hypertension Recognition in Adolescents, a Small but Important First Step in Cardiovascular Disease Prevention. Acad Pediatr 2020; 20:163-165. [PMID: 31445203 PMCID: PMC7032989 DOI: 10.1016/j.acap.2019.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/09/2019] [Accepted: 08/16/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Elyse Olshen Kharbanda
- HealthPartners Institute (EO Kharbanda, SE Asche, JD Nordin, HL Ekstrom, SP Dehmer, D Bredeson, and PJ O'Connor), Minneapolis, Minn.
| | - Stephen E Asche
- HealthPartners Institute (EO Kharbanda, SE Asche, JD Nordin, HL Ekstrom, SP Dehmer, D Bredeson, and PJ O'Connor), Minneapolis, Minn
| | - Alan Sinaiko
- Department of Pediatrics, University of Minnesota (A Sinaiko), Minneapolis, Minn
| | - James D Nordin
- HealthPartners Institute (EO Kharbanda, SE Asche, JD Nordin, HL Ekstrom, SP Dehmer, D Bredeson, and PJ O'Connor), Minneapolis, Minn
| | - Heidi L Ekstrom
- HealthPartners Institute (EO Kharbanda, SE Asche, JD Nordin, HL Ekstrom, SP Dehmer, D Bredeson, and PJ O'Connor), Minneapolis, Minn
| | - Steven P Dehmer
- HealthPartners Institute (EO Kharbanda, SE Asche, JD Nordin, HL Ekstrom, SP Dehmer, D Bredeson, and PJ O'Connor), Minneapolis, Minn
| | - Dani Bredeson
- HealthPartners Institute (EO Kharbanda, SE Asche, JD Nordin, HL Ekstrom, SP Dehmer, D Bredeson, and PJ O'Connor), Minneapolis, Minn
| | - Patrick J O'Connor
- HealthPartners Institute (EO Kharbanda, SE Asche, JD Nordin, HL Ekstrom, SP Dehmer, D Bredeson, and PJ O'Connor), Minneapolis, Minn
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13
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Kharbanda EO, Asche SE, Dehmer SP, Sinaiko AR, Ekstrom HL, Trower N, O'Connor PJ. Impact of updated pediatric hypertension guidelines on progression from elevated blood pressure to hypertension in a community-based primary care population. J Clin Hypertens (Greenwich) 2019; 21:560-565. [PMID: 30980615 DOI: 10.1111/jch.13539] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/13/2019] [Accepted: 03/26/2019] [Indexed: 11/27/2022]
Abstract
In 2017, definitions for pediatric hypertension were updated. A threshold of 130/80 mm Hg was introduced for stage 1 hypertension in adolescents, and children with obesity were removed from the reference population, lowering the 95th percentile, compared to the 2004 Fourth Report. The impact of these changes on care for youth with elevated blood pressure has not been well described. The objective of this study was to compare the 2017 and 2004 criteria for hypertension, evaluating how they impact estimates of risks for elevated blood pressure to progress to hypertension. Data came from youth 10-17 years of age with ≥2 elevated blood pressure measurements (≥90th percentile or ≥120/80 mm Hg) between 04/15/2014 and 04/14/2016 and three additional measurements over two subsequent years. Blood pressures were recorded in primary care practices within a large health system, as part of routine care. Rates of incident hypertension following persistent elevated blood pressure based on the 2017 guidelines vs the 2004 Fourth Report were compared. We found, among 2025 youth with persistent elevated blood pressure, 46% were female and mean age was 14.6 years. Over 2 years of follow-up, progression to hypertension occurred in 5.9% using the 2017 guidelines vs 1.1% using 2004 Fourth Report definitions. Using the 2017 criteria, progression was most common in older youth and those with obesity. In conclusion, for most youth, elevated blood pressure does not progress to hypertension within 2 years. However, progression from elevated blood pressure to hypertension was more than 5-fold greater when applying the 2017 guidelines compared to the older 2004 Fourth Report criteria.
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Affiliation(s)
| | | | | | - Alan R Sinaiko
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
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14
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Richardson KM, Fouquet SD, Kerns E, McCulloh RJ. Impact of Mobile Device-Based Clinical Decision Support Tool on Guideline Adherence and Mental Workload. Acad Pediatr 2019; 19:828-834. [PMID: 30853573 PMCID: PMC6732014 DOI: 10.1016/j.acap.2019.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 02/05/2019] [Accepted: 03/02/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the individual-level impact of an electronic clinical decision support (ECDS) tool, PedsGuide, on febrile infant clinical decision making and cognitive load. METHODS A counterbalanced, prospective, crossover simulation study was performed among attending and trainee physicians. Participants performed simulated febrile infant cases with use of PedsGuide and with standard reference text. Cognitive load was assessed using the NASA-Task Load Index (NASA-TLX), which determines mental, physical, temporal demand, effort, frustration, and performance. Usability was assessed with the System Usability Scale (SUS). Scores on cases and NASA-TLX scores were compared between condition states. RESULTS A total of 32 participants completed the study. Scores on febrile infant cases using PedsGuide were greater compared with standard reference text (89% vs 72%, P = .001). NASA-TLX scores were lower (ie, more optimal) with use of PedsGuide versus control (mental 6.34 vs 11.8, P < .001; physical 2.6 vs 6.1, P = .001; temporal demand 4.6 vs 8.0, P = .003; performance 4.5 vs 8.3, P < .001; effort 5.8 vs 10.7, P < .001; frustration 3.9 vs 10, P < .001). The SUS had an overall score of 88 of 100 with rating of acceptable on the acceptability scale. CONCLUSIONS Use of PedsGuide led to increased adherence to guidelines and decreased cognitive load in febrile infant management when compared with the use of a standard reference tool. This study employs a rarely used method of assessing ECDS tools using a multifaceted approach (medical decision-making, assessing usability, and cognitive workload,) that may be used to assess other ECDS tools in the future.
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Affiliation(s)
| | - Sarah D Fouquet
- Department of Medical Informatics and Telemedicine, Children’s Mercy Kansas City, Kansas City, MO, USA
| | - Ellen Kerns
- Department of Pediatrics, Children’s Hospital & Medical Center, 8200 Dodge Street, Omaha, NE, 68114, USA,Affiliation at the time work was completed: Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, MO, USA
| | - Russell J McCulloh
- Department of Pediatrics, Children’s Hospital & Medical Center, 8200 Dodge Street, Omaha, NE, 68114, USA,Affiliation at the time work was completed: Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, MO, USA
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15
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Sezgin E, Weiler M, Weiler A, Lin S. Proposing an Ecosystem of Digital Health Solutions for Teens With Chronic Conditions Transitioning to Self-Management and Independence: Exploratory Qualitative Study. J Med Internet Res 2018; 20:e10285. [PMID: 30190253 PMCID: PMC6231785 DOI: 10.2196/10285] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/28/2018] [Accepted: 06/25/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Chronic disease management is critical to quality of life for both teen patients with chronic conditions and their caregivers. However, current literature is largely limited to a specific digital health tool, method, or approach to manage a specific disease. Guiding principles on how to use digital tools to support the transition to independence are rare. Considering the physiological, psychological, and environmental changes that teens experience, the issues surrounding the transition to independence are worth investigating to develop a deeper understanding to inform future strategies for digital interventions. OBJECTIVE The purpose of this study was to inform the design of digital health solutions by systematically identifying common challenges among teens and caregivers living with chronic diseases. METHODS Chronically ill teens (n=13) and their caregivers (n=13) were interviewed individually and together as a team. Verbal and projective techniques were used to examine teens' and caregivers' concerns in-depth. The recorded and transcribed responses were thematically analyzed to identify and organize the identified patterns. RESULTS Teens and their caregivers identified 10 challenges and suggested technological solutions. Recognized needs for social support, access to medical education, symptom monitoring, access to health care providers, and medical supply management were the predominant issues. The envisioned ideal transition included a 5-component solution ecosystem in the transition to independence for teens. CONCLUSIONS This novel study systematically summarizes the challenges, barriers, and technological solutions for teens with chronic conditions and their caregivers as teens transition to independence. A new solution ecosystem based on the 10 identified challenges would guide the design of future implementations to test and validate the effectiveness of the proposed 5-component ecosystem.
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Affiliation(s)
- Emre Sezgin
- Research Information Solutions and Innovation, The Research Institute, Nationwide Children's Hospital, Columbus, OH, United States
| | - Monica Weiler
- Stratos Innovation Group, Columbus, OH, United States
| | | | - Simon Lin
- Research Information Solutions and Innovation, The Research Institute, Nationwide Children's Hospital, Columbus, OH, United States
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16
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Kharbanda EO, Asche SE, Sinaiko AR, Ekstrom HL, Nordin JD, Sherwood NE, Fontaine PL, Dehmer SP, Appana D, O’Connor P. Clinical Decision Support for Recognition and Management of Hypertension: A Randomized Trial. Pediatrics 2018; 141:peds.2017-2954. [PMID: 29371241 PMCID: PMC5810603 DOI: 10.1542/peds.2017-2954] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Although blood pressure (BP) is routinely measured in outpatient visits, elevated BP and hypertension are often not recognized. We evaluated whether an electronic health record-linked clinical decision support (CDS) tool could improve the recognition and management of hypertension in adolescents. METHODS We randomly assigned 20 primary care clinics within an integrated care system to CDS or usual care. At intervention sites, the CDS displayed BPs and percentiles, identified incident hypertension on the basis of current or previous BPs, and offered tailored order sets. The recognition of hypertension was identified by an automated review of diagnoses and problem lists and a manual review of clinical notes, antihypertensive medication prescriptions, and diagnostic testing. Generalized linear mixed models were used to test the effect of the intervention. RESULTS Among 31 579 patients 10 to 17 years old with a clinic visit over a 2-year period, 522 (1.7%) had incident hypertension. Within 6 months of meeting criteria, providers recognized hypertension in 54.9% of patients in CDS clinics and 21.3% of patients in usual care (P ≤ .001). Clinical recognition was most often achieved through visit diagnoses or documentation in the clinical note. Within 6 months of developing incident hypertension, 17.1% of CDS subjects were referred to dieticians or weight loss or exercise programs, and 9.4% had additional hypertension workup versus 3.9% and 4.2%, respectively (P = .001 and .046, respectively). Only 1% of patients were prescribed an antihypertensive medication within 6 months of developing hypertension. CONCLUSIONS The CDS had a significant, beneficial effect on the recognition of hypertension, with a moderate increase in guideline-adherent management.
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Affiliation(s)
| | | | - Alan R. Sinaiko
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | | | | | - Nancy E. Sherwood
- HealthPartners Institute, Minneapolis, Minnesota; and,Division of Epidemiology and Community Health and
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