Clinical Decision Support Tool for Elevated Pediatric Blood Pressures

Attitude, knowledge, and practice of medical students and pediatric physicians towards blood pressure measurement and hypertension in children: The impact of educational sessions

Accurate blood pressure measurement in pediatric patients is crucial for the proper diagnosis and management of hypertension in children. Understanding the level of attitude, knowledge, and practices (AKP) of medical students and physicians on pediatric blood pressure (BP) measurement and hypertension is essential. This is to assess their awareness of this subject which is often overlooked and where research is lacking. This study aims to evaluate the extent of AKP, among medical students and pediatric doctors regarding hypertension and BP measurement in children, and to determine the impact of educational sessions on their AKP. In a cross-sectional study, a self-designed questionnaire composed of several questions about AKP was prepared and validated. After obtaining informed consent, the questionnaire was distributed online to medical students and pediatric physicians with 168 responses, 140 medical students, and 28 pediatric physicians. This was followed by an educational awareness session about measuring blood pressure and hypertension in children. After the session, a post-awareness questionnaire was administered, gathering 145 responses. The average scores for AKP were calculated, and pre- and post-awareness session responses were compared within each group, P < .05 was regarded as significant. Among the medical students, 53.6% were somewhat aware of pediatric hypertension; 29.3% measured BP during their pediatric course, and 85% did not participate in pediatric hypertension education. Among physicians, 12.5% were exposed to pediatric patients with hypertension in the past year, 25% never measured BP in routine pediatric visits, and only 25% used normative BP tables. Average scores (out of 5) for attitude, knowledge, and practices were 3.57 (0.55), 2.51 (0.71), and 2.42 (0.68), respectively, with significantly higher scores in post-educational session, 4.56 (0.47), 4.06 (0.72), and 4.25 (0.76), respectively. The AKP among medical students and pediatric physicians regarding pediatric hypertension are inadequate, ranging from little to moderate. The impact of educational sessions is significant and very useful and should be incorporated into the teaching of medical students especially in the last years of study and ground meetings of pediatric physicians.

Accuracy of Electronic Health Record Phenotypes to Detect Recognition of Hypertension in Pediatric Primary Care

OBJECTIVE

To evaluate the accuracy of extractable electronic health record (EHR) data to define clinician recognition of hypertension in pediatric primary care.

METHODS

We used EHR data to perform a cross-sectional study of children aged 3 to 18 years at well-visits in Connecticut from 2018 to 2023 (n = 50,290) that had either 1) incident hypertension (hypertensive blood pressure [BP] at the well-visit and ≥2 prior hypertensive BPs without prior diagnosis of hypertension) or 2) isolated hypertensive BP at the well-visit without necessarily having prior hypertensive BPs. We tested the accuracy of EHR phenotypes to detect recognition of incident hypertension or hypertensive BP using structured elements, including diagnosis codes, problem list entries, number of BP measurements, orders, and follow-up information. The primary outcome of hypertension recognition was determined by chart review.

RESULTS

Among 239 children with incident hypertension and a random sample of 220 children with hypertensive BP, 13% in each sample had clinician recognition of hypertension and hypertensive BP, respectively. An algorithm using International Classification of Diseases, Tenth Revision (ICD-10) encounter diagnosis code, ICD-10 problem list, or multiple BPs during the visit had the highest area under the curve (AUC) for attention to incident hypertension (AUC, 0.84; sensitivity, 71.9%; specificity, 95.7%). Adding follow-up BP information to this algorithm had the highest AUC for attention to hypertensive BP (AUC, 0.85; sensitivity, 75.9%; specificity, 93.2%). For patients with hypertension recognition by chart review, ∼20% had only free text documentation of hypertension without any structured elements.

CONCLUSIONS

EHR phenotypes for hypertension recognition have high specificity and moderate sensitivity and may be used in clinician decision support to improve guideline-recommended care.

Pediatric High Blood Pressure Recognition Associated With Electronic Decision Support: A Cohort Analysis

BACKGROUND

Pediatric high blood pressure (BP) predicts future cardiovascular disease events. High BP is improperly measured, underrecognized, and undermanaged especially in disadvantaged populations. In a large, diverse, academic pediatric practice, we detail the associations of a comprehensive initiative with high BP provider recognition.

METHODS

A comprehensive BP initiative was promulgated including (1) retraining providers and staff on BP management; (2) deploying equipment at 55+ sites; and (3) electronic decision support tool alerting staff and clinicians and suggesting management. During the 14-month preintervention and 14-month postintervention periods, data on BP and patient characteristics were collected. The outcome was incident BP recognition defined as any of the following: BP-specific International Classification of Diseases, Tenth Revision, diagnosis; problem list entry; specialty referral; diagnostic testing; repeat visit; or antihypertensives. Dichotomized as under versus at or over 13 years of age, analyses utilized interrupted time series and multivariable-adjusted logistic regression.

RESULTS

From preintervention (children, n=105 674; adolescents, n=54 365) to postintervention (children, n=87 917; adolescents, n=56 470), the proportion measured with high BP declined in children and adolescents (30% versus 14% and 30% versus 15%, respectively, each P<0.001). Post-intervention, high BP provider recognition was 58% higher in children (4.6%-7.3%) and 43% higher in adolescents (7.9% versus 11.3%; P<0.001 for both). The improvement was not different in disadvantaged race, ethnicity, or zip codes.

CONCLUSIONS

A comprehensive BP initiative was associated with more appropriate high BP measurement and recognition including in disadvantaged populations. Future work may address the low overall and nonsustained recognition and consideration of electronic decision support for pediatric BP management and mitigating disparities.

High Blood Pressure in Children Aged 3 to 12 Years Old With Overweight or Obesity

Objective: (1) To describe the prevalence of high blood pressure (BP) and the association with BMI in young children with overweight/obesity; (2) to evaluate the accuracy of a single high BP to diagnose sustained hypertension over three visits. Methods: We used pre-intervention data from the Improving Pediatric Obesity Practice Using Prompts (iPOP-UP) trial. We included children aged 3-12 years with BMI ≥85th percentile at well-visits in 2019-2021 at 84 primary care practices in 3 US health systems in the Northeast, Midwest, and South. BP percentiles were calculated from the first visit with BP recorded during the study period. Hypertensive-range BP was defined by the 2017 American Academy of Pediatrics guideline. We tested the association between BMI classification and hypertensive BP using multivariable logistic regression. Results: Of 78,280 children with BMI ≥85th percentile, 76,214 (97%) had BP recorded during the study period (mean 7.4 years, 48% female, 53% with overweight, and 13% with severe obesity). The prevalence of elevated or hypertensive BP was 31%, including 27% in children with overweight and 33%, 39%, and 49% with class I, II, and III obesity, respectively. Higher obesity severity was associated with higher odds of hypertensive BP in the multivariable model. Stage 2 hypertensive BP at the initial visit had specificity of 99.1% (95% confidence interval 98.9-99.3) for detecting sustained hypertension over ≥3 visits. Conclusions: High BP is common in 3- to 12-year-olds with overweight/obesity, with higher obesity severity associated with greater hypertension. Children with overweight/obesity and stage 2 BP are likely to have sustained hypertension and should be prioritized for evaluation. Trial Registration: ClinicalTrials.gov Identifier: NCT05627011.

Improving Pediatric Hypertension Screening in an Academic Primary Care Setting

Introduction

Adherence to the American Academy of Pediatrics clinical practice guidelines for screening and managing high blood pressure (BP) is low. This team sought to improve recognition and documentation of relevant diagnoses in patients aged 13-20 years who presented to general pediatric clinics.

Methods

The primary outcome measure was the proportion of office visits for patients ages 13-20 with a BP ≥ 120/80 with a visit or problem list diagnosis of hypertension or elevated BP. Secondary measures included (1) the proportion of patients who had their BP measured in the right arm, (2) the proportion of patients who had a mid-arm circumference measurement recorded, and (3) the proportion of patients who had a second BP reading measured at the visit. Interventions addressed key drivers for evidence-based high BP screening: standard BP measurement, electronic health record clinical decision support, and clinical pathway adoption. Data were collected over a twenty-seven-month period and plotted using the Laney p' chart.

Results

Provider documentation of elevated BP or hypertension improved from a baseline mean of 24% in April 2020 through January 2022 to 41% in February 2021 through June 2022. All secondary outcome measures also demonstrated significant improvement.

Conclusions

This project demonstrates the feasibility of improving adherence to best practices of BP measurement in primary care clinics through education, acquisition of resources, and implementation of electronic health record flags for abnormal values.

Impact of a Clinical Decision Support System for Addressing Physical Activity and/or Healthy Eating during Smoking Cessation Treatment: Hybrid Type I Randomized Controlled Trial (Preprint)

Background

People who smoke have other risk factors for chronic diseases, such as low levels of physical activity and poor diet. Clinical decision support systems (CDSSs) might help health care practitioners integrate interventions for diet and physical activity into their smoking cessation programming but could worsen quit rates.

Objective

The aims of this study are to assess the effects of the addition of a CDSS for physical activity and diet on smoking cessation outcomes and to assess the implementation of the study.

Methods

We conducted a pragmatic hybrid type I effectiveness-implementation trial with 232 team-based primary care practices in Ontario, Canada, from November 2019 to May 2021. We used a 2-arm randomized controlled trial comparing a CDSS addressing physical activity and diet to treatment as usual and used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to measure implementation outcomes. The primary outcome was self-reported 7-day tobacco abstinence at 6 months.

Results

We enrolled 5331 participants in the study. Of these, 2732 (51.2%) were randomized to the intervention group and 2599 (48.8%) to the control group. At the 6-month follow-up, 29.7% (634/2137) of respondents in the intervention arm and 27.3% (552/2020) in the control arm reported abstinence from tobacco. After multiple imputation, the absolute group difference was 2.1% (95% CI −0.5 to 4.6; F_1,1000.42=2.43; P=.12). Mean exercise minutes changed from 32 (SD 44.7) to 110 (SD 196.1) in the intervention arm and from 32 (SD 45.1) to 113 (SD 195.1) in the control arm (group effect: B=−3.7 minutes; 95% CI −17.8 to 10.4; P=.61). Servings of fruit and vegetables changed from 2.64 servings to 2.42 servings in the intervention group and from 2.52 servings to 2.45 servings in the control group (incidence rate ratio for intervention group=0.98; 95% CI 0.93-1.02; P=.35).

Conclusions

A CDSS for physical activity and diet may be added to a smoking cessation program without affecting the outcomes. Further research is needed to improve the impact of integrated health promotion interventions in primary care smoking cessation programs.

Trial Registration

ClinicalTrials.gov NCT04223336 https://www.clinicaltrials.gov/ct2/show/NCT04223336

International Registered Report Identifier (IRRID)

RR2-10.2196/19157