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Adherence to the 2017 Clinical Practice Guidelines for Pediatric Hypertension in Safety-Net Clinics
Allison J Carroll1, Yacob G Tedla2, Roxane Padilla3
1Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Insights
Adherence to pediatric hypertension guidelines remains low, with under half of children receiving timely diagnosis and follow-up. A clinical decision support (CDS) tool improved diagnosis but was underutilized, highlighting implementation challenges.
Area of Science:
- Pediatric Hypertension Management
- Clinical Practice Guidelines
- Health Informatics
Background:
- The 2017 Clinical Practice Guideline (CPG) for pediatric hypertension (PHTN) aims to improve diagnosis and management.
- Despite its recommendations, barriers to CPG adherence have been identified, impacting a significant proportion of children with elevated blood pressure.
Purpose of the Study:
- To evaluate adherence to the 2017 CPG for PHTN diagnosis and management.
- To assess the utilization and impact of a clinical decision support (CDS) tool for calculating blood pressure percentiles in children.
Main Methods:
- A cross-sectional study analyzed electronic health records from 74 federally qualified health centers between January 2018 and December 2019.
- Included were children aged 3-17 with blood pressure at or above the 90th percentile or diagnosed with elevated blood pressure or PHTN.
- Logistic regression identified factors associated with guideline adherence, including CDS tool use and follow-up visit attendance.
Main Results:
- Guideline-adherent diagnosis was observed in 37.8% of children with blood pressure ≥90th percentile and 5.7% with blood pressure ≥95th percentile.
- The CDS tool was used in 45.1% of cases and was associated with a 2.14-fold increased odds of PHTN diagnosis.
- Guideline-adherent follow-up was achieved in 45.4% (≥90th percentile) and 17.1% (≥95th percentile) of children.
Conclusions:
- Fewer than 50% of children with elevated blood pressure met guideline adherence for diagnosis and follow-up.
- While the CDS tool improved diagnosis rates, its underuse presents an implementation gap.
- Further research is needed to optimize the implementation of tools supporting PHTN diagnosis, management, and follow-up.
Importance:
The 2017 Clinical Practice Guideline (CPG) for the diagnosis and management of pediatric hypertension (PHTN) categorizes a greater proportion of children with elevated blood pressure and PHTN, yet several barriers to CPG adherence have been noted.
Objective:
To assess adherence to the 2017 CPG for the diagnosis and management of PHTN and use of a clinical decision support (CDS) tool to calculate blood pressure percentiles.
Design, Setting, And Participants:
This cross-sectional study used electronic health record-extracted data from January 1, 2018, to December 31, 2019, among patients visiting 1 of 74 federally qualified health centers in AllianceChicago, a national Health Center Controlled Network. Children and adolescents (aged 3-17 years; hereinafter referred to as children) who attended at least 1 visit and had at least 1 blood pressure reading at or above the 90th percentile or diagnosis of elevated blood pressure or PHTN were eligible for data to be included in the analysis. Data were analyzed from September 1, 2020, to February 21, 2023.
Exposures:
Blood pressure at or above the 90th or 95th percentile.
Main Outcomes And Measures:
Diagnosis of PHTN (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10], code I10) or elevated blood pressure (ICD-10 code R03.0) and CDS tool use; blood pressure management (antihypertensive medication, lifestyle counseling, referral); and follow-up visit attendance. Descriptive statistics described the sample and rates of guideline adherence. Logistic regression analyses identified patient- and clinic-level associations with guideline adherence.
Results:
The sample consisted of 23 334 children (54.9% boys; 58.6% White race; median age, 8 [IQR, 4-12] years). Guideline-adherent diagnosis was observed in 8810 children (37.8%) with blood pressure at or above the 90th percentile and 146 of 2542 (5.7%) with blood pressure at or above the 95th percentile at 3 or more visits. The CDS tool was used to calculate blood pressure percentiles in 10 524 cases (45.1%) and was associated with significantly greater odds of PHTN diagnosis (odds ratio, 2.14 [95% CI, 1.10-4.15]). Among 15 422 children with blood pressure at or above the 95th percentile, antihypertensive medication was prescribed to 831 (5.4%), lifestyle counseling was provided to 14 841 (96.2%), and blood pressure-related referrals were given to 848 (5.5%). Guideline-adherent follow-up was observed in 8651 of 19 049 children (45.4%) with blood pressure at or above the 90th percentile and 2598 of 15 164 (17.1%) with blood pressure at or above the 95th percentile. Differences in guideline adherence by patient- and clinic-level factors were observed.
Conclusions And Relevance:
In this study, fewer than 50% of children with elevated blood pressure had a guideline-adherent diagnosis code or attended guideline-adherent follow-up. Using a CDS tool was associated with guideline-adherent diagnosis, but the tool was underused. Further work is needed to understand how to best support implementation of tools promoting PHTN diagnosis, management, and follow-up.
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