Implementation of a clinical decision support tool for hypertension in a rural health system

Elevated blood pressure (BP) and hypertension are often overlooked in pediatric care. We adapted a pediatric hypertension clinical decision support (CDS) for a primarily rural health system and compared CDS impact across varied implementation approaches.

In this cluster randomized trial, 40 primary care clinics were randomized 1:1:1 to CDS with high-intensity implementation, CDS with low-intensity implementation, or usual care (UC). Low-intensity implementation was limited to online training. High-intensity CDS implementation included in-person and online training, monthly check-ins and feedback regarding CDS use. Patients 6-17 years with BP measured at a primary care visit from August 1, 2022 to January 31, 2024 were eligible. Outcomes were remeasurement of elevated BP during a visit and recognition of hypertension within 6 months of meeting criteria. Analyses adjusted for clustered study design and patient characteristics.

Of 9155 patients with an elevated BP, remeasurement during the visit occurred for 51.5% at high-intensity, 23.6% at low-intensity, and 6.2% at UC clinics. Among 578 patients with incident hypertension, recognition was 42.8% at high-intensity, 24.5% at low-intensity and 14.4% at UC clinics. Patients attending high or low-intensity CDS clinics were more likely than those at UC to have elevated BP remeasured (adjusted odds ratio [aOR] 8.70; 95% CI 5.68-13.3) and to have their hypertension clinically recognized (aOR 2.94; 1.00-8.60). High-intensity implementation was more effective than low-intensity implementation for repeat BP measurement (aOR 3.45; 1.88-6.33) and hypertension recognition (aOR 2.31; 1.08-4.98).

CDS improved pediatric BP care in a primarily rural health system while effectiveness varied by implementation approach.