High blood pressure in children underdiagnosed, undertreated in safety-net clinics
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Key takeaways:
- Less than half of children with elevated blood pressure are properly diagnosed or receive recommended follow-up.
- Pediatric hypertension clinical decision support tools are not utilized enough.
A review of electronic health records data showed that fewer than half of children with elevated BP have a guideline-adherent diagnosis code or attended guideline-adherent follow-up, and that clinical decision support tools are underused.
“Elevated BP and hypertension remain underdiagnosed and undertreated among children seen in safety-net clinics, despite the availability of a clinical decision support tool,” Allison J. Carroll, PhD, research assistant professor of psychiatry, behavioral sciences and preventive medicine at Northwestern University Feinberg School of Medicine, told Healio. “Moreover, we found persistent sociodemographic differences, where girls, racially and ethnically minoritized children, and younger children were less likely to have a guideline-adherent diagnosis, treatment, or follow-up visit documented in the electronic health record.”
Data were derived from Carroll AJ, et al. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2023.7043.
In a cross-sectional study, Carroll and colleagues assessed adherence to the 2017 clinical practice guideline for the diagnosis and management of pediatric hypertension, as well as the use of a clinical decision support tool to calculate BP percentiles, using EHR data from federally qualified health centers in Alliance Chicago, a national Health Center Controlled Network. Data was collected between January 2018 through December 2019. Researchers included 23,334 children and adolescents who attended at least one visit and had at least one BP reading at or above the 90th percentile or a diagnosis of elevated BP or pediatric hypertension. The median age was 8 years; 54.9% were boys and 58.6% were white. The primary outcome was a diagnosis of pediatric hypertension or elevated BP and clinical decision support tool use; BP management (medication, lifestyle counseling, referral); and follow-up visit attendance.
The findings were published in JAMA Network Open.
Within the cohort, researchers observed guideline-adherent diagnoses for 37.8% of children with a BP at or above the 90th percentile and for 5.7% of children with a BP at or above the 95th percentile at three or more visits.
The clinical decision support tool was used to calculate BP percentiles in 45.1% of cases and was associated with significantly greater odds of a pediatric hypertension diagnosis, with an OR of 2.14 (95% CI, 1.1-4.15).
Among 15,422 children with BP at or above the 95th percentile, only 5.4% were prescribed antihypertensive medication, whereas 96.2% received lifestyle counseling and 5.5% received BP-related referrals.
Among children with BP at or above the 90th percentile, 45.4% received guideline-adherent follow-up; however, just 17.1% of children with BP at or above the 95th percentile received guideline-adherent follow-up.
The researchers noted that the findings underscore the “evidence-to-practice gap” in guideline implementation, noting that the pediatric hypertension clinical decision support tool was not utilized frequently.
“Unfortunately, the pediatric hypertension clinical decision support tool implemented in AllianceChicago clinics was used on fewer than half the patients with elevated blood pressure readings and uptake was significantly lower in rural compared with urban clinics,” the researchers wrote. “These findings are consistent with prior studies in pediatric hypertension and more broadly, indicating that these tools are effective but have low adoption rates.”
The researchers concluded that comprehensive implementation strategies are needed to increase uptake of effective clinical decision support tools and to promote guideline-adherent diagnosis and management of pediatric hypertension.
“The underdiagnosis and undertreatment of elevated BP among children, particularly children from minoritized populations, will contribute to the burden of hypertension and heart disease among adults,” Carroll told Healio. “Early prevention and intervention on BP among children is key to averting future morbidity and mortality.”
Carroll said further research is needed to identify and test strategies to equitably implement the clinical practice guideline and evidence-based innovations, such as clinical decision supports, to increase the rates of guideline-adherent diagnosis, treatment and follow-up of elevated BP and pediatric hypertension.
For more information:
Allison J. Carroll, PhD, can be reached at allison.carroll@northwestern.edu; Twitter: @acarrollphd.
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