Correlates of Adherence to the 2017 Clinical Practice Guidelines for Pediatric Hypertension in Safety-Net Clinics: A Two-Year Cross-Sectional Study

Abstract

Importance: The 2017 Clinical Practice Guideline (CPG) has categorized a greater proportion of children with elevated blood pressure (BP) or pHTN, and yet several barriers to CPG adherence have been noted. Objective: To assess adherence to the 2017 CPG for the diagnosis and management of pHTN. Design: Cross-sectional study using electronic health record-extracted data (January 1, 2018 to December 31, 2020). Setting: AllianceChicago, a national Health Center Controlled Network of federally qualified health centers. Participants: Children and adolescents (ages ≥3 and <18) who attended ≥1 visit and had ≥1 BP reading ≥90th percentile or diagnosis of elevated BP or pHTN. Exposure: BP ≥90th percentile or ≥95th percentile. Main Outcomes and Measures: 1) diagnosis of pHTN or elevated BP, 2) BP management (antihypertensive medication, lifestyle counseling, referral), and 3) follow-up visit attendance. Descriptive statistics described the sample and rates of guideline adherence. Logistic regression analyses identified patient- and clinic-level predictors of primary outcomes. Results: Guideline-adherent diagnosis was observed in 8,811/23,334 (37.8%) children with BP ≥90th percentile, 6,427/15,423 (41.6%) children with BP ≥95th percentile, and 146/2,542 (5.7%) children with ≥3 visits with BP ≥95th percentile. A clinical decision support tool was used to calculate BP percentiles in 45.1% of cases and was associated with significantly greater odds of pHTN diagnosis (OR: 6.18, 95%CI: 5.06, 9.40). Among children with BP ≥95th percentile, antihypertensive medication was prescribed to 795/15,422 (5.2%) children, lifestyle counseling was provided to 14,841/15,422 (96.2%), and a BP-related referral was given to 848/15,422 (5.5%). Children seen at clinics in rural versus urban settings were more likely to be prescribed antihypertensive medication (OR: 1.96, 95%CI: 1.59, 2.41) and less likely to be given a BP-related referral (OR: 0.01, 95%CI: 0.00, 0.06). Guideline-adherent follow-up was observed in 8,651/19,049 (45.4%) children with BP ≥90th percentile and 2,598/15,164 (17.1%) children with BP ≥95th percentile. Conclusions and Relevance: Fewer than 50% of children with elevated BP had a guideline-adherent diagnosis code or attended guideline-adherent follow-up. Using the clinical decision support tool increased guideline-adherent diagnosis, but was underutilized. Further work is needed to understand how to best support implementation of tools promoting pHTN diagnosis, management, and follow-up.

Perspectives of Primary Care Clinicians on the Diagnosis and Treatment of Pediatric Hypertension

“…Moreover, pairing population health tools with other technologies may further support adherence to the guideline recommendations for pHTN management. Clinical decision support tools have been shown to increase management of hypertension in adults,18 though these tools have been less effective for pHTN, perhaps due in part to hypertension diagnosis and management being a quality metric for adults but not children 19,20…”

Adherence to Hypertension Guidelines in Children—What Is All the Hype?

“…Application of the 2017 CPG to existing National Health and Nutrition Examination Survey data found an increase in the prevalence of hypertension based on reclassification per the updated BP definitions, categories, and stages among children aged 8 to 17 years . The study by Carroll and colleagues used data from AllianceChicago, a national Health Center Controlled Network of 74 federally qualified health centers, to primarily evaluate whether there was clinician adherence to the diagnosis and management of pediatric hypertension using the 2017 CPG, and secondarily, whether a clinical decision support (CDS) tool was used to calculate BP percentiles and inform clinical practice.…”

“…Furthermore, diagnosis and management decisions for pediatric hypertension for children up to age 13 years are contingent on conversion of systolic and diastolic BP to percentiles integrating age, sex, and height . In busy clinical practice, this can be cumbersome, so it is not surprising that of the 23 334 children with elevated BP included in the study by Carroll and colleagues, only 38% had a corresponding International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) code, and in those with hypertension during the study period, only 6% had a corresponding ICD-10 code, with variable associations of hypertension noted among those with sociodemographic differences. What is even more disappointing, but also not surprising, is that a CDS tool, available within the electronic health record that calculated BP percentiles and provided recommendations for rechecking the BP and adding the appropriate diagnosis, was used less than half of the time .…”

“…In busy clinical practice, this can be cumbersome, so it is not surprising that of the 23 334 children with elevated BP included in the study by Carroll and colleagues, only 38% had a corresponding International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) code, and in those with hypertension during the study period, only 6% had a corresponding ICD-10 code, with variable associations of hypertension noted among those with sociodemographic differences. What is even more disappointing, but also not surprising, is that a CDS tool, available within the electronic health record that calculated BP percentiles and provided recommendations for rechecking the BP and adding the appropriate diagnosis, was used less than half of the time . Interestingly, despite the fact that clinicians did not document a hypertension ICD-10 diagnosis code or use the CDS tool in most patients, more than 95% of patients received some form of lifestyle counseling .…”

“…What is even more disappointing, but also not surprising, is that a CDS tool, available within the electronic health record that calculated BP percentiles and provided recommendations for rechecking the BP and adding the appropriate diagnosis, was used less than half of the time . Interestingly, despite the fact that clinicians did not document a hypertension ICD-10 diagnosis code or use the CDS tool in most patients, more than 95% of patients received some form of lifestyle counseling . This potentially highlights the burden of accurate documentation and coding of diagnoses, independent of management decisions.…”