Improving Diagnosis of Hypertension in Children (IDHC)

As childhood obesity has increased, so has pediatric hypertension. Pediatric hypertension is associated with target organ damage, or changes in organ systems such as left ventricular hypertrophy, proteinuria and renal failure, retinopathy, and vascular dementia, all of which require timely intervention. While hypertension treatment is safe and effective, pediatric hypertension diagnosis is often missed. Reasons for under-diagnosis include difficulty measuring blood pressure (BP) in children; complexity of pediatric BP standards; lack of adoption of electronic resources for interpreting BP; and lack of knowledge of standards for followup, evaluation, and treatment.

This project developed, implemented, and evaluated the impact of the “Improving Diagnosis of Hypertension in Children” (IDHC) program in a large network of community-based practices that serves primarily minority families. The intervention included training to improve measurement of BP, education for clinicians and parents, and clinical decision support (CDS) within an electronic health record (EHR). The goal of the CDS was to facilitate diagnosis of hypertension and make recommendations for followup, evaluation, and management.

The specific aims of the project were as follows:

• Design of a quality improvement program to improve diagnosis of hypertension in children. 
• Implementation and evaluation of the IDHC program in a large network of primary care practices. 

IDHC was developed with input from provider interviews, observation of nursing staff, and usability testing of the CDS. Six clinical practices were randomized to a control or intervention group in this cluster trial. Nurses and medical assistants in all practices received training in appropriate measurement technique and a brief recorded hypertension lecture, while the intervention practices also received a childhood hypertension curriculum and the advanced IDHC CDS tool. Data were collected over two 15-month periods--a baseline period and an intervention period.

The principal outcomes were the proportion of children ages 3 to 17 who met clinical criteria for hypertension or elevated blood pressure, with a diagnosis of hypertension recorded in charts. During the baseline period 47,669 individual children were seen in the six practices; 7.2 percent of the children met the criteria. During the followup intervention period, 48,821 individual children were seen with 6.5 percent meeting the same criteria. Findings indicated that diagnostic rates of hypertension did not improve post-intervention. The rates of recognition and recording of elevated BP or hypertension were higher in the control group. However, provider recognition of abnormal BP improved post-intervention in both the control and IDHC groups. The researchers believe that additional interventions that target children and parents are needed and should be developed in the future.