P0399 - Missed Opportunities in Pediatric Hypertension: Increasing Recognition of Elevated Blood Pressures in Outpatient Pediatric Clinics Through Automatic Alerts

Background: Pediatric hypertension can predispose children to adult cardiovascular disease and can be the first presentation of significant medical conditions. However, it is recognized that pediatric hypertension is underdiagnosed due to difficulty identifying elevated blood pressures (BPs). Evidence suggests that electronic medical record (EMR) automated alerts (e.g. best practice advisory, BPA) can improve detection rate of pediatric hypertension. However, published efforts have been variably successful. We developed a multi-level BPA to improve the detection rate of elevated BPs in a large academic pediatric program.

Methods: A retrospective analysis of eleven continuity clinics with pediatric resident representation was performed at a large academic pediatric teaching program during 3 periods (baseline 11/2016-4/2017, pilot sites 4/2018-9/2018, all sites 1/2019-7/2019). All health maintenance exams between 3 and 19 years were assessed for a systolic blood pressure (SBP) at or above stage 1 hypertension (>95th percentile) by the 4th Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents criteria. Demographics, diagnoses, BP, and height were reviewed for all visits. Clinic notes were reviewed for visits with a SBP >95th percentile. After baseline assessment, a two stage BPA was developed to aid in identification of elevated BPs at the intake and provider level prompting repeat BP assessment with implementation. Retrospective review of the response to the BPA was performed.

Results: A total of 45,744 patient visits were assessed over the three periods; 504 visits had SBPs >95th percentile (399 visits [1.6%] prior to the BPA, 105 visits [0.5%] after the BPA). Of these, recognition of elevated BP and/or diagnosis of hypertension was documented in the EMR in 18.3% of visits with SBP >95th percentile prior to BPA implementation compared to 32.4% of visits with SBP >95th percentile after BPA implementation (p=0.002). When the BPA was followed as intended with repeat BP measurement, 90.8% of initially elevated SBPs normalized to less than the 95th percentile, and recognition of an elevated BP increased from 14.1% (n=453) to 84.3% (n=51) when rechecked (p<0.0001). Given the rate of normalization after recheck, despite 75.5% recheck compliance after BPA implementation, 77.9% of all final SBPs >95th percentile resulted from visits without a recheck of an initial elevated BP.

Conclusions: These data demonstrate that a BPA can increase identification of elevated BPs in the pediatric population. The improvement was marked with full BPA compliance as demonstrated by repeating a BP measurement. Additionally, incorporation of an elevated BPA requirement for recheck of BP as outlined in current guidelines leads to marked reductions in false positive elevated BPs. When applied, this should reduce the burden of clinical decision making by providers during the time constraints of primary care visits.