High Blood Pressure Recognition in a Pediatric Primary Care Clinic: A Quality Improvement Initiative

Purpose/Objectives: Diagnosis of pediatric hypertension is challenging. We sought to characterize and improve the monthly recognition rate of hypertension in our primary care clinic to at least 20% within 6 months.

Design/Methods: Records were reviewed from well child visits between August 2020 and May 2021 with blood pressure readings consistent with elevated blood pressure, stage 1 hypertension, or stage 2 hypertension as defined by the 2017 American Academy of Pediatrics Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Recognition of high blood pressure was defined as having a blood pressure-related diagnosis in the patient’s problem list or having a discussion of high blood pressure in progress notes. Patient characteristics were recorded including age, sex, language spoken, race, ethnicity, and blood pressure category. Chi square analysis was used to compare these characteristics between patients with recognized and unrecognized blood pressure elevation. Starting in December 2020, interventions to address key drivers included two instances of provider education, inclusion of blood pressure percentiles throughout the electronic medical record, and implementation of note templates to include calculation of blood pressure percentiles as well as a clickable menu of actions based on a patient’s blood pressure reading.

Results: Prior to interventions, elevated blood pressure or hypertension was recognized in 24 of 414 encounters (6%) with a monthly range between 4% and 10%. Patients with recognized hypertension were more likely to have stage 2 hypertension (41.7% vs 6.7%, p<0.001). There were no significant differences in age, sex, race, ethnicity, and language in children with recognized or unrecognized hypertension. During the intervention period, elevated blood pressure or hypertension was recognized in 113 of 590 encounters (19%). Monthly recognition gradually improved to a high of 27% (Figure 1). In the intervention period, patients with recognized hypertension were more likely to be male (61.1% vs 38.9%, p=0.004). There were no significant differences in age, race, ethnicity, language, and blood pressure category during the intervention period.

Conclusion/Discussion: Pediatric hypertension often remains unrecognized, but recognition can improve through provider education, note template additions, and electronic medical record interventions. Further quality improvement interventions are necessary to improve hypertension recognition and prevent long term morbidity and mortality in our patient population.