Correlates of Adherence to the 2017 Clinical Practice Guidelines for Pediatric Hypertension in Safety-Net Clinics: A Two-Year Cross-Sectional Study
Authors: Carroll Allison J. , Tedla Yacob G. , Padilla Roxane , Jain Arjit , Segovia Eduardo , Moin Anoosh , Wallace Andrea S. , Sanuade Olutobi A. , Langman Craig B. , Mohanty Nivedita , Smith Justin D. 
Published: October 2022

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 ≥90thpercentile or diagnosis of elevated BP or pHTN.

Exposure

BP ≥90thpercentile or ≥95thpercentile.

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 ≥90thpercentile, 6,427/15,423 (41.6%) children with BP ≥95thpercentile, and 146/2,542 (5.7%) children with ≥3 visits with BP ≥95thpercentile. 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 ≥95thpercentile, 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 ≥90thpercentile and 2,598/15,164 (17.1%) children with BP ≥95thpercentile.

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.

Key points

Question

To what extent are clinicians adhering to the 2017 Clinical Practice Guideline for pediatric hypertension diagnosis, management, and follow-up?

Findings

In this cross-sectional study of 23,334 children (3-17 years old) with elevated blood pressure, less than half of children had a corresponding diagnosis in their medical chart or attended the recommended follow-up visit. A clinical decision support tool that aided in classifying blood pressure values increased rates of diagnosis, but was underutilized.

Meaning

Findings suggest that pediatric hypertension and elevated blood pressure remain underdiagnosed and undertreated among high-risk children, which portends negative health consequences in adulthood.