The promise and potential hazards of adenovirus gene therapy
Authors: L S YOUNG, V MAUTNER
Journal: Gut (2001)

<h3>Abstract</h3> <h3>Importance</h3> 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. <h3>Objective</h3> To assess adherence to the 2017 CPG for the diagnosis and management of pHTN. <h3>Design</h3> Cross-sectional study using electronic health record-extracted data (January 1, 2018 to December 31, 2020). <h3>Setting</h3> AllianceChicago, a national Health Center Controlled Network of federally qualified health centers. <h3>Participants</h3> Children and adolescents (ages ≥3 and &lt;18) who attended ≥1 visit and had ≥1 BP reading ≥90<sup>th</sup> percentile or diagnosis of elevated BP or pHTN. <h3>Exposure</h3> BP ≥90<sup>th</sup> percentile or ≥95<sup>th</sup> percentile. <h3>Main Outcomes and Measures</h3> 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. <h3>Results</h3> Guideline-adherent diagnosis was observed in 8,811/23,334 (37.8%) children with BP ≥90<sup>th</sup> percentile, 6,427/15,423 (41.6%) children with BP ≥95<sup>th</sup> percentile, and 146/2,542 (5.7%) children with ≥3 visits with BP ≥95<sup>th</sup> 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 ≥95<sup>th</sup> 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 ≥90<sup>th</sup> percentile and 2,598/15,164 (17.1%) children with BP ≥95<sup>th</sup> percentile. <h3>Conclusions and Relevance</h3> 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. <h3>Key points</h3> <h3>Question</h3> To what extent are clinicians adhering to the 2017 Clinical Practice Guideline for pediatric hypertension diagnosis, management, and follow-up? <h3>Findings</h3> 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. <h3>Meaning</h3> Findings suggest that pediatric hypertension and elevated blood pressure remain underdiagnosed and undertreated among high-risk children, which portends negative health consequences in adulthood.