IMPROVING THE DETECTION OF HYPERTENSION IN PEDIATRIC AMBULATORY VISITS

• Other Authors: The University of Arizona College of Medicine - Phoenix
• Language: en_US
• Published: The University of Arizona. 2015
• Subjects: Ambulatory Visits
• Online Access: http://hdl.handle.net/10150/550100

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. === Background and Significance The prevalence of pediatric hypertension (HTN) has increased in the past several decades and is projected to continue to rise.2 Because normal blood pressure (BP) values in children depend on age, sex, and height, HTN is difficult to recognize. If not diagnosed during childhood, HTN poses several long‐term health risks.4,10 Electronic medical records (EMR) have tools to help recognize elevated BP in children. Unfortunately, many clinicians are unaware of these support tools, and pediatric HTN is underdiagnosed. Research Question This study is designed to improve the detection of HTN in children. Methods This is a prospective quality improvement (QI) study completed at a teaching institution with rotating physicians. We reviewed the charts of 1697 children aged 3 to 18 years who were seen by physicians for well‐child visits in March, June, July, August, November 2014, and January 2015. We recorded children with elevated BP and determined if HTN was recognized (noted in the assessment/plan or BP repeated). We used March as our baseline detection rate and completed five interventions, one before each month. All interventions consisted of PowerPoint presentations for medical personnel (physicians, nurses, medical assistants). The last two interventions consisted of a change in the EMR (BP percentiles displayed in a summary page) and signs hung in the clinic. Pre‐ and post‐intervention data underwent analysis, and we examined factors that may impact early detection of HTN. Results Of the 1697 children, 188 (11.1%) had elevated BP. The prevalence of elevated BP declined from the pre‐intervention month to post‐intervention months (March 13.5%, June 10.3%, July 9.7%, August 9.2%, November 12.5%). The prevalence returned to baseline by January (13.5%). The recognition of elevated BP improved from 25% in March to 44% and 55% in June and July, respectively. There was a decline in detection from July to August and November (55% to 41% and 35%). There was improved detection again from November to January (35% to 48%). Factors that increased the detection of HTN were obesity (χ2=22.9, p=0.000002), systolic BP >120 (χ2=8.1, p=0.0045), and a past history of elevated BP (χ2=5.1, p=0.024). Conclusions Our educational interventions improved the absolute detection of HTN. Repetition of interventions and involvement of the whole care team were important for sustaining the improvements, especially for a teaching institution with rotating physicians. Repeated interventions may not be necessary for private practice clinics. The improved detection correlated with a steady decline in the prevalence of HTN, probably related to blood pressures that were falsely elevated due to patient anxiety and incorrect cuff sizing. Obesity, systolic BP>120, and past history of at least one elevated BP significantly improved the detection. This QI project was not intended to determine the efficacy of each intervention, but rather to improve the detection rate as a whole. We cannot conclude whether the monthly changes were due to chance, but we can conclude that we improved the overall detection.