Improving Recognition and Management of Hypertension in Youth: Comparing Approaches for Extending Effective CDS for use in a Large Rural Health System - Project Summary
Hypertension (HT) in youth tracks into adulthood, contributing to adult cardiovascular morbidity and mortality.
National guidelines for the diagnosis and treatment of HT in children and adolescents were last updated in
2017, with definitions for HT that vary by age. To date, most children and adolescents with elevated blood
pressure (BP) or HT are not diagnosed or inadequately treated. Factors that contribute to these deficits in care
include: the need to translate pediatric BP measures into BP percentiles, lack of clinician familiarity with
pediatric HT guidelines, and competing demands at clinical encounters.
Electronic health record (EHR)-linked clinical decision support (CDS) can be used to address these barriers
and improve the identification and management of elevated BP and HT in children and adolescents. With
funding from NHLBI, our team developed, implemented, and evaluated a sophisticated web-based, EHR-linked
CDS to provide patient-specific clinical care recommendations in real time and in accordance with national
guidelines for BP management in youth. In a 2-year cluster randomized trial in 20 urban and suburban primary
care clinics in an integrated health system in Minnesota, we demonstrated that our CDS increased repeat
measurement of elevated BP during a visit and more than doubled clinician recognition of HT, while promoting
dietitian referrals and additional next steps in care consistent with national guidelines. The CDS system was
well accepted by providers and as such, is now standard of care in 55 primary care and 17 subspecialty clinics
serving children across our health system. Implementation of this CDS, now referred to as Peds & TeenBP, in
a new health system is a logical next step, yet optimal strategies for adaptation and implementation of CDS in
clinics serving rural populations have not been well described.
In the current proposal, we will implement Peds & TeenBP in a large health system with many clinics located in
rural regions of Minnesota, Wisconsin and North Dakota. In order to compare approaches to implementation of
Peds & TeenBP to usual care, we will randomly assign 15 primary care clinics to receive high-intensity
implementation (CDS with online and in-person training, and audit-feedback), 15 clinics to receive low-intensity
implementation (CDS with online training only), and 15 clinics will continue with usual care (no CDS). Primary
outcomes are repeat BP measurement and HT recognition. Secondary outcomes include management of HT
and BP control at 12-month follow-up. As rural children face reduced access to pediatric subspecialists, tools
such as Peds & TeenBP are needed. The proposed comparison of high-intensity and low-intensity approaches
to implementation, with a focus on delivery of a new intervention in a rural healthcare setting, is consistent with
AHRQ’s research priorities in providing meaningful decision support while increasing evidence to support
adoption across a health system.
