Clinical Decision Support Tool Proves Useful in Adolescent Hypertension

01/25/18

By Will Boggs MD

NEW YORK (Reuters Health) - A clinical decision support (CDS) tool linked to electronic health records (EHR) improves the detection and management of hypertension in adolescents, researchers report.

“I was surprised to see the magnitude of the increase in hypertension recognition in the intervention clinics,” Dr. Elyse O. Kharbanda from HealthPartners Institute, Minneapolis, Minnesota, told Reuters Health by email. “In the usual care clinics, hypertension was clinically recognized in 21% of patients meeting clinical criteria versus 55% in the intervention clinics.”

Dr. Kharbanda and colleagues developed TeenBP, an EHR-linked CDS tool that significantly increased the recognition of a single blood pressure (BP) measurement at or above the 95th percentile and evaluated its effectiveness in improving clinical recognition and early management of adolescents with incident hypertension.

The 2-year, cluster-randomized trial included 31,579 patients age 10 to 17 from 20 primary care clinics. Ten clinics were randomly assigned to the TeenBP CDS, and 10 were assigned to usual care.

Within 6 months of meeting the criteria for incident hypertension, 54.9% of the CDS patients versus 21.3% of the usual care patients were clinically recognized, according to the January 25 Pediatrics online report.

Even with this recognition, only 10.1% of patients at intervention clinics and 5.2% of patients at usual care sites had hypertension or elevated BP added to their problem lists.

Patients at intervention clinics were more likely than patients at usual care clinics to undergo evaluations for secondary causes of hypertension or target-organ damage (9.4% vs. 4.2%), to receive referrals to dietitians or to weight-loss or exercise programs (17.1% vs. 3.9%), and to undergo lipid screening when indicated (14.4% vs. 5.3%).

The provision of antihypertensive medication within 6 months of meeting the criteria did not differ significantly between intervention patients and usual care patients (1% vs. 0.4%; P=0.48).

Most primary care providers who responded to surveys thought the CDS was useful in identifying patients with elevated BP or hypertension (92%), agreed that time using the CDS was time well spent (94%), and indicated that the CDS tool was useful for shared decision-making (95%).

“Decision support tools can be optimized to promote efficient and guideline adherent care,” Dr. Kharbanda said. “However, even in our intervention clinics, there was room for improvement in the recognition and management of incident hypertension.”

“The clinical decision support tool was optimized to be consistent with the clinical workflow and specifics of the electronic health record,” she explained. “We also conducted in-person training at the start of the study and after the first study year. In order to implement in another clinical setting or health system, one would first need to understand the workflow and electronic health record and make any necessary modifications. Training and feedback to promote use of the decision support tool would also be important.”

Dr. Kharbanda added, “Recognition of hypertension is an important first step, but there is a need for effective methods for promoting lifestyle changes, diet, and exercise in this population.”

Dr. Michael G. Semanik from University of Wisconsin-Madison, who recently reviewed the use of EHR to identify children with elevated BP and hypertension, told Reuters Health by email, “By any design metric, TeenBP is a successful clinical decision support system. So the thing that surprises me is that 45% of hypertensive patients still went unrecognized!”

“I don’t think this diminishes TeenBP’s success - more than doubling the hypertension recognition rate is a great result - but it speaks to the complexity inherent to any medical decision making,” he said. “Although treatment algorithms and clinical decision support design have improved with time, there’s still a fair amount of complexity that we’re not capturing.”

“Although there’s no way of measuring this, I believe that the in-person training and monthly feedback sessions were critical to TeenBP’s success,” Dr. Semanik said. “Not only did it show that the clinical administration was invested in TeenBP, but it gave a face to the CDS: hypertension recognition became something that was important to actual people, not just the computer. The human component matters.”

TeenBP is intended to be a Web-based tool, according to the report, but it is still undergoing revision in light of the updated 2017 hypertension guidelines.

SOURCE: http://bit.ly/2DzgBU3

Pediatrics 2018.

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