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van Gelderen E, Psoter KJ, Faria R, Pruette C, Brady TM. Clinician response after receipt of abnormal pediatric ambulatory blood pressure monitoring - characteristics associated with inertia and action. Pediatr Nephrol 2024; 39:2725-2732. [PMID: 38761222 DOI: 10.1007/s00467-024-06404-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/23/2024] [Accepted: 05/07/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Ambulatory Blood Pressure Monitoring (ABPM) is recommended for diagnosis and management of hypertension. We aimed to identify characteristics associated with physician action after receipt of abnormal findings. METHODS This was a retrospective cross-sectional analysis of patients 5-22 years old who underwent 24-h ABPM between 2003-2022, met criteria for masked or ambulatory hypertension, and had a pediatric nephrology clinic visit within 2 weeks of ABPM. "Action" was defined as medication change/initiation, lifestyle or adherence counseling, evaluation ordered, or interpretation with no change. Characteristics of children with/without 1 or more actions were compared using Student t-tests and Chi-square. Regression analyses explored the independent association of patient characteristics with physician action. RESULTS 115 patients with masked (n = 53) and ambulatory (n = 62) hypertension were included: mean age 13.0 years, 48% female, 38% Black race, 21% with chronic kidney disease, and 25% overweight/obesity. 97 (84%) encounters had a documented physician action. Medication change (52%), evaluation ordered (40%), and prescribed lifestyle change (35%) were the most common actions. Adherence counseling for medication and lifestyle recommendations were documented in 3% of encounters. 24-h, wake SBP load, and sleep DBP load were significantly higher among those with physician action. Patients with > 1 action had greater adiposity, SBP, and dipping. Neither age, obesity, nor kidney disease were independently associated with physician action. CONCLUSIONS While most abnormal ABPMs were acted upon, 16% did not have a documented action. Greater BP load was one of the few characteristics associated with physician action. Of potential actions, adherence counseling was underutilized.
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Affiliation(s)
- Evelien van Gelderen
- Johns Hopkins Pediatrics, Johns Hopkins University School of Medicine, Rubenstein Child Health Building Suite 3057, 200 N Wolfe St, Baltimore, MD, 21287, USA
| | - Kevin J Psoter
- Johns Hopkins Pediatrics, Johns Hopkins University School of Medicine, Rubenstein Child Health Building Suite 3057, 200 N Wolfe St, Baltimore, MD, 21287, USA
| | - Rafi Faria
- Johns Hopkins Pediatrics, Johns Hopkins University School of Medicine, Rubenstein Child Health Building Suite 3057, 200 N Wolfe St, Baltimore, MD, 21287, USA
| | - Cozumel Pruette
- Johns Hopkins Pediatrics, Johns Hopkins University School of Medicine, Rubenstein Child Health Building Suite 3057, 200 N Wolfe St, Baltimore, MD, 21287, USA
| | - Tammy M Brady
- Johns Hopkins Pediatrics, Johns Hopkins University School of Medicine, Rubenstein Child Health Building Suite 3057, 200 N Wolfe St, Baltimore, MD, 21287, USA.
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Hanevold CD, Brady TM. Screening and Management of Pediatric High Blood Pressure-Challenges to Implementing the Clinical Practice Guideline. Curr Hypertens Rep 2024; 26:259-271. [PMID: 38460067 DOI: 10.1007/s11906-024-01298-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/11/2024]
Abstract
PURPOSE OF REVIEW Elevated blood pressure (BP) and hypertension in childhood convey risk for hypertension and cardiovascular events in adulthood. Early recognition of abnormal BPs is key to preventing or lessening this risk. However, the process for making the diagnosis of hypertension is complex, and overall adherence to the 2017 American Academy of Pediatrics Clinical Practice Guidelines (CPG) is poor. We will review obstacles to adherence to the CPG and approaches designed to improve the diagnosis and management of hypertension in children. RECENT FINDINGS Baseline data from the multi-center quality improvement intervention, "Boosting Primary Care Awareness and Treatment of Hypertension" (BP-CATCH), demonstrate that childhood hypertension remains underdiagnosed. Other studies confirm a lack of compliance with the process outlined in the CPG. The provision of electronic prompts, coaching, and education results in modest improvements. The combination of embedded medical record tools and education seems to offer the most hope for improvement.
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Affiliation(s)
- Coral D Hanevold
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.
| | - Tammy M Brady
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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3
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Goulding M, Ryan G, Frisard C, Stevens E, Person S, Goldberg R, Garg A, Lemon SC. Pediatric High Blood Pressure Follow-Up Guideline Adherence in a Massachusetts Health Care System. Acad Pediatr 2024; 24:506-513. [PMID: 37487799 PMCID: PMC10803632 DOI: 10.1016/j.acap.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/10/2023] [Accepted: 07/15/2023] [Indexed: 07/26/2023]
Abstract
OBJECTIVES To describe adherence to the American Academy of Pediatrics' (AAP) 2017 clinical practice guidelines for follow-up after high blood pressure (BP) screening by pediatric and family medicine providers in a Massachusetts health care system and to assess differences in receipt of follow-up according to child- and clinic-level factors. METHODS Electronic health record data were analyzed for children aged 3 to 17years who had an outpatient primary care visit during 2018 with a high BP screening (according to AAP guidelines). We classified AAP guideline adherent follow-up as BP follow-up within 6months after an elevated finding (+2-week buffer) and within 2weeks after a hypertensive finding (+2-week buffer). Differences in receipt of guideline adherent follow-up by child- and clinic-level factors were assessed via multilevel mixed effects logistic regression models. RESULTS The median age of the 4563 included children was 12years and 43% were female. Overall, guideline adherent follow-up was received by 17.7% of children within the recommended time interval; 27.4% for those whose index BP was elevated and 5.4% for those whose index BP was hypertensive. Modeling revealed older children and those belonging to clinics with more providers, smaller patient panels, and smaller proportion of Medicaid patients were more likely to receive adherent follow-up. CONCLUSIONS Few children received guideline adherent BP follow-up and most differences in adherence were related to clinic resources. System-level interventions are needed to improve BP follow-up.
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Affiliation(s)
- Melissa Goulding
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences (M Goulding, G Ryan, C Frisard, E Stevens, A Garg, and SC Lemon), University of Massachusetts Chan Medical School, Worcester, Mass.
| | - Grace Ryan
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences (M Goulding, G Ryan, C Frisard, E Stevens, A Garg, and SC Lemon), University of Massachusetts Chan Medical School, Worcester, Mass.
| | - Christine Frisard
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences (M Goulding, G Ryan, C Frisard, E Stevens, A Garg, and SC Lemon), University of Massachusetts Chan Medical School, Worcester, Mass.
| | - Elise Stevens
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences (M Goulding, G Ryan, C Frisard, E Stevens, A Garg, and SC Lemon), University of Massachusetts Chan Medical School, Worcester, Mass.
| | - Sharina Person
- Division of Biostatistics and Health Services Research, Department of Population and Quantitative Health Sciences (S Person), University of Massachusetts Chan Medical School, Worcester, Mass.
| | - Robert Goldberg
- Division of Epidemiology, Department of Population and Quantitative Health Sciences (R Goldberg), University of Massachusetts Chan Medical School, Worcester, Mass.
| | - Arvin Garg
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences (M Goulding, G Ryan, C Frisard, E Stevens, A Garg, and SC Lemon), University of Massachusetts Chan Medical School, Worcester, Mass; Child Health Equity Center, Department of Pediatrics (A Garg), University of Massachusetts Chan Medical School, Worcester, Mass.
| | - Stephenie C Lemon
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences (M Goulding, G Ryan, C Frisard, E Stevens, A Garg, and SC Lemon), University of Massachusetts Chan Medical School, Worcester, Mass.
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Bothe TL, Hulpke-Wette M, Barbarics B, Patzak A, Pilz N. Accuracy of cuff-less, continuous, and non-invasive blood pressure measurement in 24-h ABPM in children aged 5-17. Blood Press 2023; 32:2255704. [PMID: 37683118 DOI: 10.1080/08037051.2023.2255704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/30/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023]
Abstract
PURPOSE Ambulatory, cuff-less blood pressure (BP) measurement devices are a promising trend to alleviate the strains of conventional, cuff-based BP determination. Cuff-less devices circumvent discomfort and nocturnal arousal reactions which can be triggered by cuff inflation from conventional, cuff-based ambulatory blood pressure measurement devices. Mitigating these discomforts is especially desirable when performing measurement in children. In this study we want to assess the clinical validity of a cuff-less BP measurement device for 24-h measurements in children and adolescents. MATERIALS AND METHODS We compared the simultaneously retrieved BP data of the cuff-less SOMNOtouch NIBP and the cuff-based Mobil-O-Graph in 24-h use in 90 children in the range from 5 to 17 years old. RESULTS A total of 1218 valid measurement pairs showed a mean deviation of 0.99 mmHg (limits of agreement: 21.44/-19.46) for systolic and 3.03 mmHg (limits of agreement: 24.37/-18.31) for diastolic BP values. Patient-specific difference of means was within 15 mmHg in 97.7% (systolic BP) and 93.2% (diastolic BP) patients. 25.6% of nocturnal cuff inflations led to determinable, BP-relevant arousal reactions. CONCLUSIONS The SOMNOtouch NIBP demonstrated little measurement deviation of mean BP compared to the cuff-based technique over a broad spectrum of 24-h, ambulatory BP measurements in children and adolescents. Cuff-less blood pressure measurement relieves the issue of nocturnal arousal reactions which are shown to be frequently induced by cuff-based measurements. Driven by these promising results, we encourage ongoing efforts to create enough evidence on cuff-less BP measurement to promote it into broad clinical application.
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Affiliation(s)
- Tomas L Bothe
- Institute of Physiology, Center for Space Medicine and Extreme Environments Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Hulpke-Wette
- Prevention Practice for Cardiovascular Diseases in Children and Adolescents, Göttingen, Germany
| | - Boris Barbarics
- Prevention Practice for Cardiovascular Diseases in Children and Adolescents, Göttingen, Germany
| | - Andreas Patzak
- Institute of Translational Physiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Niklas Pilz
- Institute of Translational Physiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Thürmann L, Bauer M, Ferland M, Messingschlager M, Schikowski T, von Berg A, Heinrich J, Herberth G, Lehmann I, Standl M, Trump S. Undiagnosed Pediatric Elevated Blood Pressure Is Characterized by Induction of Proinflammatory and Cytotoxic Mediators. Hypertension 2023; 80:2425-2436. [PMID: 37675573 PMCID: PMC10581429 DOI: 10.1161/hypertensionaha.123.21489] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/23/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Inflammatory processes have been suggested as a culprit of vascular damage in pediatric hypertension. We aimed to investigate transcriptional changes of immune modulators and determine their association with office blood pressure in adolescents who were not diagnosed with hypertension at the time of the study visit. METHODS Office blood pressure measurements and blood samples were taken from adolescents of 2 German birth cohorts, GINIplus (The German Infant Study on the Influence of Nutrition Intervention Plus Air Pollution and Genetics on Allergy Development; discovery cohort, n=1219) and LISA (Influences of Lifestyle-related factors on the Immune System and the Development of Allergies in Childhood; validation cohort, n=809), during the 15-year follow-up visit and categorized based on the European Society of Hypertension Guideline. Hs-CRP (high-sensitivity C-reactive protein) and expression of 51 genes encoding cytokines/receptors and transcription factors were analyzed. RESULTS The prevalence of elevated systolic blood pressure (overweight/obese) was 14.0% (5.1%) and 16.4% (5.2%) in the discovery and validation cohorts, respectively. An enhanced cytotoxic (GZMB, PRF1, IL2RB) and proinflammatory (FOS, IL1B, hs-CRP) immune profile was observed in association with the hypertension class in both cohorts. Expression of hs-CRP and IL1B was driven by overweight with IL1B being identified as a mediator between body mass index and elevated systolic blood pressure (adj.β/95% CI, 0.01/0.0002-0.02). The association of GZMB (adjusted odds ratio/95% CI, 1.67/1.26-2.21; P=0.0004) and PRF1 (adjusted odds ratio/95% CI, 1.70/1.26-2.29; P=0.0005) in the hypertension class remained significant in normal-weight individuals without parental predisposition. These effects were confirmed in LISA. CONCLUSIONS Adolescent hypertension is not limited to known risk groups. As adolescents in the hypertension class show an inflammatory profile similar to that of established hypertension in adults, blood pressure monitoring at a young age is critical to ensure early intervention and prevention of adverse sequelae.
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Affiliation(s)
- Loreen Thürmann
- Molecular Epidemiology Unit, Center of Digital Health, Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, associated partner of the German Center for Lung Research (DZL) (L.T., M.M., I.L., S.T.)
| | - Mario Bauer
- Department of Environmental Immunology, Helmholtz Centre for Environmental Research-UFZ, Leipzig, Germany (M.B., G.H.)
| | - Maike Ferland
- Institute of Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany (M.F., J.H., M.S.)
| | - Marey Messingschlager
- Molecular Epidemiology Unit, Center of Digital Health, Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, associated partner of the German Center for Lung Research (DZL) (L.T., M.M., I.L., S.T.)
| | - Tamara Schikowski
- IUF - Leibniz Research Institute for Environmental Medicine, Düsseldorf, Germany (T.S.)
| | - Andrea von Berg
- Research Institute, Department of Pediatrics, Marien-Hospital-Wesel, Germany (A.v.B.)
| | - Joachim Heinrich
- Institute of Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany (M.F., J.H., M.S.)
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, Ludwig Maximilians University of Munich, Germany (J.H.)
- Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, School of Population & Global Health, The University of Melbourne, Australia (J.H.)
| | - Gunda Herberth
- Department of Environmental Immunology, Helmholtz Centre for Environmental Research-UFZ, Leipzig, Germany (M.B., G.H.)
| | - Irina Lehmann
- Molecular Epidemiology Unit, Center of Digital Health, Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, associated partner of the German Center for Lung Research (DZL) (L.T., M.M., I.L., S.T.)
| | - Marie Standl
- Institute of Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany (M.F., J.H., M.S.)
| | - Saskia Trump
- Molecular Epidemiology Unit, Center of Digital Health, Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, associated partner of the German Center for Lung Research (DZL) (L.T., M.M., I.L., S.T.)
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Carroll AJ, Mohanty N, Wallace AS, Langman C, Smith JD. Perspectives of Primary Care Clinicians on the Diagnosis and Treatment of Pediatric Hypertension. FAMILY & COMMUNITY HEALTH 2023; 46:123-127. [PMID: 36799945 PMCID: PMC9942119 DOI: 10.1097/fch.0000000000000358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The purpose of this study was to contextualize the challenges of diagnosing and managing pediatric hypertension (pHTN) in federally qualified health centers. We conducted a survey among primary care clinicians (N = 72) who treat children (3-17 years old) in a national network of health centers. Clinicians reported practices of blood pressure (BP) measurement, barriers to diagnosis and management of pHTN, and use of population health tools. Most clinicians (83%) used electronic devices to measure BP, only 49% used manual BP readings for follow-up measurements, and more than half measured BP at each encounter. The highest-rated barrier to pHTN management was lack of comfort with antihypertensive medications (71% of respondents). Few clinicians (10%) had used population health tools, but most (78%) indicated they would like to use them for pHTN. These results offer clinician-level insights regarding implementation of the pHTN guideline in pediatric primary care settings.
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Affiliation(s)
- Allison J. Carroll
- Psychiatry and Behavioral Sciences and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago IL USA
| | - Nivedita Mohanty
- Department of Pediatrics, Northwestern University Feinberg School of Medicine and AllianceChicago, Chicago IL USA
| | | | - Craig Langman
- Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago IL USA
| | - Justin D. Smith
- Department of Population Health Sciences, Division of Health System Innovation and Research, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City UT USA
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Chakraborty K, Bhattacharya D, Kanwar P. Sudden-Onset Blindness in a Child With Hypertensive Emergency: Unmasking of Chronic Kidney Disease. Cureus 2022; 14:e29233. [PMID: 36277567 PMCID: PMC9578665 DOI: 10.7759/cureus.29233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2022] [Indexed: 11/17/2022] Open
Abstract
A 10-year-old male presented with sudden-onset diminution of vision in both eyes. On systemic examination, he had severe hypertension, no pulse deficit, short stature, and no other focal neurological deficit. Dilated fundoscopy showed bilateral grade 4 hypertensive retinopathy with macular star formation. Detailed laboratory investigations revealed a stage 5 chronic kidney disease (CKD). We present this case to highlight this rare ocular manifestation of CKD in pediatric age group.
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Höcht C, Allo MA, Polizio AH, Morettón MA, Carranza A, Chiappetta DA, Choi MR. New and developing pharmacotherapies for hypertension. Expert Rev Cardiovasc Ther 2022; 20:647-666. [PMID: 35880547 DOI: 10.1080/14779072.2022.2105204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Despite the significant contribution of hypertension to the global burden of disease, disease control remains poor worldwide. Considering this unmet clinical need, several new antihypertensive drugs with novel mechanisms of action are under development. AREAS COVERED The present review summarizes the recent advances in the development of emerging pharmacological agents for the management of hypertension. The latest technological innovations in the design of optimized formulations of available antihypertensive drugs and the potential role of the modification of intestinal microbiota to improve blood pressure (BP) control are also covered. EXPERT OPINION Significant efforts have been made to develop new antihypertensive agents with novel actions that target the main mechanisms involved in resistant hypertension. Sacubitril/valsartan may emerge as a potential first-line drug due to its superiority over renin angiotensin system inhibitors, and SGLT2 inhibitors can reduce BP in difficult-to-control hypertensive patients with type 2 diabetes. In addition, firibastat and aprocitentan may expand the therapeutic options for resistant hypertension by novel mechanism of actions. Since gut dysbiosis not only leads to hypertension but also causes direct target organ damage, prebiotics and probiotics could represent a potential strategy to prevent or reduce the development of hypertension and to contribute to BP control.
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Affiliation(s)
- Christian Höcht
- Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Departamento de Farmacología, Buenos Aires, Argentinaa.,Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Instituto de Tecnología Farmacéutica y Biofarmacia (InTecFyB), Buenos Aires, Argentinab
| | - Miguel A Allo
- Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Departamento de Farmacología, Buenos Aires, Argentinaa.,Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Instituto de Tecnología Farmacéutica y Biofarmacia (InTecFyB), Buenos Aires, Argentinab
| | - Ariel Héctor Polizio
- Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Departamento de Farmacología, Buenos Aires, Argentinaa.,Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Instituto de Tecnología Farmacéutica y Biofarmacia (InTecFyB), Buenos Aires, Argentinab
| | - Marcela A Morettón
- Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Instituto de Tecnología Farmacéutica y Biofarmacia (InTecFyB), Buenos Aires, Argentinab.,Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Departamento de Tecnología Farmacéutica, Buenos Aires, Argentinac.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Argentina
| | - Andrea Carranza
- Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Departamento de Farmacología, Buenos Aires, Argentinaa.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET) - Universidad de Buenos Aires, Instituto Alberto C. Taquini de Investigaciones en Medicina Traslacional (IATIMET), Buenos Aires, Argentinae
| | - Diego A Chiappetta
- Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Instituto de Tecnología Farmacéutica y Biofarmacia (InTecFyB), Buenos Aires, Argentinab.,Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Departamento de Tecnología Farmacéutica, Buenos Aires, Argentinac.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Argentina
| | - Marcelo Roberto Choi
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET) - Universidad de Buenos Aires, Instituto Alberto C. Taquini de Investigaciones en Medicina Traslacional (IATIMET), Buenos Aires, Argentinae.,Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Departamento de Ciencias Biológicas, Buenos Aires, Argentina f
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Knapp AA, Carroll AJ, Mohanty N, Fu E, Powell BJ, Hamilton A, Burton ND, Coldren E, Hossain T, Limaye DP, Mendoza D, Sethi M, Padilla R, Price HE, Villamar JA, Jordan N, Langman CB, Smith JD. A stakeholder-driven method for selecting implementation strategies: a case example of pediatric hypertension clinical practice guideline implementation. Implement Sci Commun 2022; 3:25. [PMID: 35256017 PMCID: PMC8900435 DOI: 10.1186/s43058-022-00276-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 02/19/2022] [Indexed: 12/21/2022] Open
Abstract
Abstract
Background
This article provides a generalizable method, rooted in co-design and stakeholder engagement, to identify, specify, and prioritize implementation strategies. To illustrate this method, we present a case example focused on identifying strategies to promote pediatric hypertension (pHTN) Clinical Practice Guideline (CPG) implementation in community health center-based primary care practices that involved meaningful engagement of pediatric clinicians, clinic staff, and patients/caregivers. This example was chosen based on the difficulty clinicians and organizations experience in implementing the pHTN CPG, as evidenced by low rates of guideline-adherent pHTN diagnosis and treatment.
Methods
We convened a Stakeholder Advisory Panel (SAP), comprising 6 pediatricians and 5 academic partners, for 8 meetings (~12 h total) to rigorously identify determinants of pHTN CPG adherence and to ultimately develop a testable multilevel, multicomponent implementation strategy. Our approach expanded upon the Expert Recommendations for Implementation Change (ERIC) protocol by incorporating a modified Delphi approach, user-centered design methods, and the Implementation Research Logic Model (IRLM). At the recommendation of our SAP, we gathered further input from youth with or at-risk for pHTN and their caregivers, as well as clinic staff who would be responsible for carrying out facets of the implementation strategy.
Results
First, the SAP identified 17 determinants, and 18 discrete strategies were prioritized for inclusion. The strategies primarily targeted determinants in the domains of intervention characteristics, inner setting, and characteristics of the implementers. Based on SAP ratings of strategy effectiveness, feasibility, and priority, three tiers of strategies emerged, with 7 strategies comprising the top tier implementation strategy package. Next, input from caregivers and clinic staff confirmed the feasibility and acceptability of the implementation strategies and provided further detail in the definition and specification of those strategies.
Conclusions
This method—an adaptation of the ERIC protocol—provided a pragmatic structure to work with stakeholders to efficiently identify implementation strategies, particularly when supplemented with user-centered design activities and the intuitive organizing framework of the IRLM. This generalizable method can help researchers identify and prioritize strategies that align with the implementation context with an increased likelihood of adoption and sustained use.
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Sivasubramanian R, Meyers KE. Hypertension in Children and Adolescents with Turner Syndrome (TS), Neurofibromatosis 1 (NF1), and Williams Syndrome (WS). Curr Hypertens Rep 2021; 23:18. [PMID: 33779870 DOI: 10.1007/s11906-021-01136-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW Turner syndrome (TS), neurofibromatosis type 1(NF1), and William Syndrome (WS) are 3 genetic conditions that are all associated with a substantial increase in risk of hypertension. In this review, we focus on factors leading to hypertension and on clinical manifestations and management of hypertension in children and adolescents with these genetic conditions RECENT FINDINGS: In most instances, hypertension is secondary. There is a high prevalence of masked hypertension in TS; however, the extent to which control of the BP helps reduce the risk of aortic dissection/aneurysm in TS is not yet fully elucidated. Vasculopathies are the least emphasized but most important manifestation of NF1. Of note, routine screening for pheochromocytoma in NFI is not recommended as it is not cost-effective. Cardiovascular complications are the major cause of death in patients with WBS. ABPM identifies patients without overt aortic or renovascular narrowing. Antihypertensive agents such as ARBs that have direct vascular wall effects and agents that inhibit oxidative stress (minoxidil) should be considered, even in those who do not exhibit overt hypertension. Elevated blood pressure in children and adolescence manifests early with end-organ changes and when left untreated, increases risk for premature onset of cardiovascular disease. Vigilant monitoring of the blood pressure is recommended. Accurate early diagnosis and management of hypertension will delay or prevent target organ damage and ensure a healthier transition to adulthood among children afflicted with these conditions.
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Affiliation(s)
- Ramya Sivasubramanian
- Division of Pediatric Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, 9th Floor Beurger Building, 3405 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Kevin E Meyers
- Division of Pediatric Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, 9th Floor Beurger Building, 3405 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
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