TeenBP: Development and Piloting of an EHR-Linked Clinical Decision Support System to Improve Recognition of Hypertension in Adolescents

Early identification of chronic kidney disease: it is time to enhance patient and population-based informatics tools for general practitioners

Chronic kidney disease (CKD) is a global public health issue that can lead to several complications such as, kidney failure, cerebro/cardiovascular disease, and death.There is a well-documented "awareness gap" among general practitioners (GPs) to recognize CKD. As shown by estimates stemming from the Health Search Database (HSD) of the Italian College of General Practitioners and Primary Care (SIMG), no substantial changes were observed in terms of the incident rate of CKD over the last 10 years. Namely, 10.3 to 9.5 per 1,000 new cases of CKD were estimated in 2012 and 2021, respectively. Thus, strategies to reduce under-recognized cases are needed. Early identification of CKD might improve patient's quality of life and clinical outcomes. In this context, patient- and population-based informatic tools may support both opportunistic and systematic screening of patients at greater risk of CKD. As such, the new effective pharmacotherapies for CKD would be proficiently administered. To this aim, these two complimentary tools have been developed and will be further implemented by GPs.The effectiveness of these instruments in identifying the condition at an early stage and reducing the burden of CKD on the national health system needs to be verified according to the new regulations on medical device (MDR: (EU) 2017/745).

Clinical Decision Support for the Diagnosis and Management of Adult and Pediatric Hypertension

PURPOSE OF REVIEW

To review literature from 2016 to 2019 on clinical decision support (CDS) for diagnosis and management of hypertension in children and adults.

RECENT FINDINGS

Ten studies described hypertension CDS systems. Novel advances included the integration of patient-collected blood pressure data, automated information retrieval and management support, and use of CDS in low-resource/developing-world settings and in pediatrics. Findings suggest that CDS increases hypertension detection/control, yet many children and adults with hypertension remain undetected or undercontrolled. CDS challenges included poor usability (from lack of health record integration, excessive data entry requests, and wireless connectivity challenges) and lack of clinician trust in blood pressure measures. Hypertension CDS has improved but not closed gaps in the detection and control of hypertension in children and adults. The studies reviewed indicate that the usability of CDS and the system where CDS is deployed (e.g., commitment to high-quality blood pressure measurement/infrastructure) may impact CDS's ability to increase hypertension detection and control.

Clinical Decision Support for Recognizing and Managing Hypertensive Blood Pressure in Youth: No Significant Impact on Medical Costs

OBJECTIVE

To evaluate economic costs from the health system perspective of an electronic health record-based clinical decision support (CDS) tool, TeenBP, designed to assist in the recognition and management of hypertension in youth.

METHODS

Twenty primary care clinics within an integrated health system were randomized to the TeenBP CDS or usual care (UC), with patient enrollment from 4/15/14 to 4/14/16. The 12-month change in standardized medical care costs for insured patients aged 10 to 17 years without prior hypertension were calculated for each study arm. The primary analysis compared patients with ≥1 visit with blood pressure (BP) ≥95th percentile (isolated hypertensive BP), and secondary analyses compared patients with ≥3 visits within one year with BP ≥95th percentile (incident hypertension). Generalized estimating equation models estimated the difference-in-differences in costs between groups over time.

RESULTS

Among 925 insured patients with an isolated hypertensive BP, the pre-to-post change in overall costs averaged $22 more for TeenBP CDS versus UC patients over 12 months, but this difference was not statistically significant (P = .723). Among 159 insured patients with incident hypertension, the pre-to-post change in overall costs over 12 months was higher by $227 per person on average for TeenBP CDS versus UC patients, but this difference also was not statistically significant (P = .313).

CONCLUSIONS

The TeenBP CDS intervention was previously found to significantly improve identification and management of hypertensive BP in youth, and in this study, we find that this tool did not significantly increase care costs in its first 12 months of clinical use.

Clinical Implementation of Predictive Models Embedded within Electronic Health Record Systems: A Systematic Review

Predictive analytics using electronic health record (EHR) data have rapidly advanced over the last decade. While model performance metrics have improved considerably, best practices for implementing predictive models into clinical settings for point-of-care risk stratification are still evolving. Here, we conducted a systematic review of articles describing predictive models integrated into EHR systems and implemented in clinical practice. We conducted an exhaustive database search and extracted data encompassing multiple facets of implementation. We assessed study quality and level of evidence. We obtained an initial 3393 articles for screening, from which a final set of 44 articles was included for data extraction and analysis. The most common clinical domains of implemented predictive models were related to thrombotic disorders/anticoagulation (25%) and sepsis (16%). The majority of studies were conducted in inpatient academic settings. Implementation challenges included alert fatigue, lack of training, and increased work burden on the care team. Of 32 studies that reported effects on clinical outcomes, 22 (69%) demonstrated improvement after model implementation. Overall, EHR-based predictive models offer promising results for improving clinical outcomes, although several gaps in the literature remain, and most study designs were observational. Future studies using randomized controlled trials may help improve the generalizability of findings.

Impact of updated pediatric hypertension guidelines on progression from elevated blood pressure to hypertension in a community-based primary care population

In 2017, definitions for pediatric hypertension were updated. A threshold of 130/80 mm Hg was introduced for stage 1 hypertension in adolescents, and children with obesity were removed from the reference population, lowering the 95th percentile, compared to the 2004 Fourth Report. The impact of these changes on care for youth with elevated blood pressure has not been well described. The objective of this study was to compare the 2017 and 2004 criteria for hypertension, evaluating how they impact estimates of risks for elevated blood pressure to progress to hypertension. Data came from youth 10-17 years of age with ≥2 elevated blood pressure measurements (≥90th percentile or ≥120/80 mm Hg) between 04/15/2014 and 04/14/2016 and three additional measurements over two subsequent years. Blood pressures were recorded in primary care practices within a large health system, as part of routine care. Rates of incident hypertension following persistent elevated blood pressure based on the 2017 guidelines vs the 2004 Fourth Report were compared. We found, among 2025 youth with persistent elevated blood pressure, 46% were female and mean age was 14.6 years. Over 2 years of follow-up, progression to hypertension occurred in 5.9% using the 2017 guidelines vs 1.1% using 2004 Fourth Report definitions. Using the 2017 criteria, progression was most common in older youth and those with obesity. In conclusion, for most youth, elevated blood pressure does not progress to hypertension within 2 years. However, progression from elevated blood pressure to hypertension was more than 5-fold greater when applying the 2017 guidelines compared to the older 2004 Fourth Report criteria.

Clinical decision support directed to primary care patients and providers reduces cardiovascular risk: a randomized trial

Objective

To test the hypothesis that use of a clinical decision support (CDS) system in a primary care setting can reduce cardiovascular (CV) risk in patients.

Materials and Methods

Twenty primary care clinics were randomly assigned to usual care (UC) or CDS. For CDS clinic patients identified algorithmically with high CV risk, rooming staff were prompted by the electronic health record (EHR) to print CDS that identified evidence-based treatment options for lipid, blood pressure, weight, tobacco, or aspirin management and prioritized them based on potential benefit to the patient. The intention-to-treat analysis included 7914 adults who met high CV risk criteria at an index clinic visit and had at least one post-index visit, accounted for clustering, and assessed impact on predicted annual rate of change in 10-year CV risk over a 14-month period.

Results

The CDS was printed at 75% of targeted visits, and providers reported 85% to 98% satisfaction with various aspects of the intervention. Predicted annual rate of change in absolute 10-year CV risk was significantly better in CDS clinics than in UC clinics (-0.59% vs. +1.66%, -2.24%; P < .001), with difference in 10-year CV risk at 12 months post-index favoring the CDS group (UC 24.4%, CDS 22.5%, P < .03).

Discussion

Deploying to both patients and providers within primary care visit workflow and limiting CDS display and print burden to two mouse clicks by rooming staff contributed to high CDS use rates and high provider satisfaction.

Conclusion

This EHR-integrated, web-based outpatient CDS system significantly improved 10-year CV risk trajectory in targeted adults.

Clinical Decision Support for Recognition and Management of Hypertension: A Randomized Trial

OBJECTIVES

Although blood pressure (BP) is routinely measured in outpatient visits, elevated BP and hypertension are often not recognized. We evaluated whether an electronic health record-linked clinical decision support (CDS) tool could improve the recognition and management of hypertension in adolescents.

METHODS

We randomly assigned 20 primary care clinics within an integrated care system to CDS or usual care. At intervention sites, the CDS displayed BPs and percentiles, identified incident hypertension on the basis of current or previous BPs, and offered tailored order sets. The recognition of hypertension was identified by an automated review of diagnoses and problem lists and a manual review of clinical notes, antihypertensive medication prescriptions, and diagnostic testing. Generalized linear mixed models were used to test the effect of the intervention.

RESULTS

Among 31 579 patients 10 to 17 years old with a clinic visit over a 2-year period, 522 (1.7%) had incident hypertension. Within 6 months of meeting criteria, providers recognized hypertension in 54.9% of patients in CDS clinics and 21.3% of patients in usual care (P ≤ .001). Clinical recognition was most often achieved through visit diagnoses or documentation in the clinical note. Within 6 months of developing incident hypertension, 17.1% of CDS subjects were referred to dieticians or weight loss or exercise programs, and 9.4% had additional hypertension workup versus 3.9% and 4.2%, respectively (P = .001 and .046, respectively). Only 1% of patients were prescribed an antihypertensive medication within 6 months of developing hypertension.

CONCLUSIONS

The CDS had a significant, beneficial effect on the recognition of hypertension, with a moderate increase in guideline-adherent management.

Evaluation of an Electronic Clinical Decision Support Tool for Incident Elevated BP in Adolescents

OBJECTIVE

To evaluate, among adolescents 10 to 17 years of age with an incident hypertensive blood pressure (BP; ≥95th percentile) at a primary care visit, whether TeenBP, a novel electronic health record-linked clinical decision support tool (CDS), improved recognition of elevated BP, and return for follow-up BP evaluation.

METHODS

We conducted a pragmatic cluster randomized trial in 20 primary care clinics in a large Midwestern medical group. Ten clinics received the TeenBP CDS, including an alert to remeasure a hypertensive BP at that visit, an alert that a hypertensive BP should be repeated in 1 to 3 weeks, and patient-specific order sets. In the 10 usual care (UC) clinics, elevated BPs were displayed in red font in the electronic health record. For comparisons between CDS and UC we used generalized linear mixed models.

RESULTS

The study population included 607 CDS patients and 607 UC patients with an incident hypertensive BP. In adjusted analyses, at the index visit, CDS patients were more likely to have their hypertensive BP on the basis of ≥2 BP measurements (47.1% vs 27.6%; P = .007) and to have elevated BP (International Classification of Diseases, Ninth Revision code 796.2) diagnosed (28.2% vs 4.2%; P < .001). In a multivariate model adjusted for age, sex, systolic BP percentile, and visit type, rates for repeat BP measurement within 30 days were 14.3% at TeenBP CDS clinics versus 10.6% at UC clinics (P = .07).

CONCLUSIONS

The TeenBP CDS intervention significantly increased repeat BP measurement at the index visit and recognition of a hypertensive BP. Rates for follow-up BP measurement at 30 days were low and did not differ between TeenBP and UC subjects.

The Use of Electronic Health Records to Identify Children with Elevated Blood Pressure and Hypertension

Elevated blood pressures often go unrecognized in pediatric patients, potentially putting children and adolescents at risk for the sequelae of untreated hypertension. This may be partially due to the complexity involved in diagnosing elevated pediatric blood pressures, which demands a high cognitive workload from providers. Tools built into electronic health records have the potential to alleviate this workload, and studies investigating these tools confirm they show promise in improving elevated blood pressure recognition. However, the current tools are not perfect, and determining the optimal design and implementation of future iterations requires further study. The proper integration of patient-generated blood pressure readings, such as those obtained during ambulatory blood pressure monitors, also requires careful consideration.

Predicting Hypertension Among Children With Incident Elevated Blood Pressure

OBJECTIVE

To develop a model to predict hypertension risk among children with incident elevated blood pressure (BP); to test the external validity of the model.

METHODS

A retrospective cohort study was conducted in 3 organizations: Kaiser Permanente Colorado was the model derivation site; HealthPartners of Minnesota and Kaiser Permanente Northern California served as external validation sites. During study years 2006 through 2012, all children aged 3 through 17 years with incident elevated BP in an outpatient setting were identified. The predictor variables were demographic and clinical characteristics collected during routine care. Cox proportional hazards regression was used to predict subsequent hypertension, and diagnostic statistics were used to assess model performance.

RESULTS

Among 5598 subjects at the derivation site with incident elevated BP, 160 (2.9%) developed hypertension during the study period. Eight characteristics were used to predict hypertension risk: age, sex, race, BP preceding incident elevated BP, body mass index percentile, systolic BP percentile, diastolic BP percentile, and clinical setting of the incident elevated BP. At the derivation site, the model discriminated well between those at higher versus lower risk of hypertension (c-statistic = 0.77). At external validation sites, the observed risk of hypertension was higher than the predicted risk, and the model showed poor discrimination (c-statistic ranged from 0.64 to 0.67).

CONCLUSIONS

Among children with incident elevated BP, a risk model demonstrated good internal validity with respect to predicting subsequent hypertension. However, the risk model did not perform well at 2 external validation sites, which might limit transportability to other settings.

CDS, UX, and System Redesign - Promising Techniques and Tools to Bridge the Evidence Gap

Introduction:

In this special issue of eGEMs, we explore the struggles related to bringing evidence into day-to-day practice, what I define as the “evidence gap.” We are all aware of high quality evidence in the form of guidelines, randomized clinical trials for treatments and diagnostic tests, and clinical prediction rules, which are all readily available online. We also know that electronic health records (EHRs) are now ubiquitous in health care and in most practices across the country. How we marry this high quality evidence and the practice of medicine through effective decision support is a major challenge.

About the Issue:

All of the articles in this issue explore, in some fashion, CDS systems and how we can best bring providers and their work environment to the evidence. We are at the very early stages of the science of usability. Much more research and funding is needed in this area if we hope to improve the dissemination and implementation of evidence in practice. While the featured examples, techniques, and tools in the special issue are a promising start to improving usability and CDS, many of the papers highlight current gaps in knowledge and a great need for generalizable approaches. The great promise is for “learning” approaches to generate new evidence and to integrate this evidence in reliable, patient-centered ways at scale using new technology. Closing the evidence gap is a real possibility, but only if the community works together to innovate and invest in research on the best ways to disseminate, communicate, and implement evidence in practice.