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.
Our team has developed, implemented, and evaluated a clinical decision support (CDS) tool to appropriately identify high blood pressure in children. In a previous study, we showed that in a large urban and suburban health system, our CDS tool successfully promoted care consistent with national guidelines, improved recognition of high blood pressure, and was well accepted by providers. This study will adapt the existing CDS for use in a primarily rural health system and compare approaches to CDS implementation in 45 primary care clinics treating children in Minnesota, Wisconsin and North Dakota, thus advancing implementation science and addressing a critical need for youth at-risk for cardiovascular disease and with limited access to pediatric subspecialty care.
