For childhood hypertension (HTN), accurate diagnosis and optimal clinical management are essential. National guidelines are available, yet the diagnosis of HTN in childhood is often missed, and management may not follow guidelines due to the complexity of interpreting youth blood pressure standards, diagnosing HTN, and variable familiarity with childhood HTN among providers. Evidence suggests that wide adherence to HTN guidelines would result in lower risk among youths for target organ damage and HTN-related cardiovascular disease in adulthood. The overarching goal of the proposed project is to optimize an effective and feasible implementation strategy package to increase adherence to clinical practice guidelines for childhood HTN. The centerpiece of the proposed project is a provider-facing population panel management (PPM) tool with clinical decision support. Prior research indicates that multiple specific implementation strategies are needed to institute practice- and provider-level adoption of PPM tools. Consequently, we will focus on 4 broad strategy types: stakeholder involvement, readiness planning, training, and ongoing audit and feedback.
The aims of the proposed project are:
Aim 1. Refine a population panel management tool that addresses multilevel implementation barriers;
Aim 2. Develop and then optimize a multicomponent implementation strategy package;
and Aim 3. Evaluate the impact of the implementation. Using participatory research methods involving a group of stakeholders (physicians, practice managers) from the AllianceChicago network of community health centers, with input from a scientific advisory board, we will 1) tailor an existing PPM tool to adhere to the latest guidelines for childhood HTN; 2) use an adapted concept mapping approach for selection of implementation strategies to support adoption of the tool; and 3) engage in a data-driven process to optimize the strategy package to address barriers and effectiveness of the strategies in changing guideline-relevant physician behavior. We will use a hybrid effectiveness-implementation trial design with a randomized rollout for optimization with each successive cluster in 24 total practices, to evaluate the impact of the PPM tool for HTN among youth age 5 to 17 years. The principal outcomes are: practice- and provider-level 1) rates of guideline- adherent HTN diagnosis and 2) key indicators of the impact of implementing the PPM tool, and the strategy package to support its use, at the practice and provider levels. Multilevel implementation outcome evaluation using EHR, survey, and key informant interview data, will determine the acceptability, adoption, appropriateness, cost, feasibility, fidelity, reach, and sustainability. The proposed research has the potential to improve identification, diagnosis, and management of HTN in primary care settings for high-risk youth by implementing best practice guidelines using an EHR-integrated PPM tool with clinical decision support. Should the strategy package for PPM tool adoption be successful for childhood HTN, findings will be translatable to other settings and for PPM of other chronic cardiovascular conditions that affect overall population health.
The research outlined in this proposal meets a growing need to address hypertension in childhood, which is a critical health disparity that is currently poorly identified and managed despite the recent release of best practice guidelines. The project uses a pragmatic approach to optimizing the supports that providers in safety- net healthcare organizations need to implement the guidelines and improve care for children with hypertension. The study will test the effectiveness of a population-based approach to hypertension care, gather comprehensive data on its implementation, and evaluate the costs.
