Improving recognition of elevated blood pressure in pediatric primary care patients

Background: Elevated blood pressure (BP) is increasingly prevalent in the pediatric population, and has important long term health risks. Yet studies show that pediatricians often fail to recognize elevated BP. Local Problem and Aims: To improve recognition and management of elevated BPs among patients age 3 and older attending well child care visits at two pediatric primary care practices we aimed to (1) improve provider knowledge regarding the diagnosis and management of hypertension and (2) increase the percentage of patients with BP ≥90% with a repeat blood pressure documented to 70% over a 2 year period. Methods and Interventions: At two large academic primary care practices, we implemented a multi-faceted process improvement effort to improve recognition and confirmation of elevated BPs. We developed a clinical algorithm to guide clinicians in the diagnosis and management of elevated BP, initially adapted from 2004 AAP consensus guidelines and then modified to align with the updated 2017 AAP guidelines (figure 1). We also surveyed primary care providers about their knowledge of blood pressure guidelines and workflow practices. We performed multiple PDSA cycles including educational talks, signage around the practices, equipment enhancements, and contests for clinical assistants. We measured the percentage of children with elevated BPs who had their BP re-measured appropriately. Results: At baseline 58% of pediatric primary care providers (n=47) reported awareness that the AAP recommends measuring BP starting at age 3, 58% knew that 3 visits were needed to diagnose hypertension, 23% incorrectly thought a child's weight was needed to calculate the BP percentile, and 72% knew that height was required. Prior to guideline implementation, 26% of primary care provider respondents reported that they always/usually reviewed blood pressure percentiles, compared with 55% after the intervention (n=48; p12 years of age, children with obesity, and in cases when the BP seemed high. The percentage of BPs being rechecked appropriately increased from a baseline mean of 6% to 33% at Practice 1 (figure 2). At Practice 2, the percentage increased from a baseline mean of 18% to 57% (figure 3). All changes were statistically significant. Conclusions: A multi-pronged interdisciplinary improvement effort enabled the development of a standardized clinical algorithm and processes for the recognition and conf