Hypertension screening:Documentation and
ManagementWashington Heights Family Heath Center
How well do we continue to screen for hypertension
( HTN) and what are we doing about it?
Definitions:
Prehypertension: ≥ 90th percentile but < 95th
percentile
Stage 1 HTN: ≥ 95th percentile up to
5mmHg above the 99th percentile
Stage 2 HTN: ≥ 5mmHg above the 99th
percentile
Rationale for focus on HTN in our practice
Increased likelihood of HTN in adulthood.1, 4
Premature atherosclerosis2
Early development of CVD3, 4
Reduction of BP in adults reduces cardiovascular morbidity and mortality.3
Screening occurs in outpatient setting
Aim Statement To (re-) educate 100% of providers on the NHBPEP
guidelines for BP screening To maintain ≥ 95% rate of BP measurement for all children > 3yo
during their annual WCC
To increase BP percentile (BP%) documentation to ≥ 95% for original and repeat BPs
To have > 80% of provider acknowledge and categorize staging of elevated BP
To create an ACN-specific algorithm for follow up and referral of children with elevated BP, and to have > 80% of providers follow such an algorithm
Baseline Data
Total WCC: 119
BP Documented
95% (113/119)
BP Percentile Documented: 80% (90/113)
BP > 90th Percentile:
26% (23/90)
Elevated BP Addressed:
65% (15/23)
Elevated BP Not
Addressed: 35% (35/13)
Normal BP: 4% (67/90)
BP Percentile Not
Documented 20% (23/113)
BP >90th Percentile
39% (9/23)
Elevated BP Addressed: 33% (3/9)
Elevated BP Not
Addressed: 66% (6/9)
Normal BP: 61% (14/23)
BP Not Documented 5%(6/119)
Normal BP: 74%
(8/23)
PDSA I-III: Education and reinforcement for providers
Powerpoint presentation on BP guidelines given to all providers
Reminder notes on the computers
Emails and report card
PDSA II: Reminder Notes
PDSA III: Many e-mail reminders to F6 ….and report card
PRE (n=119) MID (n=60) FINAL (n=77)0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
BP MeasurementDocumentation of BP%
Abnormal BP recognizedDocumentation of BP% for Rechecked BPs
Recognition that Recheck BP was abnormal
Time
Perc
ent
of t
otal
Progress over time in BP documentation and recognition of abnormal values
• Education• Post-it reminders
• E-mails• Report card
To have >
80% of providers acknowledge and categorize staging of elevated BP
High BP: Now what?...Recommendations from Nephrology
Time Course to Recheck Abnormal BPs (if asymptomatic) First Detection – Return within 2
weeks Second Detection –
Return within 2 weeks Third Detection – Dx
of preHTN/HTN, proceed with appropriate work up
PDSA IV: Rechecking Abnormal BPs:A. BP Only Visit or B. School Nurse Note
MA Candida Rodriguez
What happened to pts with high BP?
BP ≥ 90th percentile:6 /77 (~8%)
Two repeat
BPs?
• 2 Seen by renal + full work-up - 1 Work-up negative. Started on
amlodipine- 1 RUS abnormal. Close
follow-up planned• 1 partial work-up (labs but no RUS/echo) - Referred to renal but
no appt scheduled
Yes: 3/6 No: 3/6
• 1 did not return for re-check
• 2 school RN form given and not returned
2/3 repeat at clinic. 1/3 check by home RNAll confirmed. Stage I
Barriers Dynamaps tend to run high, requiring
frequent re-checks Already trialing manual BP with one
MA Planning to purchase stethoscopes Requires additional education and
training Currently have to exit and re-enter note
to document re-check BP %ile using F6 Plan to upgrade Eclypsis to
automatically calculate AND record BP %ile
Only 50% completion rate for BP repeats once high value identified
HTN management order set
BP-only visit School nurse
BP check form
Spread to other ACN sites
Change Package: Spreading HTN Management Algorithm and Eclypsis Order-set
If Elevate BP (confirmed on 3 separate visits) Pre HTN (without comorbid conditions)
Counsel about life-style changes Check UA Refer to Renal 3-6 months
Pre-HTN (with comorbid conditions) Check UA Refer to Renal 2-3 months
Stage I HTN Check UA, Renal Sonogram, Chem 10, ECHO, TSH Refer to Renal in 1-2 Months
Stage II HTN Page Renal 87111
Does Screening Matter? (Matthew Thompson et al. Pediatrics 2013)
STUDY QUESTION: Does screening for HTN in children and adolescents reduce adverse cardiovascular outcomes in adults?
STUDY DESIGN: Systematic review of trials and controlled observational studies in asymptomatic children and adolescents on the effectiveness and harms of screening and treatment, as well as accuracy of blood pressure measurement.
RESULTS: No studies evaluated the effects of screening for HTN on health outcomes. Sensitivities and specificities of child hypertension for the later presence of adult hypertension were wide ranging (0–0.63 and 0.77–1.0, respectively). Associations between child HTN and carotid intima media thickening and proteinuria in young adults were inconsistent.
CONCLUSIONS: There is no direct evidence that screening for hypertension in children and adolescents reduces adverse cardiovascular outcomes in adults.
Resources 1. Falkner B, et al. Blood Pressure Variability and Classification of
Prehypertension and Hypertension in Adolescence. Pediatrics 2008;122:238-242
2. Berenson GS, et al. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. The Bogalusa Heart Study. N Engl J Med 1998; 338:1650-1656
3. MacMahon S, et. al. Blood pressure, stroke, and coronary heart disease. Part 1, Prolonged differenced in blood pressure: prospective observational studies for the regression dilution bias. Lancet 1990;225:765-774
4. Arslanian SS, et al. Systolic Blood Pressure in Childhood Predicts Hypertension and Metabolic Syndrome Later in Life. Pediatrics 2007; 119:237-246
5. Shapiro DJ, et al. Hypertension Screening During Ambulatory Pediatric Visits in the United States, 2000-2009. Pediatrics 2012;130:604-610.
Thank you!!! Team 181stAttendingsSteve CaddleRebecca FriedmanMelanie GissenMelissa GlassmanAdriana MatizDodi MeyerKim NobleJohn RauschNoe RomoMinna SaslawDana SirotaMAs Aurora GomezKarina GuzmanMaribel JimenezPetra OrtizCandida Rodriguez
And special thank you to Dr. Robert Woroniecki & the
Renal Team!
ResidentsEdna AkotoSerine AvagyanOliver Barry Anna GayAndy GeneslawCarly GomesLaura KurekNatasha LiShannon NeesMonica PrietoSarah RichmanVanessa SalcedoEmily SkodaZoya TreysterJason WinklerDaniel YuSam Zhao