Diagnosis Of Pediatric Hypertension Research Articles

Abstract 13501: Gaps in Care With Pediatric Hypertension Diagnosis: Role of Social Determinants of Health

Background: Primary hypertension (HTN) in pediatrics is a significant public health concern with increasing prevalence. The risk for adult HTN and end-organ damage begins in childhood. Therefore, evidence-based guidelines were developed by the American Academy of Pediatrics (AAP) in 2017 with detailed recommendations on screening and diagnosis. Ongoing follow-up is essential for diagnosis (at least 3 follow-up visits are needed to diagnose HTN if BP is high). However, gaps in care(GIC) exist in detecting and diagnosing HTN in clinical practice with barriers to accurate HTN detection at the patient, provider, and health system levels. Patient factors such as social determinants of health (SDoH), including the Childhood Opportunity Index (COI), leading to GIC with recommended follow-up needed for HTN diagnosis at primary care visits are poorly understood. Methods: A total of 69,960 patients aged 6-22 years seen at Nemours Children’s Health in DE and PA between August 2017- March 2019 formed the cohort. SDoH, including language, race, ethnicity, and COI, were explored. Data were analyzed using descriptive statistics and logistic regression. Results: Only 596 patients(0.9%) had HTN or were recognized as having a high BP. 73%(432) patients had over a 1-year GIC. GIC was associated with insurance type(P=0.05) and having 2 or fewer caregivers(P=0.004). GIC was not associated with race, ethnicity, language, interpreter use, or COI. Conclusions: Despite evidence-based guidelines, HTN detection remains poor. Patient factors, including insurance and the number of caregivers, likely lead to GIC with follow-up for HTN in pediatric patients. However, GIC for routine HTN follow-up are not broadly associated with SDoH. Other barriers likely exist at the provider and health system level leading to GIC and poor HTN detection.

Abstract 15624: The Impact of One versus Three Readings on Pediatric Hypertension Diagnosis is Mediated via Diastolic Blood Pressure

Introduction: Blood pressure (BP) is affected by many factors. In pre-teen children, the hypertension (HTN) threshold is about 4 mmHg higher for systolic and about 3 mmHg for diastolic BP. Single BP reading is the norm in real life clinical practice even as HTN guidelines and research use multiple BP readings. There is limited data on the within-visit BP variability in children. The National Health and Nutrition Examination Survey (NHANES) is a population-based survey and 3 BP readings are obtained using a standardized protocol. We aimed to study the difference between single versus 3 BP readings using NHANES data. Methods: In the 2017-2018 NHANES, participants aged 8 years and older underwent BP measurement using 2 protocols. The auscultation protocol (AP) was administered by a physician using a mercury sphygmomanometer. The oscillometric protocol (OP) was administered by a health technician using an Omron HEM-907 XL device. We included participants 8 to 17 years old with 3 AP and 3 OP BP readings for comparison and excluded those with DBP of zero. Results: There were 1126 subjects who met inclusion criteria. The proportion of SBP readings with a difference of at least 5 mmHg between the initial and subsequent 2 BP readings was greater with OP but greater with AP for DBP (Table 2). Similar trend was noted with comparison of initial and mean of all 3 BP readings. Coefficient of variation was higher for DBP than SBP. The proportion of patients with hypertension range BP was significantly higher for DBP than for SBP (table 3). Conclusions: Diastolic BP shows more variability with multiple measurements. Hypertension range BP was noted more often with the initial DBP measurement than with 3 BP readings.

Diagnosis of Pediatric Hypertension: European Society of Hypertension-Recommended 24-Hour vs. 24-Hour-Day-Night Ambulatory Blood Pressure Thresholds.

The impact of diagnosing pediatric hypertension based on all three-24-hour, day and night ambulatory blood pressure (ABP) thresholds (combined ABP threshold) vs. conventionally used 24-hour ABP threshold is not known. In this cross-sectional, retrospective study from a tertiary care outpatient clinic, we evaluated the diagnosis of hypertension based on the 24-hour European Society of Hypertension (ESH) and combined ESH ABP thresholds in untreated children with essential hypertension. The American Academy of Pediatrics (AAP) and Fourth Report thresholds were used to classify office blood pressure (OBP). In 159 children, aged 5-18 years, the 24-hour ESH and combined ESH thresholds classified 82% (95th confidence interval (CI) 0.68, 0.97) ABP similarly with the area under the curve (AUC) of 0.86 (95th CI 0.80, 0.91). However, the AUC of the 2 ABP thresholds was significantly higher in the participants with office hypertension than office normotension, with OBP classified by the AAP (AUC 0.93, 95th CI 0.84, 0.98 vs. 0.80, 95th CI 0.71, 0.88) or Fourth Report (AUC 0.93, 95th CI 0.83, 0.98 vs. 0.81, 95th CI 0.73, 0.88) threshold. With OBP classified by the either OBP threshold, the combined ESH threshold diagnosed significantly more masked hypertension (MH) (difference 15%, 95th CI 4.9, 24.7; P = 0.00); however, the diagnosis of white coat hypertension (WCH) by the 2 ABP thresholds did not differ significantly (difference 4%, 95th CI 1.8, 10; P = 0.16). In children with essential hypertension, the 24-hour and combined ESH thresholds have a stronger agreement for diagnosing WCH than MH.

Under Diagnosis of Pediatric Hypertension

Under Diagnosis of Pediatric Hypertension

Optimizing the implementation of a population panel management intervention in safety-net clinics for pediatric hypertension (The OpTIMISe\u2013Pediatric Hypertension Study)

BackgroundThough clinical practice guidelines are available, the diagnosis of pediatric hypertension (HTN) is often missed. Management may not follow guidelines due to the measurement challenges in children, complexity of interpreting youth blood pressure standards that are dependent on height, age, and sex, familiarity with diagnostic criteria, and variable comfort with management of pediatric HTN among providers. Evidence suggests that wide adoption and adherence to pediatric HTN guidelines would result in lower cardiovascular disease and kidney damage in adulthood. The proposed project will develop an implementation strategy package to increase adherence to clinical practice guidelines for pediatric HTN within safety-net community health centers (CHCs). The centerpiece of which is a provider-facing population panel management (PPM) tool and point-of-care clinical decision support (CDS). Prior research indicates that multiple discrete implementation strategies (e.g., stakeholder involvement, readiness planning, training, ongoing audit and feedback) are needed to institute practice- and provider-level adoption of such tools.MethodsUsing participatory research methods involving stakeholders from a practice-based research network of CHCs, with input from scientific advisors, the project aims to (1) employ user-centered design methods to tailor an existing CDS tool for use at the point of care and optimize cohort management with a PPM tool to support adherence to the latest pediatric HTN guidelines, and (2) use a stakeholder-driven method for selecting implementation strategies that support tool adoption and increase guideline-adherent physician behaviors. Multilevel process evaluation using surveys and key informant interview data will assess the acceptability, adoption, appropriateness, cost, and feasibility of the PPM tool and its multicomponent implementation strategy package. Usability testing will be conducted with the PPM tool to iteratively refine features and ensure proper functionality.DiscussionThe proposed research has the potential to improve identification, diagnosis, and management of HTN in primary care settings for high-risk youth by assisting healthcare providers in implementing the American Academy of Pediatrics’ 2017 guidelines using an EHR-integrated PPM tool with CDS. Should the strategy package for PPM tool adoption be successful for pediatric HTN, findings will be translatable to other settings and PPM of other chronic cardiovascular conditions affecting overall population health.

OS 26-05 HOW TO ACCURATELY DEFINE PEDIATRIC HYPERTENSION

Objective: The 2004 US Fourth Report recommends that diagnosis of pediatric hypertension should be based on blood pressure (BP) measurements on at least three separate occasions. However, there is no sufficient evidence to support this decision. The aim of this study was to assess the change in prevalence of elevated BP obtained on three separate visits in children and adolescents worldwide. Design and Method: Pubmed and Embase databases were searched for eligible studies published in English up to November 15, 2015. Included studies were population-based and reporting about the prevalence of elevated BP in pediatric populations on two or three separate occasions. The decreased percentage of elevated BP between the first and the subsequent one or two visits was calculated to assess the change in prevalence of elevated BP. Results: A total of 19 studies with 172,579 participants aged 3–20 years were included. The prevalence of elevated BP decreased across visits, from 5.4%-19.4% at the first visit, to 2.5%-12.8% at the second visit, and to 0.3%-8.2% at the third visit. When compared to visit 1, the prevalence of elevated BP decreased by 26.7%-79.9% at visit 2, and by 52.3%-94.4% at visit 3. Conclusions: Our results support the recommendation of the 2004 US Fourth Report that repeated measurements at three separate visits might be required to accurately define hypertension in children and adolescents.

LBPS 02–31 DEFINITION OF PEDIATRIC HYPERTENSION

Objective: The 2004 US Fourth Report recommends that diagnosis of pediatric hypertension should be based on blood pressure (BP) measurements on at least three separate occasions. However, there is no sufficient evidence to support this decision. The aim of this systematic review was to assess the change in prevalence of elevated BP obtained on three separate visits in children and adolescents worldwide. Design and Method: Pubmed and Embase databases were searched for eligible studies published in English up to November 15, 2015. Included studies were population-based and reporting about the prevalence of elevated BP in pediatric populations on two or three separate occasions. The decreased percentage of elevated BP between the first and the subsequent one or two visits was calculated to assess the change in prevalence of elevated BP. Results: A total of 22 studies with 179,561 participants aged 3–20 years were included in the present systematic review. The prevalence of elevated BP decreased across visits, from 4.6%-19.4% at the first visit, to 2.5%-14.2% at the second visit, and to 0.3%-8.2% at the third visit. When compared to visit 1, the prevalence of elevated BP decreased by 10.5%-80.7% at visit 2, and by 48.1%-93.5% at visit 3. Conclusions: The prevalence of elevated BP decreased substantially from the first visit to the subsequent visits. Our results support the recommendation of the 2004 US Fourth Report that repeated measurements at three separate visits might be required to accurately define hypertension in children and adolescents.

Pediatric Hypertension: A Primer for the Busy Primary Care Provider

Hypertension affects up to 5% of all children in the United States. The prevalence of “essential” hypertension in particular is rising in tandem with the childhood obesity epidemic. The primary care provider acts as the first-line of contact for many of these children and has an important role in early detection and referral to subspecialty care when needed. Despite published recommendations from the American Academy of Pediatrics on blood pressure screening at well child visits, adherence to these recommendations remains suboptimal. Elevated blood pressure readings, especially in non-obese children, may be overlooked. This may be due to a variety of factors including unfamiliarity of the primary care provider with pediatric blood pressure norms, time constraints in a busy practice, or the assumption that the elevated reading is an isolated clinically insignificant finding that could be dealt with at a later visit. This is particularly worrisome for children with secondary hypertension, which tends to be more severe and almost always requires anti-hypertensive therapy to prevent end organ damage. In this mini-review we present a case of a late diagnosis of secondary hypertension that had gone unnoticed for years. We then review relevant literature and suggest a clinical approach to the hypertensive child in a concise format useful for the busy primary care provider. A consistent clinical approach and firm understanding of the basic principles of pediatric hypertension diagnosis and management can prevent untoward outcomes related to a missed diagnosis.

Development of a simple tool for diagnosis and initial approach to hypertension and pre-hypertension in children and youth

Background: Hypertension and pre-hypertension in children and adolescents are frequently missed despite current screening recommendations and the potential benefit for early diagnosis and intervention. Difficulty in interpretation of office blood pressure readings in children has been partially blamed for the significant under-diagnosis of childhood hypertension. The objective of our group was to develop and evaluate a simple tool designed to assist primary health care physicians to interpret office blood pressure readings in children and adolescents. Methods: A multi-disciplinary advisory group in our institution undertook the development of a diagnostic tool based on currently accepted gold standard parameters. Input from Family Physicians and Pediatricians was used in the design process. The tool was then distributed among Family Physicians in our catchment area and evaluated with a post-distribution survey. Results: A laminated one page summary of pediatric blood pressure parameters and initial approach to pediatric hypertension was created and distributed. Feedback from primary care physicians was mostly positive and supportive of this initiative. Conclusions: Innovating and simplifying the screening process for hypertension and pre-hypertension in childhood may promote early detection and intervention however the effect of such initiatives on the rate of diagnosis of pediatric hypertension will need to be tested prospectively by appropriately designed studies.

Captopril-enhanced renal scintigraphy in the diagnosis of pediatric hypertension

Hypertension in childhood is no longer a rare condition mainly secondary to renal, or renovascular diseases, as a growing proportion of children are obese and hypertensive, with the phenotype of metabolic syndrome. Thus, we need to reconsider our practice in the examination of the hypertensive child and redefine the place of non-invasive methods for screening of renovascular hypertension, and specifically, to evaluate the value of captopril-enhanced renal scintigraphy at the two ends of the palette: the obese child with hypertension and the severely hypertensive prepubertal child. Renal artery stenosis in children is mainly due to fibromuscular dysplasia and stenoses associated with syndromes involving single or multiple smaller branch vessels. This explains the low specificity and sensitivity of the color-Doppler ultrasound method and captopril renal scintigraphy. Even the more sophisticated computed tomography (CT) and magnetic resonance imaging (MRI) angiographic techniques are, at present, not sensitive enough to exclude stenoses of the small branches definitely. Thus, children in whom there is a strong suggestion of renovascular hypertension should undergo angiography with a view to endovascular treatment, as non-invasive imaging has no significant benefit and might lead to a delay in treatment. In the cases when the probability of renovascular disease is moderate a basic assessment of renal function and structure is sufficient. In the neonate, catheter-associated thromboembolic disease is among the most common causes hypertension. It should be controlled medically until the patient is old enough to undergo angiography and angioplasty successfully. Thus, in this age group, there is a place for functional imaging with renal sonography and angiotensin-converting enzyme inhibitor (ACEI) renography to detect hemodynamically significant renovascular disease, with the limitations mentioned above. However, the rapid technical evolution of non-invasive methods requires periodic re-consideration of the actual standpoints.

The association of continuity of care on the diagnosis of hypertension in children and adolescents

Hypertension among pediatric patients is an underdiagnosed condition. As continuity of care has been found to increase quality of pediatric care, we undertook this study to assess effect of continuity on diagnosis of pediatric hypertension. This is a retrospective analysis of 774 hypertensive patients, ages 3-18 years between June 1999 and October 2007 within the MetroHealth System in northeastern Ohio. The proportion of hypertensive patients diagnosed was assessed using coding within the electronic medical record. Continuity was assessed using the usual provider of care, defined as the number of visits to the most frequent provider divided by the total number of visits in the study period. Overall continuity did not have a statistically significant association with diagnosis (OR 0.7, CI 0.4-1.4). Our research indicates that continuity does not significantly affect diagnosis of hypertension in pediatric patients. Other approaches should be investigated to improve the significant underdiagnosis of pediatric hypertension.