Hypertension screening: Documentation and Management Washington Heights Family Heath Center.

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 Measurement

Documentation of BP%

Abnormal BP recognized

Documentation of BP% for Rechecked BPs

Recognition that Recheck BP was abnormal

Time

Perc

en

t of

tota

lProgress 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 181st

AttendingsSteve 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