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

2. How well do we continue to screen for hypertension ( HTN) and what are we doing about it?

3. Definitions:  Prehypertension:  ≥ 90 th percentile but < 95 th percentile  Stage 1 HTN:  ≥ 95 th percentile up to 5mmHg above the 99 th percentile  Stage 2 HTN:  ≥ 5mmHg above the 99 th percentile

4. Rationale for focus on HTN in our practice  Increased likelihood of HTN in adulthood. 1, 4  Premature atherosclerosis 2  Early development of CVD 3, 4  Reduction of BP in adults reduces cardiovascular morbidity and mortality. 3  Screening occurs in outpatient setting

5. 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

6. Baseline Data Total WCC: 119 BP Documented 95% (113/119) BP Percentile Documented: 80% (90/113) BP > 90 th 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 >90 th 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)

7. 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

8. PDSA II: Reminder Notes

9. PDSA III: Many e-mail reminders to F6 ….and report card

10. Progress over time in BP documentation and recognition of abnormal values Education Post-it reminders E-mails Report card

11. To have > 80% of providers acknowledge and categorize staging of elevated BP

12. 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

13. PDSA IV: Rechecking Abnormal BPs: A. BP Only Visit or B. School Nurse Note MA Candida Rodriguez

14. What happened to pts with high BP? BP ≥ 90 th 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 RN All confirmed. Stage I

15. 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

16.  HTN management order set  BP-only visit  School nurse BP check form Spread to other ACN sites

17. 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

18. 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.

19. 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.

20. Thank you!!! Team 181st Attendings Steve Caddle Rebecca Friedman Melanie Gissen Melissa Glassman Adriana Matiz Dodi Meyer Kim Noble John Rausch Noe Romo Minna Saslaw Dana Sirota MAs Aurora Gomez Karina Guzman Maribel Jimenez Petra Ortiz Candida Rodriguez And special thank you to Dr. Robert Woroniecki & the Renal Team! Residents Edna Akoto Serine Avagyan Oliver Barry Anna Gay Andy Geneslaw Carly Gomes Laura Kurek Natasha Li Shannon Nees Monica Prieto Sarah Richman Vanessa Salcedo Emily Skoda Zoya Treyster Jason Winkler Daniel Yu Sam Zhao