In 2004, The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents was released by the National Institutes of Health1 with the intention of providing a clear set of guidelines to help clinicians identify and treat childhood hypertension. Despite the increased attention paid to childhood hypertension since then, most children and adolescents with elevated blood pressure (BP) still go unrecognized and undiagnosed during clinical encounters.2,3 There are likely many contributing factors that lead to the underrecognition of pediatric hypertension,3 but the fact that clinicians providing care to children and adolescents do not have a simple, single BP value to reference creates significant complexity for what should be a relatively straightforward problem.

Various approaches to this problem have been proposed, ranging from creation of a simplified table of BP values to automated display of BP percentiles within the electronic health record.4,5 Most recently, in the American Academy of Pediatrics’ (AAP) 2017 “Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents,” a simplified table was included in which only age and sex are taken into consideration for use in screening children and adolescents for elevated BP readings. However, these simplified tools do not definitively identify hypertension. Clinicians must still use the full BP tables in the 2017 Clinical Practice Guideline to accurately define abnormal BP in pediatric patients.

Clinical decision support (CDS), a key driver for the development and adoption of health care information technology, has great potential to help increase the recognition and treatment of children with elevated BP. CDS encompasses a variety of tools and methods designed to improve the quality of care, increase efficiency, and ultimately reduce medical errors.6 In previous studies, researchers looking at CDS tools for BP have focused on providing clinicians with access to stand-alone7 or EMR-integrated BP percentile calculators.8 Although these tools frequently lead to increased rates of hypertension recognition, even with their use, the rates of recognition are still well below acceptable levels.

These studies reveal that CDS tools are not a panacea and need to be thoughtfully developed and deployed to support high-quality clinical decision-making by all members of the health care team. The “CDS Five Rights” framework provides a series of guiding principles to help ensure a CDS tool reaches its maximum potential.9 The Five Rights state that a CDS tool must provide the following: (1) the right information, (2) to the right people, (3) through the right channels, (4) in the right intervention formats, and (5) at the right points in the workflow. Ultimately, a CDS intervention needs to be interpretable, useable, and actionable for its intended recipient.

The study by Kharbanda et al10 in this issue of Pediatrics explores how a CDS tool embedded within a clinic’s electronic health record might increase the rate of hypertension recognition and management. The TeenBP CDS developed by Kharbanda et al11 and subsequently studied10 is the most comprehensive and well-integrated pediatric BP CDS described to date. By applying the CDS Five Rights, the authors have developed a well-thought-out and effective CDS tool that more than doubled the rate of recognition compared with standard practice. Yet 45% of patients with either elevated BP or hypertension still went unrecognized by clinicians over the 2-year study period. This highlights the important message that even well-designed technology cannot solve all process-related challenges.

Additionally, although CDS tools have demonstrated some benefit and should continue to be part of the solution, we need to consider additional strategies to overcome existing gaps in the recognition of hypertension. For example, CDS systems should also directly target patients and families. After-clinic visit summaries provided to patients and caregivers should include the BP readings from the visit, their corresponding percentile, and most importantly a simple notation designating the BP as normal or high. To encourage this, tools such as the AAP Bright Futures Family Resource Tool and Resource Kit12 could be modified to include these important details. This simple step would directly engage additional stakeholders, bringing additional attention to the issue and supporting a collaborative approach to hypertension recognition.

The bottom line is that childhood hypertension is common and has important long-term health consequences.13 Recognition of abnormal BP in children and adolescents is only the first step toward prevention of adult cardiovascular disease. Although the case has been made that recognizing and treating high BP in childhood may not directly prevent adverse cardiovascular events,14 abnormal childhood BP is widely recognized as an important cardiovascular risk factor that should not be overlooked. Unfortunately, many physicians do not even measure BP unless hypertension is suspected or risk factors are present, and even if it is measured, they do not use reference BP tables.7 Although technology could help with the biases associated with hypertension recognition,3 it cannot help if the BP is not even measured in the first place. Hopefully, publication of the new AAP Clinical Practice Guideline and further development of CDS tools will help practitioners better address this problem.

AAP

American Academy of Pediatrics

BP

blood pressure

CDS

clinical decision support

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-2954.

1
National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents
.
The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents.
Pediatrics
.
2004
;
114
(
2 suppl 4th report
):
555
576
2
Hansen
ML
,
Gunn
PW
,
Kaelber
DC
.
Underdiagnosis of hypertension in children and adolescents.
JAMA
.
2007
;
298
(
8
):
874
879
[PubMed]
3
Brady
TM
,
Solomon
BS
,
Neu
AM
,
Siberry
GK
,
Parekh
RS
.
Patient-, provider-, and clinic-level predictors of unrecognized elevated blood pressure in children.
Pediatrics
.
2010
;
125
(
6
). Available at: www.pediatrics.org/cgi/content/full/125/6/e1286
[PubMed]
4
Mitchell
CK
,
Theriot
JA
,
Sayat
JG
,
Muchant
DG
,
Franco
SM
.
A simplified table improves the recognition of paediatric hypertension.
J Paediatr Child Health
.
2011
;
47
(
1–2
):
22
26
[PubMed]
5
Pollack
AH
,
Hanevold
C
,
Onchiri
F
,
McGuire
T
,
Flynn
JT
.
Influence of blood pressure percentile reporting on hypertension recognition [abstract].
In:
Pediatric Academic Societies Meeting
;
May 6–9, 2017
;
San Francisco, CA
. Available at: https://registration.pas-meeting.org/2017/reports/rptPAS17_Abstracts.asp. Accessed November 9, 2017
6
Centers for Medicare & Medicaid Services
. Clinical decision support: more than just ‘alerts’ tipsheet. Available at: https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/ClinicalDecisionSupport_Tipsheet-.pdf. Accessed November 5, 2017
7
Bijlsma
MW
,
Blufpand
HN
,
Kaspers
GJL
,
Bökenkamp
A
.
Why pediatricians fail to diagnose hypertension: a multicenter survey.
J Pediatr
.
2014
;
164
(
1
):
173.e7
177.e7
[PubMed]
8
Twichell
SA
,
Rea
CJ
,
Melvin
P
, et al
.
The effect of an electronic health record-based tool on abnormal pediatric blood pressure recognition.
Congenit Heart Dis
.
2017
;
12
(
4
):
484
490
[PubMed]
9
Teich
J
,
Saldana
L
,
Levick
D
.
Improving Outcomes With Clinical Decision Support: An Implementer’s Guide
.
Chicago, IL
:
Himss Publishing
;
2012
10
Kharbanda
EO
,
Asche
SE
,
Sinaiko
AR
, et al
.
Clinical decision support for recognition and management of hypertension: a randomized trial.
Pediatrics
.
2018
;
141
(
2
):
e20172954
11
Kharbanda
EO
,
Nordin
JD
,
Sinaiko
AR
, et al
.
TeenBP: development and piloting of an EHR-linked clinical decision support system to improve recognition of hypertension in adolescents.
EGEMS (Wash DC)
.
2015
;
3
(
2
):
1142
[PubMed]
12
American Academy of Pediatrics
. Resources for families. Available at: https://brightfutures.aap.org/families/Pages/Resources-for-Families.aspx. Accessed November 9, 2017
13
Flynn
JT
.
High blood pressure in the young: why should we care?
Acta Paediatr
.
2018
;
107
(
1
)
14
19
[PubMed]
14
Moyer
VA
;
U.S. Preventive Services Task Force
.
Screening for primary hypertension in children and adolescents: U.S. Preventive Services Task Force recommendation statement.
Ann Intern Med
.
2013
;
159
(
9
):
613
619
[PubMed]

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.