Improving Recognition and Management of Hypertension in Youth: Comparing Approaches for Extending Effective CDS for use in a Large Rural Health System

项目摘要 青年高血压(HT)一直持续到成年，导致成人心血管疾病的发病率和死亡率。 关于儿童和青少年高血压的诊断和治疗的国家指南上一次更新是在 2017年，HT的定义因年龄而异。到目前为止，大多数血液升高的儿童和青少年 血压(BP)或高血压没有得到诊断或治疗不当。造成这些护理不足的因素 包括：需要将儿科血压测量转换为血压百分位数，临床医生缺乏对 儿科羟色胺指南，以及临床上相互竞争的要求。 电子健康记录(EHR)链接的临床决策支持(CDS)可以用来解决这些障碍 加强对儿童和青少年血压和高血压升高的识别和管理。使用 在NHLBI的资助下，我们的团队开发、实施和评估了一个复杂的基于Web、与EHR链接的 CDS实时提供针对患者的临床护理建议，并符合国家 青年BP管理指南。在一项为期两年的整群随机试验中，在20个城市和郊区的初选 明尼苏达州综合医疗系统中的护理诊所，我们证明我们的CDS增加了重复 就诊期间测量血压升高，临床医生对高血压的认可度增加一倍以上，同时促进 营养师转介和其他下一步护理符合国家指导方针。CDS系统是 被提供者接受，因此现在是55个初级保健和17个专科诊所的标准护理 为我们整个医疗系统的儿童提供服务。实施此CDS，现在称为PEDS和TeenBP，在 新的卫生系统是顺理成章的下一步，但也是#年适应和实施疾病预防控制系统的最佳战略 为农村人口服务的诊所并没有得到很好的描述。 在当前的提案中，我们将在拥有许多诊所的大型医疗系统中实施儿科和TeenBP 明尼苏达州、威斯康星州和北达科他州的农村地区。为了比较实施的方法， 儿科和少年儿童接受常规护理，我们将随机分配15家初级保健诊所接受高强度 实施(CDS在线和面对面培训，以及审计反馈)，15家诊所接受低强度培训 实施(仅限在线培训的CDS)，15个诊所将继续提供常规护理(无CDS)。主要 结果是重复测量血压和识别高血压。次要结果包括高血压的治疗 BP对照组在12个月的随访期。随着农村儿童面临获得儿科专科医生、工具 例如儿科和TeenBP是需要的。高强度和低强度方法的建议比较 实施，重点是在农村保健环境中提供新的干预措施，这与 AHRQ的研究重点是提供有意义的决策支持，同时增加证据支持 在整个卫生系统中采用。

Project Summary Hypertension (HT) in youth tracks into adulthood, contributing to adult cardiovascular morbidity and mortality. National guidelines for the diagnosis and treatment of HT in children and adolescents were last updated in 2017, with definitions for HT that vary by age. To date, most children and adolescents with elevated blood pressure (BP) or HT are not diagnosed or inadequately treated. Factors that contribute to these deficits in care include: the need to translate pediatric BP measures into BP percentiles, lack of clinician familiarity with pediatric HT guidelines, and competing demands at clinical encounters. Electronic health record (EHR)-linked clinical decision support (CDS) can be used to address these barriers and improve the identification and management of elevated BP and HT in children and adolescents. With funding from NHLBI, our team developed, implemented, and evaluated a sophisticated web-based, EHR-linked CDS to provide patient-specific clinical care recommendations in real time and in accordance with national guidelines for BP management in youth. In a 2-year cluster randomized trial in 20 urban and suburban primary care clinics in an integrated health system in Minnesota, we demonstrated that our CDS increased repeat measurement of elevated BP during a visit and more than doubled clinician recognition of HT, while promoting dietitian referrals and additional next steps in care consistent with national guidelines. The CDS system was well accepted by providers and as such, is now standard of care in 55 primary care and 17 subspecialty clinics serving children across our health system. Implementation of this CDS, now referred to as Peds & TeenBP, in a new health system is a logical next step, yet optimal strategies for adaptation and implementation of CDS in clinics serving rural populations have not been well described. In the current proposal, we will implement Peds & TeenBP in a large health system with many clinics located in rural regions of Minnesota, Wisconsin and North Dakota. In order to compare approaches to implementation of Peds & TeenBP to usual care, we will randomly assign 15 primary care clinics to receive high-intensity implementation (CDS with online and in-person training, and audit-feedback), 15 clinics to receive low-intensity implementation (CDS with online training only), and 15 clinics will continue with usual care (no CDS). Primary outcomes are repeat BP measurement and HT recognition. Secondary outcomes include management of HT and BP control at 12-month follow-up. As rural children face reduced access to pediatric subspecialists, tools such as Peds & TeenBP are needed. The proposed comparison of high-intensity and low-intensity approaches to implementation, with a focus on delivery of a new intervention in a rural healthcare setting, is consistent with AHRQ’s research priorities in providing meaningful decision support while increasing evidence to support adoption across a health system.