Background
Pediatric hypertension is underrecognized, affecting 4% of adolescents in the USA with an additional 10% having elevated BP. Disparities exist among racial/ethnic groups. The global aim of this initiative is to improve recognition of elevated BP and hypertension and eliminate disparities in adolescents at the three NYU Langone Hospital Long Island primary care ambulatory sites.

Methods
Data between 2019-2021 was analyzed to determine prevalence and distribution of elevated BP and hypertension in patients >13 years by sex, race/ethnicity, and preferred language. Continuous variables were compared using Wilcoxon rank-sum test, and Chi-square/Fisher’s exact tests utilized for categorical variables. SAS v9.4 was used with statistical significance if p-value <0.05.

An interprofessional QI team was chartered to standardize BP measurement and improve recognition/management of adolescent hypertension. QI measures included percentage of appropriate documentation of elevated BP and hypertension in the care plan, timely primary care follow-up, and appropriate nephrology referral. Random sampling of 10-15 adolescents/month per site with elevated BP were reviewed. Data for 6 months was utilized for baseline QI measures. Our SMART aim is to increase recognition and appropriate follow-up by 25% from baseline across all sites in twelve months. Key driver diagram was constructed, and change ideas implemented using PDSA cycles. Interventions included multi-modal education and site visits to standardize BP measurement. BP reference and management algorithm handouts were distributed. Data were analyzed quarterly and plotted using run charts.

Results
Retrospective data from 2019-2021 (n=6158) showed 32% prevalence of elevated BP and hypertension in our cohort, 66.3% of which were male. Race/ethnicity distribution of adolescents with elevated BP and hypertension were 37.1% Black, 31.9% Hispanic, 31.7% White, and 27.7% Asian. Distribution by preferred language revealed 33.1% Spanish and 32.1% English (remainder other).

Appropriate documentation of elevated BP and hypertension in the care plan improved by 4.5 % (from 2% to 6.5%). Inter-site comparison revealed site-site variations, with the largest improvement of 11% at our Patient-Centered Medical Home. Twelve-month baseline for timely primary care follow-up and appropriate nephrology referral were 7% and 13%, respectively. 

Conclusion
The prevalence of elevated BP was higher in our cohort, potentially due to variations in BP measurement, and was targeted by our interventions. We achieved our SMART aim of increased recognition and documentation of adolescents with elevated BP and hypertension through standardization of BP measurement and provider education. Our next step is to target timely primary care follow-up and appropriate nephrology referral. An additional goal is to identify and reduce disparities across race, ethnicity, and preferred language for recognition and management of adolescent hypertension.

Measurement of Ambulatory Blood Pressure (BP) Standardization (MAPS) in Adolescents: A Quality Improvement (QI) Initiative

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