512176
research-article2013
CPJXXX10.1177/0009922813512176Clinical PediatricsYoon et al
Brief Report
Differences in Blood Pressure Monitoring for Children and Adolescents With Hypertension Among Pediatric Cardiologists and Pediatric Nephrologists
Clinical Pediatrics 2014, Vol. 53(10) 1008–1012 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922813512176 cpj.sagepub.com
Esther Y. Yoon, MD, MPH1, Kristin Kopec, BS1, Brigitte McCool, MPH1, Gary Freed, MD, MPH1, Albert Rocchini, MD1, David Kershaw, MD1, David Hanauer, MD1, and Sarah Clark, MPH1 Introduction Hypertension is a common chronic condition in children and adolescents with prevalence estimates of 5%.1 Children with primary or secondary hypertension are managed primarily in the subspecialty domain by pediatric cardiologists or nephrologists. Prior work has described specialty differences in the use of antihypertensive medications and diagnostic tests for children and adolescents with primary hypertension.2-4 However, physicians’ approach to blood pressure (BP) monitoring for children and adolescents with hypertension has not been previously investigated. Pediatric cardiologists and pediatric nephrologists may differ in their use of blood pressure monitoring. Pediatric hypertension guidelines5 recommend ambulatory blood pressure monitoring (ABPM), where a portable BP monitor is placed on a patient’s upper arm and when the ABPM device is returned to the clinic, data are downloaded and interpreted by trained clinic personnel.5 ABPM is the recommended method in the evaluation of masked, white coat, and nocturnal hypertension and to assess cardiovascular disease (CVD) risk in patients with hypertension and chronic kidney disease.6 In contrast, home blood pressure monitoring (HBPM) is a long-term program of self-monitoring BP at home that is widely recommended and successfully used to track BP trajectory in adult patients with known or suspected hypertension.7 Importantly, differences in BP monitoring by subspecialists have potential implications for patient outcomes. The purpose of this study was to quantify the use of outof-clinic blood pressure monitoring for children and adolescents with hypertension by pediatric cardiologists and pediatric nephrologists.
Methods We conducted an electronic medical record review of subspecialty appointments for patients aged 5 to 19
years who had a scheduled visit for evaluation and/or management of hypertension at outpatient pediatric cardiology or nephrology clinics at an academic medical center from February to November 2008. The study was approved by the institutional review board of the University of Michigan Medical School.
Study Design and Subjects We identified potential study subjects by examining daily appointment logs describing reasons for visit at pediatric cardiology and pediatric nephrology clinics during the 10-month study period. Patients with new versus return visits to subspecialty clinics were included in the study. If patients had more than one scheduled visit at the same subspecialty clinic during the study period, we reviewed the first visit only. If patients saw both subspecialties during the study period, we reviewed the first subspecialty scheduled visit only.
Variables of Interest Hypertension Diagnosis. If physicians mentioned diagnosis of primary hypertension or elevated BP in the visit note, we categorized them as having primary hypertension. If physicians mentioned secondary causes of hypertension (eg, cardiac, kidney, or endocrine causes, including, but not limited to, coarctation of aorta, glomerulonephritis, chronic kidney disease, adrenal insufficiency, or autoimmune thyroiditis) or diagnosis of secondary hypertension, we categorized them as having secondary hypertension.
1
University of Michigan, Ann Arbor, MI, USA
Corresponding Author: Esther Y. Yoon, Child Health Evaluation and Research (CHEAR) Unit, University of Michigan, 300 N. Ingalls Street, Room 6C11, Ann Arbor, MI 48109-5456, USA. Email: [email protected]
1009
Yoon et al Blood Pressure Measurement. We reviewed systolic (SBP) and diastolic blood pressure (DBP) values obtained during visit and calculated BP percentiles based on patient’s age, gender, and height for children ≤17 years. BP values were categorized as normotensive (both SBP and DBP
research-article2013
CPJXXX10.1177/0009922813512176Clinical PediatricsYoon et al
Brief Report
Differences in Blood Pressure Monitoring for Children and Adolescents With Hypertension Among Pediatric Cardiologists and Pediatric Nephrologists
Clinical Pediatrics 2014, Vol. 53(10) 1008–1012 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922813512176 cpj.sagepub.com
Esther Y. Yoon, MD, MPH1, Kristin Kopec, BS1, Brigitte McCool, MPH1, Gary Freed, MD, MPH1, Albert Rocchini, MD1, David Kershaw, MD1, David Hanauer, MD1, and Sarah Clark, MPH1 Introduction Hypertension is a common chronic condition in children and adolescents with prevalence estimates of 5%.1 Children with primary or secondary hypertension are managed primarily in the subspecialty domain by pediatric cardiologists or nephrologists. Prior work has described specialty differences in the use of antihypertensive medications and diagnostic tests for children and adolescents with primary hypertension.2-4 However, physicians’ approach to blood pressure (BP) monitoring for children and adolescents with hypertension has not been previously investigated. Pediatric cardiologists and pediatric nephrologists may differ in their use of blood pressure monitoring. Pediatric hypertension guidelines5 recommend ambulatory blood pressure monitoring (ABPM), where a portable BP monitor is placed on a patient’s upper arm and when the ABPM device is returned to the clinic, data are downloaded and interpreted by trained clinic personnel.5 ABPM is the recommended method in the evaluation of masked, white coat, and nocturnal hypertension and to assess cardiovascular disease (CVD) risk in patients with hypertension and chronic kidney disease.6 In contrast, home blood pressure monitoring (HBPM) is a long-term program of self-monitoring BP at home that is widely recommended and successfully used to track BP trajectory in adult patients with known or suspected hypertension.7 Importantly, differences in BP monitoring by subspecialists have potential implications for patient outcomes. The purpose of this study was to quantify the use of outof-clinic blood pressure monitoring for children and adolescents with hypertension by pediatric cardiologists and pediatric nephrologists.
Methods We conducted an electronic medical record review of subspecialty appointments for patients aged 5 to 19
years who had a scheduled visit for evaluation and/or management of hypertension at outpatient pediatric cardiology or nephrology clinics at an academic medical center from February to November 2008. The study was approved by the institutional review board of the University of Michigan Medical School.
Study Design and Subjects We identified potential study subjects by examining daily appointment logs describing reasons for visit at pediatric cardiology and pediatric nephrology clinics during the 10-month study period. Patients with new versus return visits to subspecialty clinics were included in the study. If patients had more than one scheduled visit at the same subspecialty clinic during the study period, we reviewed the first visit only. If patients saw both subspecialties during the study period, we reviewed the first subspecialty scheduled visit only.
Variables of Interest Hypertension Diagnosis. If physicians mentioned diagnosis of primary hypertension or elevated BP in the visit note, we categorized them as having primary hypertension. If physicians mentioned secondary causes of hypertension (eg, cardiac, kidney, or endocrine causes, including, but not limited to, coarctation of aorta, glomerulonephritis, chronic kidney disease, adrenal insufficiency, or autoimmune thyroiditis) or diagnosis of secondary hypertension, we categorized them as having secondary hypertension.
1
University of Michigan, Ann Arbor, MI, USA
Corresponding Author: Esther Y. Yoon, Child Health Evaluation and Research (CHEAR) Unit, University of Michigan, 300 N. Ingalls Street, Room 6C11, Ann Arbor, MI 48109-5456, USA. Email: [email protected]
1009
Yoon et al Blood Pressure Measurement. We reviewed systolic (SBP) and diastolic blood pressure (DBP) values obtained during visit and calculated BP percentiles based on patient’s age, gender, and height for children ≤17 years. BP values were categorized as normotensive (both SBP and DBP
