Skip to main content

Advertisement

SpringerLink
Log in

Clinician response after receipt of abnormal pediatric ambulatory blood pressure monitoring – characteristics associated with inertia and action

  • Original Article
  • Published:
Pediatric Nephrology Aims and scope Submit manuscript

Abstract

Background

Ambulatory Blood Pressure Monitoring (ABPM) is recommended for diagnosis and management of hypertension. We aimed to identify characteristics associated with physician action after receipt of abnormal findings.

Methods

This was a retrospective cross-sectional analysis of patients 5–22 years old who underwent 24-h ABPM between 2003–2022, met criteria for masked or ambulatory hypertension, and had a pediatric nephrology clinic visit within 2 weeks of ABPM. “Action” was defined as medication change/initiation, lifestyle or adherence counseling, evaluation ordered, or interpretation with no change. Characteristics of children with/without 1 or more actions were compared using Student t-tests and Chi-square. Regression analyses explored the independent association of patient characteristics with physician action.

Results

115 patients with masked (n = 53) and ambulatory (n = 62) hypertension were included: mean age 13.0 years, 48% female, 38% Black race, 21% with chronic kidney disease, and 25% overweight/obesity. 97 (84%) encounters had a documented physician action. Medication change (52%), evaluation ordered (40%), and prescribed lifestyle change (35%) were the most common actions. Adherence counseling for medication and lifestyle recommendations were documented in 3% of encounters. 24-h, wake SBP load, and sleep DBP load were significantly higher among those with physician action. Patients with > 1 action had greater adiposity, SBP, and dipping. Neither age, obesity, nor kidney disease were independently associated with physician action.

Conclusions

While most abnormal ABPMs were acted upon, 16% did not have a documented action. Greater BP load was one of the few characteristics associated with physician action. Of potential actions, adherence counseling was underutilized.

Graphical abstract

A higher resolution version of the Graphical abstract is available as Supplementary information

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Data availability

The datasets generated during and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.

Abbreviations

ABPM:

Ambulatory blood pressure monitoring

BMI:

Body mass index

BP:

Blood pressure

BPI:

Blood pressure index

CKD:

Chronic kidney disease

CVD:

Cardiovascular disease

DBP:

Diastolic blood pressure

EMR:

Electronic medical record

HTN:

Hypertension

LVH:

Left ventricular hypertrophy

LVM:

Left ventricular mass

LVMI:

Left ventricular mass index

OSA:

Obstructive sleep apnea

SBP:

Systolic blood pressure

SD:

Standard deviation

SW:

Social work

References

  1. CDC (2022) Heart disease facts. https://www.cdc.gov/heartdisease/index.htm

  2. Candelino M, Tagi VM, Chiarelli F (2022) Cardiovascular risk in children: a burden for future generations. Ital J Pediatr 48:57. https://doi.org/10.1186/s13052-022-01250-5

    Article  PubMed  PubMed Central  Google Scholar 

  3. de Ferranti SD, Steinberger J, Ameduri R et al (2019) Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association. Circulation 139:e603–e634. https://doi.org/10.1161/CIR.0000000000000618

    Article  PubMed  Google Scholar 

  4. Song P, Zhang Y, Yu J et al (2019) Global prevalence of hypertension in children: a systematic review and meta-analysis. JAMA Pediatr 173:1154–1163. https://doi.org/10.1001/jamapediatrics.2019.3310

    Article  PubMed  PubMed Central  Google Scholar 

  5. Gallibois CM, Jawa NA, Noone DG (2017) Hypertension in pediatric patients with chronic kidney disease: management challenges. Int J Nephrol Renovasc Dis 10:205–213. https://doi.org/10.2147/IJNRD.S100891

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Brady TM, Solomon BS, Neu AM et al (2010) Patient-, provider-, and clinic-level predictors of unrecognized elevated blood pressure in children. Pediatrics 125:e1286-1293. https://doi.org/10.1542/peds.2009-0555

    Article  PubMed  Google Scholar 

  7. Moin A, Mohanty N, Tedla YG et al (2020) Under-recognition of pediatric hypertension diagnosis: Examination of 1 year of visits to community health centers. J Clin Hypertens (Greenwich) 23:257–264. https://doi.org/10.1111/jch.14148

    Article  PubMed  Google Scholar 

  8. Barletta G-M, Pierce C, Mitsnefes M et al (2018) Is blood pressure improving in children with chronic kidney disease? Hypertension 71:444–450. https://doi.org/10.1161/HYPERTENSIONAHA.117.09649

    Article  CAS  PubMed  Google Scholar 

  9. Kasanagottu K, Mukamal KJ, Landon BE (2024) Predictors of treatment intensification in uncontrolled hypertension. J Hypertens 42:283–291. https://doi.org/10.1097/HJH.0000000000003598

    Article  CAS  PubMed  Google Scholar 

  10. Jain A, Abramovitz B, Desilva R (2022) Applying standard AOBP measurements in a CKD Clinic and its effect on nephrologists’ hypertension management inertia. Am J Kidney Dis 79:S108. https://doi.org/10.1053/j.ajkd.2022.01.360

    Article  Google Scholar 

  11. Arakawa K, Imazu R, Morinaga Y et al (2023) Clinical inertia in the hypertensive patients treated by hypertension specialists. J Hypertens 41:e482. https://doi.org/10.1097/01.hjh.0000917832.54573.cc

    Article  Google Scholar 

  12. van der Linden EL, Agyemang C, van den Born B-JH (2020) Hypertension control in sub-Saharan Africa: Clinical inertia is another elephant in the room. J Clin Hypertens 22:959–961. https://doi.org/10.1111/jch.13874

    Article  Google Scholar 

  13. Milman T, Joundi RA, Alotaibi NM, Saposnik G (2018) Clinical inertia in the pharmacological management of hypertension. Medicine (Baltimore) 97:e11121. https://doi.org/10.1097/MD.0000000000011121

    Article  PubMed  Google Scholar 

  14. Khoury PR, Mitsnefes M, Daniels SR, Kimball TR (2009) Age-specific reference intervals for indexed left ventricular mass in children. J Am Soc Echocardiogr 22:709–714. https://doi.org/10.1016/j.echo.2009.03.003

    Article  PubMed  Google Scholar 

  15. Flynn JT, Daniels SR, Hayman LL et al (2014) Update: Ambulatory Blood Pressure Monitoring in Children and Adolescents. Hypertension 63:1116–1135. https://doi.org/10.1161/HYP.0000000000000007

    Article  CAS  PubMed  Google Scholar 

  16. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents (2004) The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 114:555–576. https://doi.org/10.1542/peds.114.S2.iv

    Article  Google Scholar 

  17. Flynn JT, Kaelber DC, Baker-Smith CM et al (2017) Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics 140:e20171904. https://doi.org/10.1542/peds.2017-1904

    Article  PubMed  Google Scholar 

  18. Lee J, McCulloch CE, Flynn JT et al (2020) Prognostic value of ambulatory blood pressure load in pediatric CKD. Clin J Am Soc Nephrol 15:493–500. https://doi.org/10.2215/CJN.10130819

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Hamdani G, Mitsnefes MM, Flynn JT et al (2021) Pediatric and adult ambulatory blood pressure thresholds and blood pressure load as predictors of left ventricular hypertrophy in adolescents. Hypertension 78:30–37. https://doi.org/10.1161/HYPERTENSIONAHA.120.16896

    Article  CAS  PubMed  Google Scholar 

  20. Parekh RS, Carroll CE, Wolfe RA, Port FK (2002) Cardiovascular mortality in children and young adults with end-stage kidney disease. J Pediatr 141:191–197. https://doi.org/10.1067/mpd.2002.125910

    Article  CAS  PubMed  Google Scholar 

  21. Mitsnefes MM (2002) Pediatric end-stage renal disease: heart as a target. J Pediatr 141:162–164. https://doi.org/10.1067/mpd.2002.126921

    Article  PubMed  Google Scholar 

  22. Sarnak MJ, Levey AS, Schoolwerth AC et al (2003) Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Circulation 108:2154–2169. https://doi.org/10.1161/01.CIR.0000095676.90936.80

    Article  PubMed  Google Scholar 

  23. ESCAPE Trial Group, Wühl E, Trivelli A et al (2009) Strict blood-pressure control and progression of renal failure in children. N Engl J Med 361:1639–1650. https://doi.org/10.1056/NEJMoa0902066

    Article  Google Scholar 

  24. Wilson AC, Flynn JT (2020) Blood pressure in children with chronic kidney disease: Lessons learned from the Chronic Kidney Disease in Children Cohort Study. Pediatr Nephrol 35:1203–1209. https://doi.org/10.1007/s00467-019-04288-6

    Article  PubMed  Google Scholar 

  25. Santer M, Ring N, Yardley L et al (2014) Treatment non-adherence in pediatric long-term medical conditions: systematic review and synthesis of qualitative studies of caregivers’ views. BMC Pediatr 14:63. https://doi.org/10.1186/1471-2431-14-63

    Article  PubMed  PubMed Central  Google Scholar 

  26. Pruette CS, Coburn SS, Eaton CK et al (2019) Does a multimethod approach improve identification of medication nonadherence in adolescents with chronic kidney disease? Pediatr Nephrol 34:97–105. https://doi.org/10.1007/s00467-018-4044-x

    Article  PubMed  Google Scholar 

  27. Kleinsinger F (2018) The Unmet Challenge of Medication Nonadherence. Perm J 22:18–033. https://doi.org/10.7812/TPP/18-033

    Article  PubMed  PubMed Central  Google Scholar 

  28. Bismar N, Barlow SE, Brady TM, Turer CB (2020) Pediatrician communication about high blood pressure in children with overweight/obesity during well-child visits. Acad Pediatr 20:776–783. https://doi.org/10.1016/j.acap.2019.11.012

    Article  PubMed  Google Scholar 

  29. Aujoulat I, Jacquemin P, Rietzschel E et al (2014) Factors associated with clinical inertia: an integrative review. Adv Med Educ Pract 5:141–147. https://doi.org/10.2147/AMEP.S59022

    Article  PubMed  PubMed Central  Google Scholar 

  30. Zheutlin AR, Mondesir FL, Derington CG et al (2022) Analysis of therapeutic inertia and race and ethnicity in the Systolic Blood Pressure Intervention Trial: a secondary analysis of a randomized clinical trial. JAMA Netw Open 5:e2143001. https://doi.org/10.1001/jamanetworkopen.2021.43001

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Johns Hopkins Pediatrics, Johns Hopkins University School of Medicine, Rubenstein Child Health Building Suite 3057, 200 N Wolfe St, Baltimore, MD, 21287, USA

    Evelien van Gelderen, Kevin J. Psoter, Rafi Faria, Cozumel Pruette & Tammy M. Brady

Authors
  1. Evelien van Gelderen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kevin J. Psoter
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Rafi Faria
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Cozumel Pruette
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Tammy M. Brady
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Tammy M. Brady.

Ethics declarations

Conflict of interests

The authors have no conflicts of interest relevant to this article to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Graphical abstract (PDF 74 KB)

Supplementary file2 (DOCX 20 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

van Gelderen, E., Psoter, K.J., Faria, R. et al. Clinician response after receipt of abnormal pediatric ambulatory blood pressure monitoring – characteristics associated with inertia and action. Pediatr Nephrol (2024). https://doi.org/10.1007/s00467-024-06404-7

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s00467-024-06404-7

Keywords

Search

Navigation