Boosting Primary Care Awareness and Treatment of Childhood Hypertension (BP-CATCH)

Montefiore Medicine Academic Health System

Status: Terminated

Conditions: Pediatric Hypertension

Treatments: Behavioral: Hub and Spoke co-management; Behavioral: Sustainability of changes; Behavioral: QIC with PCP and without subspecialist; Behavioral: Control condition; Behavioral: QIC with Subspecialist

Study type: Interventional

Funder types: Other; Other U.S. Federal agency

Identifiers

NCT03783650

2018-9287

R01HS026239 (U.S. AHRQ Grant/Contract)

Details and patient eligibility

About

The proposed research, building on an ongoing AHRQ-funded research project to prevent pediatric diagnostic errors in primary care (R01HS023608) and using a prospective, cluster-randomized, stepped wedge design, will investigate whether 1) a quality improvement collaborative (QIC) intervention without subspecialist involvement, 2) a QIC with subspecialists and primary care physicians (PCPs) mutually engaged, and/or 3) a hub and spoke co-diagnosis, co-management model where PCPs diagnose and manage pediatric hypertension (HTN) with a supporting subspecialist advisor, reduce errors in pediatric HTN diagnosis and management compared to each other and usual care.

Full description

Pediatric HTN causes appreciable morbidity in pediatric patients and errors in diagnosis and management are frequent and understudied, jeopardizing pediatric safety in ambulatory settings. Additionally, the gap between the number of pediatric subspecialist providers and the number needed for patient care continues to widen, and it is unclear how to best reduce burden on subspecialists, improve PCP and subspecialist communication, and improve patient outcomes. This research team, with significant experience researching ambulatory pediatric safety, conducting QICs and HTN interventions, identified six large pediatric practice groups in rural, suburban and urban locations that are committed to reducing preventable HTN patient harm, to testing the effectiveness of a QIC to improve PCP HTN diagnosis and management, and to a hub and spoke HTN co-diagnosis and co-management model. The effect demonstrated by this project using a rigorous research design and the new 2017 pediatric HTN guidelines, will motivate pediatric clinics across the country to adopt these newly-identified best practices to improve pediatric HTN care. Primary care pediatricians have an imperative to diagnose and manage HTN and elevated BP (EBP) more accurately and earlier, and to improve interactions with subspecialists to reduce the lifelong preventable harm that results from these chronic conditions. This proposal, will identify a clear implementation strategy for rigorous, evidenced-based pediatric HTN diagnosis and management, and highlight a model to increase primary and subspecialty care integration that can be reproduced across other chronic conditions.

The primary human subjects of this work are the physicians and staff within the primary care pediatric practices and their associated pediatric hypertension subspecialists whose behavior the QIC is attempting to change. In order to know if these practices and subspecialists have changed their behaviors, we will look at patient data. To be included in the data cohort, patients must have a blood pressure (BP) measurement that is elevated (>= 90th percentile for patient's sex, age, and height, or >=120/80 (regardless of sex/age/ height) at a healthcare maintenance visit or non-acute care visit (e.g. chronic disease follow-up visit). The following patients would be excluded from the data cohort:

• Prior hypertension or elevated BP diagnosis. Patient can have prior elevated BP measurements as long as no diagnosis has been made
• BP>95th percentile + 30mm or >180/120 or symptomatic patient
• Prior diagnosis of congenital heart disease, chronic kidney disease, urologic disease (e.g. posterior urethral valve, vesicoureteral reflux) or organ transplant,
• Previously included in BP-CATCH data entry
• Acute care visit (e.g., fever, viral illness, asthma attack, pain in any body part, etc.)

Enrollment: 64 patients

Sex: All

Ages: 18+ years old

Volunteers: Accepts Healthy Volunteers

Inclusion and exclusion criteria

Inclusion:

• Primary care pediatric practices who see children ages 3-22 years old.
• Practice must be able to field a 3-person core improvement team who can participate in the quality improvement collaborative.

Exclusion:

• Non-pediatric practices

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

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64 participants in 2 patient groups

Cohort 1

Experimental group

Description:

0-6 months: Quality Improvement Collaborative (QIC) with PCP and without subspecialist, Registry \& BP measurement 7-12 months: QIC with Subspecialist to improve communication and standardize, 13-18 months: Hub and Spoke co-management QIC with Primary care and Subspecialist 19-24 months: Sustainability of changes

Treatment:

Behavioral: Hub and Spoke co-management

Behavioral: QIC with Subspecialist

Behavioral: Sustainability of changes

Behavioral: QIC with PCP and without subspecialist

Cohort 2

Active Comparator group

Description:

0-6 months: Control condition Usual Care and Registry \& BP measurement, 7-12 months: Quality Improvement Collaborative (QIC) with PCP and without subspecialist 13-18 months: QIC with Subspecialist to improve communication and standardize 19-24 months: Hub and Spoke co-management QIC with Primary care and Subspecialist

Treatment:

Behavioral: Control condition

Behavioral: Hub and Spoke co-management

Behavioral: QIC with Subspecialist

Behavioral: QIC with PCP and without subspecialist