Did hypertension guidelines change practice patterns in primary care?

Did hypertension guidelines change practice patterns in primary care? | Image Credit: © Nikolai Titov - © Nikolai Titov - stock.adobe.com.

In a Canadian primary care setting, results from a study published in JAMA Network Open demonstrated that there was a significant increase in blood pressure (BP) screening and hypertension prevalence after the publication of national and international guidelines, though follow-up was suboptimal.

Hypertension prevalence in pediatrics has increased in recent decades and has been associated with increasing rates of childhood obesity, wrote Michael Wu, BSc, and colleagues. Even with the prevalence, pediatric hypertension is frequently under-diagnosed. Children with newly diagnosed hypertension in the primary care setting rarely have secondary causes compared to those receiving care from specialists.

In 2016 and 2017, respectively, guidelines were introduced in Canada and the United States by Hypertension Canada and the American Academy of Pediatrics (AAP). Of note, The Hypertension Canada guidelines recommended BP should be measured regularly in all children aged 3 years and up. The AAP recommended annual BP screenings for all children and adolescents aged 3 to 18 years and a BP screening at every visit for individuals with obesity, diabetes, chronic kidney disease, or aortic coarctation.

Impact of the guidelines were unclear. Even 6 years after publication, the investigative team stated it is unknown if the recommendations have led to changes in primary care. "To this end, we performed interrupted time series analysis to assess the change in practice following the introduction of these guidelines, including temporal changes to BP screening and follow-up, HTN prevalence, and practice patterns," they wrote.

The retrospective, multicenter, population-based cohort study used data collected from 7 Canadian provinces, and was conducted in 3 phases:

• January 1, 2011, to December 31, 2015 (era 1)
• January 1, 2016, to December 31, 2017 (washout period)
• January 1, 2018, to December 31, 2019 (era 2)

Primary outcomes included annual BP screening documentation, high BP follow-up documentation at 6 months and 1 year, hypertension prevalence, laboratory testing rates, and medication prescription rates.

The investigators used interrupted time series analysis to assess the association of the introduction of the Canadian and United States guidelines with outcomes.

In all, the study featured 343,191 children and adolescents with a first encounter mean age of 6.7 (4.6) years (50.5% female). There were 235,094 patients in era 1 and 193,473 in era 1. Of these patients, 55,550 (23.6%) had at least 1 BP measurement in era 1, while 45,006 (23.3%) had at least 1 BP measurement in era 2.

In era 2, investigators observed a significant increase in BP screening, from 26,876 of 148,554 screenings (18.1%) to 28,556 of 141,192 screenings (20.2%; β = 0.202; 95% CI, 0.009 to 0.390; [P = .04]). The increasing trend was sustained.

For follow up in era 2, a significant decreasing trend was observed for high BP measurement at 6 months and 1 year:

• 6 months - 1265 of 4941 patients with BP measurements (25.6%) to 1718 of 7321 patients with BP measurements (23.5%; β = −0.490; 95% CI, −0.758 to −0.223; [P = .001])
• 1 year - 1974 of 4941 measurements (40.0%) to 2314 of 7321 measurements (31.6%); β = −1.392; 95% CI, −1.573 to −1.212; [P < .001])

A significant increase was observed in the proportion of patients meeting hypertension criteria, from 2540 of 55 550 patients (4.6%) in era 1 to 5690 of 45 006 patients (12.6%) in era 2 (β = 0.0210; 95% CI, 0.0021 to 0.0410; [P = .03]).

No significant change was observed in the trend of laboratory testing rates in era 2.

The prescribing of medications to patients with hypertension trend decreased in era 2, from 1305 of 4941 patients prescribed medication (26.4%) to 1415 of 7321 patients prescribed medication (19.3%); β = −0.605; 95% CI, −0.830 to −0.358; [P < .001]).

"We noticed a significant increase in BP screening and HTN prevalence. In addition, there was a reduction in prescription of antihypertensive medications after the guideline introduction," concluded the study authors, who suggested that the uptake of hypertension guidelines in the primary care setting could be improved through more consistent follow-up.

Reference:

Wu M, Dart A, Kosowan L, et al. Temporal Trends in Practice Patterns After Introduction of Pediatric Hypertension Guidelines in Canada. JAMA Netw Open. 2024;7(2):e2355239. doi:10.1001/jamanetworkopen.2023.55239