Underdiagnosis of Pediatric Hypertension – An Example of the Potential of Electronic Medical Record Research for Clinical Pediatricians David C Kaelber, MD, PhD Internal Medicine and Pediatrics Physician National Library of Medicine Medical Informatics Fellow Center for Information Technology Leadership (CITL) Staff Physician Children's Hospital Boston, Brigham and Women’s Hospital, Massachusetts General Hospital, and Massachusetts General Hospital for Children

Disclosures I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

Background

2-5% of all children have hypertension. Background Adult Children Blood Pressure Stage II HTN Stage I HTN Pre-hypertensive Normal SBP >159 and/or DBP >99 SBP >139 and ≤159 and/or DBP >89 and ≤99 SBP >120 and ≤139 and/or DBP >80 and ≤89 SBP ≤120 and/or DBP ≤80 SBP and/or DBP > 99% +5mmHg for gender, age, and height SBP and/or DBP ≥ 95% and ≤ 99% +5mmHg for gender, age, and height SBP and/or DBP ≥ 90% and < 95% for gender, age, and height SBP and/or DBP < 90% for gender, age, and height Need 3 measurements for diagnosis of hypertension (HTN) or prehypertension (preHTN). 2-5% of all children have hypertension.

Study Design Design: Cohort study. Setting: Outpatient clinics in a large, academic, urban medical system in Northeast Ohio. Patients: 14187 children and adolescents age 3-18 years who were seen at least three times for well-child care between June 1999 and September 2006. Main Outcome Measures: Diagnosis of hypertension or prehypertension documented in the electronic medical record (EMR). Logistic regression analysis was performed to identify factors associated with a correct diagnosis.

EMR Data Collection Basic Information MR# birth date gender race primary care physician past medical history past surgical history family history Visit information visit date visit site BP reading(s) height reading weight reading diagnosis code(s) (ICD9) problem list code(s) (ICD9) order(s) billing code(s)

Study Results

Study Results

Study Results – HTN factors Logistic regression analysis of factors associated with having a correct diagnosis of HTN Variable OR 95%CI Age (1 year increase) 1.09 1.03-1.16 Height-for-Age Percentile (1% increase) 1.02 1.01-1.03 Weight-for-Age Percentile (1% increase) 1.00 0.98-1.01 Obesity-related diagnosis 2.61 1.49-4.55 Male Sex 1.15 0.73-1.80 African American Race 1.04 0.62-1.75 Hispanic/Latino Race 1.31 0.61-2.83 Family History of HTN 1.21 0.70-2.11 Number of Elevated Blood Pressures over 3 required 1.77 1.21-2.57 Stage 2 HTN 1.68 1.29-2.19

EMR Study1 Paper Chart Study2 Task # of hours EMR Study1 Paper Chart Study2 Planning Meetings 30 IRB Preparation 10 Data Collection 5 5764 Data Processing 15 Data Analysis Abstract Manuscript 40 TOTAL 145 5909 Distribution of Task and # of hours to complete tasks. 1 – actual time for this EMR study 2 – estimated time for equivalent paper chart study (assumes 1 minute for initial screen and 5 minutes to find and extract data)

Study Timeline April June August October December August 2007 2007 2007 2007 2007 2008 Clinical Observation IRB Approved PAS Abstract Submitted Data Obtained and Analyzed Study Design and Team ML Hanson, PW Gunn, and DC Kaelber. Underdiagnosis of Hypertension in Children and Adolescents. Journal of the American Medical Association. 298(8):874-9. 2007. 1 3rd year medical school student, 1 4th year medical school student, 1 medical informatics fellow, ~150 hours, ~17 months, $0

Clinical Research Implications (retrospective clinical research) Characteristic Old Paradigm New Paradigm Data Separate Research Database Shared Research and Clinic Database (EMR) Time 1000+ hours 100+ hours Money 100,000-1,000,000+ 0-10,000+ People Many Few Order of magnitude less time and money with electronic medical records.

Conclusions Electronic medical records have the potential to create a paradigm shift in retrospective clinical research. This paradigm shift can make clinical research much for accessible for clinical pediatricians.

dkaelber@partners.org or david.kaelber@case.edu Questions?? Comments?? dkaelber@partners.org or david.kaelber@case.edu