Improving Adherence to Pediatric Hypertension Guidelines: Go the Distance

Clinical practice guidelines became common several decades ago and were even described as “the best hope for quality improvement in the 1990s.”1 Around that same time, the film, Field of Dreams, was released. In the movie, the main character, Roy Kinsela, is inspired to build a baseball diamond on his farm when he hears a mysterious voice whispering the phrase, “if you build it, he will come,” from his cornfield.2 The developers of clinical practice guidelines seem to have a similar Field of Dreams philosophy that “if you publish it, they will follow.” The mere publication of guidelines does not guarantee changes in physician behavior or improvement in patient care. Moreover, guidelines are often developed based on efficacy studies conducted under controlled conditions, without fully incorporating evidence from real-world effectiveness studies. As a result, in the last few decades, slow provider uptake of guidelines has been the rule rather than the exception.In this issue of Pediatrics, Nugent and Kaelber leverage the TriNetX® (Cambridge, MA) database to explore hypertension guideline adherence among providers caring for youth who already have a documented diagnosis code for primary hypertension in the medical record.3 This point is crucial in that one of the largest barriers to hypertension diagnosis, recognition of elevated blood pressure, has been taken out of the equation for this study cohort. This point is reflected in the low cohort prevalence of hypertension of 0.5% compared to the expected prevalence of 2% to 5%.4The authors focus on the testing recommendations included in the 2017 American Academy of Pediatrics (AAP) clinical practice guidelines for youth with incident hypertension, specifically determining how often youth aged 1 to 17 years with a new hypertension diagnosis underwent laboratory testing, ambulatory blood pressure monitoring (ABPM), echocardiography, and renal ultrasonography, when indicated. The time period queried spanned 10 years, from 2014 to 2024, which includes data from before and after guideline publication. There are separate analyses for youth diagnosed between 2018 and 2024, as well as analyses that provide trends across the full 10-year period.While the 2017 guidelines recommended several changes to the evaluation of youth with hypertension, the need for laboratory testing to screen for underlying kidney disease and dyslipidemia for all patients was unchanged. Yet adherence to these steps was quite poor, with less than 20% of youth undergoing urinalysis testing or assessment of serum electrolytes, creatinine, or lipid levels—key first steps in the evaluation. It is possible that clinicians elected not to repeat recently performed studies or that clinicians were careful to avoid premature diagnoses by confirming elevated blood pressure after separate follow-up visits. However, when the authors allowed prior completion of recommended testing to count toward adherence and limited their analysis to youth after a third visit with a hypertension diagnosis code (thereby avoiding cases where a hypertension code was premature), adherence to these steps improved, but never reached more than 60%.Interestingly, the most common test received was an echocardiogram, occurring in 21% of patients at diagnosis. The fact that this testing, which should be reserved until the decision is made to prescribe medications (often 6 to 12 months after a trial of lifestyle change), occurred among more children compared to the other recommended tests is perplexing. Obtaining an echocardiogram can arguably be one of the most expensive and time-consuming tests, which requires a referral and a separate appointment—all hypothesized barriers to provider completion of the other recommended testing. Fortunately, there was an increase in the percentage of children receiving ABPM from 5.7% to 11.9% from 2014 to 2024.3 As ABPM is required before conferring a diagnosis of hypertension according to the clinical practice guideline, this outcome still falls far short of recommendations.The authors suggest many potential reasons for these sobering results. In addition to those mentioned above, they highlight family preferences and poor access to testing facilities as potential factors. Clinician-related barriers include poor awareness of recent guideline changes, lack of buy-in due to differing interpretations of the evidence supporting the updated recommendations, challenges absorbing and implementing the large numbers of guideline recommendations (30 total) and consensus opinion recommendations (27 total), of which many only achieved a “C” or “D” rating regarding evidence quality and strength.5 Other barriers include provider lack of self-efficacy or outcome expectancy regarding follow-up testing, minimal practical suggestions for implementation in current practice workflows and contexts, and practice inertia accumulated after years of habit.6After decades of experience with clinical practice guidelines, slow uptake and poor initial physician adherence should be expected. However, when guideline developers also invest in the creation of implementation tools, better provider and patient adherence results. A Cochrane review of the effectiveness of tools developed by practice guideline producers to implement their guidelines included four cluster randomized controlled trials. The interventions included continuing medical education modules on the guideline topic, communication tools to supplement guidelines, tailored formatting of guidelines, and academic detailing. The Cochrane review suggests that these interventions can lead to increased adherence to the guidelines.7 A pediatric example of the coordinated development of implementation tools and new practice guidelines is the revised Bright Futures: Guidelines for Health Supervision and the development of provider training modules, anticipatory guidance tools, a newsletter, and family education materials by the AAP to support provider adherence.8Earlier this year, the International Society of Hypertension (ISH) published a position paper that provides “pragmatic, globally adaptable recommendations to enhance early detection, treatment, and continuity of care for children and adolescents with elevated blood pressure,” with a multitude of tables, figures, tips, and online resources to help providers implement the guidelines.9 This paper could serve as an example of implementation tools for future hypertension guidelines. The roadmap offered by the ISH policy Statement could be integrated into efforts by the AAP’s Partnership for Policy Implementation, which aims to facilitate easier implementation of guideline recommendations by practicing clinicians and electronic health record developers.10 Rigorous guideline collaboration with committees such as the AAP Council on Quality Improvement and Patient Safety could further augment uptake of future practice guidelines by allowing the front-line voice to emerge in expert recommendations.The work by Nugent and Kaelber further suggests the importance of incorporating real-world effectiveness studies into guideline recommendation development. This is crucial not only to deliver the best patient care but also to reduce provider medicolegal liability, as guidelines can be used in medical malpractice cases to “allege a breach of standard of care.”11 It is no longer just “strength of evidence” that is important in guideline development. Guideline developers must also consider the ability for clinicians to implement those guidelines, and recognize the guideline team’s duty to aid in implementation.Often overlooked in the film Field of Dreams is that Roy Kinsella received several messages in the movie. The final phrase from the cornfield was “go the distance.”2 Similarly, developers of clinical practice guidelines also need to “go the distance” and complete the task to ensure that guidelines are applied to and have an impact on patient care. Organizations that create guidelines must also produce and promote implementation tools. It is the thoughtful and systematic implementation of guidelines that translates these published clinical recommendations into improved patient outcomes.