underdiagnosis of pediatric hypertension – an example of the potential of electronic medical...
TRANSCRIPT
Underdiagnosis of Pediatric Hypertension – An Example of the
Potential of Electronic Medical Record Research for Clinical
Pediatricians
David C Kaelber, MD, PhDInternal Medicine and Pediatrics Physician
National Library of Medicine Medical Informatics FellowCenter for Information Technology Leadership (CITL)
Staff PhysicianChildren'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
Background
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
Stage II HTN
Stage I HTN
Pre-hypertensive
Normal
Adult ChildrenBlood Pressure
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 Results4%
3%
93%
HTNPre-HTNNormal
Study ResultsHTN
Un-Dx, 376, 74%
Dx, 131, 26%
Un-Dx
Dx
Logistic regression analysis of factors associated with having a correct diagnosis of HTNVariable 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
Study Results – HTN factors
Task # of hours EMR Study1 Paper Chart Study2
Planning Meetings 30 30
IRB Preparation 10 10
Data Collection 5 5764
Data Processing 15 15
Data Analysis 30 30
Abstract 15 15
Manuscript 40 40
TOTAL 145 5909
Distribution of Task and # of hours to complete tasks.1 – actual time for this EMR study2 – 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
Study Design and
Team
IRB Approved
Data Obtained
and Analyzed
PAS Abstract
Submitted
1 3rd year medical school student, 1 4th year medical school student, 1 medical informatics fellow, ~150 hours, ~17 months, $0
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.
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.
