Clinical Decision Support for Recognition and Management of Hypertension: A Randomized Trial.

OBJECTIVES: Although blood pressure (BP) is routinely measured in outpatient visits, elevated BP and hypertension are often not recognized. We evaluated whether an electronic health record-linked clinical decision support (CDS) tool could improve the recognition and management of hypertension in adolescents. METHODS: We randomly assigned 20 primary care clinics within an integrated care system to CDS or usual care. At intervention sites, the CDS displayed BPs and percentiles, identified incident hypertension on the basis of current or previous BPs, and offered tailored order sets. The recognition of hypertension was identified by an automated review of diagnoses and problem lists and a manual review of clinical notes, antihypertensive medication prescriptions, and diagnostic testing. Generalized linear mixed models were used to test the effect of the intervention. RESULTS: Among 31 579 patients 10 to 17 years old with a clinic visit over a 2-year period, 522 (1.7%) had incident hypertension. Within 6 months of meeting criteria, providers recognized hypertension in 54.9% of patients in CDS clinics and 21.3% of patients in usual care (P ≤ .001). Clinical recognition was most often achieved through visit diagnoses or documentation in the clinical note. Within 6 months of developing incident hypertension, 17.1% of CDS subjects were referred to dieticians or weight loss or exercise programs, and 9.4% had additional hypertension workup versus 3.9% and 4.2%, respectively (P = .001 and .046, respectively). Only 1% of patients were prescribed an antihypertensive medication within 6 months of developing hypertension. CONCLUSIONS: The CDS had a significant, beneficial effect on the recognition of hypertension, with a moderate increase in guideline-adherent management.

Associations of Maternal Weight Status Before, During, and After Pregnancy with Inflammatory Markers in Breast Milk.

OBJECTIVE: The goal of this study was to examine the associations of maternal weight status before, during, and after pregnancy with breast milk C-reactive protein (CRP) and interleukin 6 (IL-6), two bioactive markers of inflammation, measured at 1 and 3 months post partum. METHODS: Participants were 134 exclusively breastfeeding mother-infant dyads taking part in the Mothers and Infants Linked for Health (MILK) study, who provided breast milk samples. Pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) were assessed by chart abstraction; postpartum weight loss was measured at the 1- and 3-month study visits. Linear regression was used to examine the associations of maternal weight status with repeated measures of breast milk CRP and IL-6 at 1 and 3 months, after adjustment for potential confounders. RESULTS: Pre-pregnancy BMI and excessive GWG, but not total GWG or postpartum weight loss, were independently associated with breast milk CRP after adjustment (ß = 0.49, P < 0.001 and ß = 0.51, P = 0.011, respectively). No associations were observed for IL-6. CONCLUSIONS: High pre-pregnancy BMI and excessive GWG are associated with elevated levels of breast milk CRP. The consequences of infants receiving varying concentrations of breast milk inflammatory markers are unknown; however, it is speculated that there are implications for the intergenerational transmission of disease risk.

National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage.

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.

TeenBP: Development and Piloting of an EHR-Linked Clinical Decision Support System to Improve Recognition of Hypertension in Adolescents.

CONTEXT: Blood pressure (BP) is routinely measured in children and adolescents during primary care visits. However, elevated BP or hypertension is frequently not diagnosed or evaluated further by primary care providers. Barriers to recognition include lack of clinician buy-in, competing priorities, and complexity of the standard BP tables. CASE DESCRIPTION: We have developed and piloted TeenBP- a web-based, electronic health record (EHR) linked system designed to improve recognition of prehypertension and hypertension in adolescents during primary care visits. MAJOR THEMES: Important steps in developing TeenBP included the following: review of national BP guidelines, consideration of clinic workflow, engagement of clinical leaders, and evaluation of the impact on clinical sites. Use of a web-based platform has facilitated updates to the TeenBP algorithm and to the message content. In addition, the web-based platform has allowed for development of a sophisticated display of patient-specific information at the point of care. In the TeenBP pilot, conducted at a single pediatric and family practice site with six clinicians, over a five-month period, more than half of BPs in the hypertensive range were clinically recognized. Furthermore, in this small pilot the TeenBP clinical decision support (CDS) was accepted by providers and clinical staff. Effectiveness of the TeenBP CDS will be determined in a two-year cluster-randomized clinical trial, currently underway at 20 primary care sites. CONCLUSION: Use of technology to extract and display clinically relevant data stored within the EHR may be a useful tool for improving recognition of adolescent hypertension during busy primary care visits. In the future, the methods developed specifically for TeenBP are likely to be translatable to a wide range of acute and chronic issues affecting children and adolescents.

National Partnership for Maternal Safety: consensus bundle on obstetric hemorrhage.

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.

National Partnership for Maternal Safety Consensus Bundle on Obstetric Hemorrhage.

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into 4 domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.

Organizational factors and change strategies associated with medical home transformation.

There is limited information about how to transform primary care practices into medical homes. The research team surveyed leaders of the first 132 primary care practices in Minnesota to achieve medical home certification. These surveys measured priority for transformation, the presence of medical home practice systems, and the presence of various organizational factors and change strategies. Survey response rates were 98% for the Change Process Capability Questionnaire survey and 92% for the Physician Practice Connections survey. They showed that 80% to 100% of these certified clinics had 15 of the 18 organizational factors important for improving care processes and that 60% to 90% had successfully used 16 improvement strategies. Higher priority for this change (P = .001) and use of more strategies (P = .05) were predictive of greater change in systems. Clinics contemplating medical home transformation should consider the factors and strategies identified here and should be sure that such a change is indeed a high priority for them.

Challenges of medical home transformation reported by 118 patient-centered medical home (PCMH) leaders.

BACKGROUND: Little is known about the most important organizational factors and strategies for transforming primary care clinics into patient-centered medical homes (PCMHs), so we studied this in newly certified medical homes in Minnesota. METHODS: We collected the following information from the first 120 clinics serving adults to be certified: (1) a 105-item survey about the presence and function of practice systems now and 3 years ago; (2) standardized composite clinic performance measures for diabetes and cardiovascular disease; and (3) a 44-item survey about PCMH transformation derived from 31 qualitative interviews about barriers, facilitators, and change strategies with participants from 9 diverse clinics. RESULTS: The response rates for the systems survey was 92.5% and was 98.3% for the survey about transformation. Nearly all the items from the qualitative interviews identified as potentially important for transformation were strongly endorsed. Eighteen items in this survey also correlated significantly (P = <.01) with change in practice systems at the level of r ≥ 0.20. However, there was little relationship between these items and either absolute levels of systems or performance on composite measures of diabetes or vascular disease quality outcomes. CONCLUSIONS: Many items in the survey about transformation seem to have face validity for leaders of certified PCMHs and to be associated with the extent to which their clinics have made systems changes. While clinics may need to find their own unique path to transformation, the items identified here should be considered in those decisions.

Evaluating body mass index-specific trimester weight gain recommendations: differences between black and white women.

INTRODUCTION: We compared the gestational weight gains of black and white women with the 2009 Institute of Medicine (IOM) recommendations to better understand the potential for successful implementation of these guidelines in clinical settings. METHODS: Prenatal and birth data for 2760 women aged 18 to 40 years with term singleton births from 2004 through 2007 were abstracted. We examined race differences in mean trimester weight gains with adjusted linear regression and compared race differences in the distribution of women who met the IOM recommendations with chi-square analyses. We stratified all analyses by prepregnancy body mass index. RESULTS: Among normal-weight and obese women, black women gained less weight than white women in the first and second trimesters. Overweight black women gained significantly less than white women in all trimesters. For both races in all body mass index categories, a minority of women (range 9.9%-32.4%) met the IOM recommended gains for the second and third trimesters. For normal-weight, overweight, and obese black and white women, 49% to 80% exceeded the recommended gains in the third trimester, with higher rates of excessive gain for white women. DISCUSSION: Less than half of the sample gained within the IOM recommended weight gain ranges in all body mass index groups and in all trimesters. The risk of excessive gain was higher for white women. For both races, excessive weight gain began by the second trimester, suggesting that counseling about the importance of weight gain during pregnancy should begin earlier, in the first trimester or prior to conception.