Guideline-Recommended Implementation of Pediatric Ambulatory Blood Pressure Monitoring (GRIP ABPM)

ABSTRACT Dr. James T. Nugent is an Instructor of Pediatrics in the Sections of Pediatric Nephrology and General Pediatrics at Yale School of Medicine. The goal of this K23 Career Development Award is to provide mentored training in applying clinical research methods to support Dr. Nugent’s development into an independent physician-scientist studying hypertension in children. Dr. Nugent’s scientific mission is to tailor cardiovascular disease prevention to the needs of disproportionately affected populations. His prior work has leveraged electronic health records and historical data to improve the care of children with hypertension in the inpatient and outpatient settings. To become an independent physician-scientist, Dr. Nugent requires the support of this K23 award to achieve the following training objectives: (1) methodologic expertise in implementation science, mixed methods, clinical decision support, trial design, and cost-effectiveness analysis; (2) direct experience in prospective human subjects research; and (3) structured professional development to lead a clinical research team. The scientific objective of the planned research is to develop and test a multilevel implementation strategy to improve the guideline-recommended use of ambulatory blood pressure monitoring (ABPM) in children and adolescents with hypertension. Screening for hypertension in childhood is recommended to prevent long-term cardiovascular morbidity and mortality. However, the diagnosis of hypertension in children is challenging due to the unreliability of office BP measurement. Therefore, current pediatric guidelines recommend performing ABPM to diagnose hypertension in children. Despite its superior accuracy, ABPM is not widely available in pediatric primary care, and we have found that only 8% of US children with hypertension have ever completed this guideline- recommended test. Practical and sustainable approaches are needed to implement guideline-based ABPM outside the subspecialty setting. In Aim 1, we will characterize the barriers to and facilitators of ABPM utilization among patients, primary care clinicians, hypertension specialists, and nurses. The results of the pre- implementation assessment in Aim 1 will inform the design and evaluation of an implementation strategy in Aim 2 to promote the completion of guideline-recommended ABPM in pediatric primary care. This multifaceted implementation strategy will have several key components, including electronic clinical decision support, the use of a centralized ABPM service, and closed-loop communication of ABPM results and recommendations from the hypertension specialist to the primary care clinician. In Aim 3, we will determine the costs associated with ABPM implementation and compare the cost-effectiveness of different ABPM screening strategies in the general pediatric population. Completion of these aims will inform an R01 to conduct a multicenter, cluster randomized trial to further optimize and test the efficacy of a multilevel implementation strategy to increase guideline-based utilization of ABPM across a national network of pediatric hypertension centers and referring primary care clinics.