Recommended tests poorly utilized in hypertensive teens

Recommended tests poorly utilized in hypertensive teens
Recommended tests poorly utilized in hypertensive teens

HealthDay News -- The number of U.S. teens with essential hypertension is increasing along with obesity rates. But these patients may not be receiving the proper tests necessary to identify organ damage, study results suggest.

Just 24% of teens with hypertension underwent an echocardiogram and 22% had a renal ultrasonography, the two tests recommended for adolescents in national hypertension guidelines, Ester Y. Yoon, MD, MPH, from the University of Michigan in Ann Arbor and colleagues reported in Archives of Pediatrics & Adolescent Medicine.

In contrast, during the study period 50% underwent at least one electrocardiogram (EKG), a test recommended for adults with hypertension, but not for children and adolescents. 

"The decision and choice of diagnostic tests to evaluate adolescents with essential hypertension warrant further study to understand the underlying rationale for those decisions and to determine treatment effectiveness," Yoon and colleagues wrote.

The researchers analyzed administrative claims data on use of echocardiogram, EKG and renal ultrasonography for 951 adolescents who had a diagnosis of essential hypertension and one or more antihypertensive medication pharmacy claims in the Michigan Medicaid program from 2003 to 2008.

Clinicians were more likely to obtain an electrocardiogram in boys than girls (odds ratio [OR]= 1.53; 95% CI : 1.06-2.21), and patients that were younger vs. those who were older (OR=1.69; 95% CI: 1.17-2.44), the researchers found. Electrocardiogram was used more often in patients who also had EKGs (OR=5.79; 95% CI: 4.02-8.36) or renal ultrasonography (OR=2.22; 95% CI: 1.54-3.20) vs. those who did not.

In addition to being the most commonly used of the three diagnostic tests, EKG was used more often by itself than the others. However, when used in conjunction with echocardiograms and/or renal ultrasonography, EKGs were more often done first or on the same day.

This may be because EKG is the least expensive of the three tests and is more readily available at point of care, the researchers suggested, and hypothesized clinicians may be choosing EKG to identify left ventricular hypertrophy instead of echogardiogram, despite EKG's relatively low sensitivity for diagnosing LVH in children (25% to 35%).

"Target organ damage cannot be ruled out based on the absence of LVH on EKGs alone," they warned.

The researchers also pointed out that it is unclear why clinicians would order EKGs and echocardiograms together -- the most common combination of tests ordered in the study -- since both tests evaluate target organ damage, instead of ordering an EKG or echocardiogram with renal ultrasonography, which is most useful for ruling out secondary causes of pediatric hypertension.

"Patterns of EKG and echocardiogram use in our study raise questions about the level of familiarity, awareness, or agreement with pediatric hypertension guideline recommendations and the rationale behind these recommendations among [clinicians] who provide primary care for children and adolescents," the researchers wrote.

They called for better strategies to educate pediatric primary care providers about pediatric hypertension guidelines to address potential barriers to adherence.

Yoon EY et al. Arch Pediatr Adolesc Med. 2012;doi:10.1001/archpediatrics.2012.1173.

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