Kaiser Permanente Study: Research Shows Importance of Second Pediatric Blood Pressure Screening

When first result is high, another reading needed to accurately diagnose hypertension.

Nearly one-quarter of children and teens who had their blood pressure screened at a primary care appointment showed a reading in the hypertensive range, but less than half of those readings could be confirmed after the blood pressure was repeated, according to a new Kaiser Permanente (No. 2 on the DiversityInc Top 50 Companies list) study released Jan. 12 in The Journal of Clinical Hypertension. The research shows the importance of taking a second blood pressure reading for those ages 3 to 17 years when the first reading is elevated.


"Pediatricians don't diagnose hypertension in children very often, but if it is there, we want to find it," said Robert James Riewerts, MD, regional chief of Pediatrics for the Southern California Permanente Medical Group. "This study is important because it demonstrates the best path to accurately diagnose hypertension in a child or teen. Taking a second blood pressure reading is something all clinicians must consider when the initial reading is elevated."

Blood pressure in youth varies considerably and can be affected by factors such as a child's anxiety. Also, determining high blood pressure in children or teens is more difficult to do than in adults because what is considered high varies based on age, gender and height.

Since this study was conducted, Kaiser Permanente in Southern California has put alerts on its electronic health records to alert clinicians when a second blood pressure reading is recommended. Also, decision-support tools were added to help clinicians determine when further evaluation is recommended.

Researchers found that for patients ages 3 to 17 years:

  • 7 percent had at least one blood pressure reading in the hypertensive range.
  • Fewer than half of the children who had their blood pressure screened would be correctly classified based solely on their first blood pressure reading of the appointment.
  • 3 percent of youth have sustained hypertension over time.

Corinna Koebnick, PhD, MSc

"Because an elevated first blood pressure in youth is common, correct identification of truly elevated blood pressure may be a first step to improve the recognition of hypertension in pediatric care," said Corinna Koebnick, PhD, MSc, of the Kaiser Permanente Southern California Department of Research & Evaluation. "If hypertension is missed, children and teens may not receive the counseling they need for lifestyle changes or medication."

This study is based on the Kaiser Permanente Southern California Children's Health Study, which includes all children and adolescents ages 2 to 19 years in Southern California who are Kaiser Permanente members. The cohort follow-up was conducted through passive surveillance of clinical care information using the electronic health record system.

The final cohort of 755,795 youths was followed during a four-year study period, January 2012 through December 2015.

Dr. Koebnick suggested that instead of calculating the average of blood pressure readings, using the lower blood pressure reading may be more efficient for most clinicians.

This study adds to previous Kaiser Permanente research aimed at improving hypertension care, including a study that found children who have a first elevated blood pressure at the doctor's office are not likely to receive the recommended follow-up blood pressure readings. Another study found that expanding blood pressure screenings to non-primary care settings can help identify more adult patients with high blood pressure.

Other authors on the paper include Yasmina D. Mohan, MPH, and Xia Li, MSc, with the Kaiser Permanente Southern California Department of Research & Evaluation in Pasadena, California; Amy H. Porter, MD, Kaiser Permanente Los Angeles Medical Center, Los Angeles; Matthew F. Daley, MD, Kaiser Permanente Institute for Health Research, Denver; Gang Luo, PhD, Department of Biomedical Informatics and Medical Education, University of Washington, Seattle; and Beatriz D. Kuizon, MD, Department of Biomedical Informatics and Medical Education, University of Washington, Seattle.

The study was supported by funds from the Kaiser Permanente Community Benefit Fund and internal operational funding from Kaiser Permanente Southern California.

Kaiser Permanente Researchers Develop New Models for Predicting Suicide Risk

Approach may offer value to health systems and clinicians in targeting interventions to prevent suicide

Originally Published by Kaiser Permanente.

Combining data from electronic health records with results from standardized depression questionnaires better predicts suicide risk in the 90 days following either mental health specialty or primary care outpatient visits, reports a team from the Mental Health Research Network, led by Kaiser Permanente research scientists.

The study, "Predicting Suicide Attempts and Suicide Death Following Outpatient Visits Using Electronic Health Records," conducted in five Kaiser Permanente regions (Colorado, Hawaii, Oregon, California and Washington), the Henry Ford Health System in Detroit, and the HealthPartners Institute in Minneapolis, was published today in the American Journal of Psychiatry.

Combining a variety of information from the past five years of people's electronic health records and answers to questionnaires, the new models predicted suicide risk more accurately than before, according to the authors. The strongest predictors include prior suicide attempts, mental health and substance use diagnoses, medical diagnoses, psychiatric medications dispensed, inpatient or emergency room care, and scores on a standardized depression questionnaire.

Dr. Simon shares what inspired him to study mental health.

"We demonstrated that we can use electronic health record data in combination with other tools to accurately identify people at high risk for suicide attempt or suicide death," said first author Gregory E. Simon, MD, MPH, a Kaiser Permanente psychiatrist in Washington and a senior investigator at Kaiser Permanente Washington Health Research Institute.

In the 90 days following an office visit:

  • Suicide attempts and deaths among patients whose visits were in the highest 1 percent of predicted risk were 200 times more common than among those in the bottom half of predicted risk.
  • Patients with mental health specialty visits who had risk scores in the top 5 percent accounted for 43 percent of suicide attempts and 48 percent of suicide deaths.
  • Patients with primary care visits who had scores in the top 5 percent accounted for 48 percent of suicide attempts and 43 percent of suicide deaths.

This study builds on previous models in other health systems that used fewer potential predictors from patients' records. Using those models, people in the top 5 percent of risk accounted for only a quarter to a third of subsequent suicide attempts and deaths. More traditional suicide risk assessment, which relies on questionnaires or clinical interviews only, is even less accurate.

The new study involved seven large health systems serving a combined population of 8 million people in nine states. The research team examined almost 20 million visits by nearly 3 million people age 13 or older, including about 10.3 million mental health specialty visits and about 9.7 million primary care visits with mental health diagnoses. The researchers deleted information that could help identify individuals.

"It would be fair to say that the health systems in the Mental Health Research Network, which integrate care and coverage, are the best in the country for implementing suicide prevention programs," Dr. Simon said. "But we know we could do better. So several of our health systems, including Kaiser Permanente, are working to integrate prediction models into our existing processes for identifying and addressing suicide risk."

Suicide rates are increasing, with suicide accounting for nearly 45,000 deaths in the United States in 2016; 25 percent more than in 2000, according to the National Center for Health Statistics.

Other health systems can replicate this approach to risk stratification, according to Dr. Simon. Better prediction of suicide risk can inform decisions by health care providers and health systems. Such decisions include how often to follow up with patients, refer them for intensive treatment, reach out to them after missed or canceled appointments — and whether to help them create a personal safety plan and counsel them about reducing access to means of self-harm.