NC MEDICAID MANAGED CARE PROPOSED ADDITIONAL QUALITY MEASURE

North Carolina Medicaid Managed Care Proposed Additional Quality Measure:

Pediatric Hypertension Screening

Executive Summary

Pediatric hypertension too often goes undiagnosed and untreated because pediatricians fail

to comply with long-standing but cumbersome guidelines for blood pressure (BP) screening. This

memo explores some causes, contributing factors, and consequences of untreated hypertension, and

evaluates some benefits and options for improving pediatric screening. It concludes with the

recommendation that NC Medicaid require Prepaid Health Plans (PHPs) and providers to comply

with the BP screening guidelines beginning in 2020, and ensure compliance by adding a BP-specific

quality measure to evaluate whether BP status is assessed.

Undiagnosed Pediatric Hypertension Has Serious, Long-term Health Consequences

Untreated childhood hypertension can result in organ damage before adulthood (Tu, Eckert,

DiMeglio, Yu, & Jung, 2011) and has serious, long-term consequences, including a higher risk for

hypertension (Tu et al., 2011), stroke, cardiovascular disease, and kidney disease during adulthood

(Lauer & Clarke, 1989). Pediatric hypertension is frequently undiagnosed, especially when mild to

moderate and not associated with an underlying disease (Bijlsma, Blufpand, Kaspers, & Bokenkamp,

2014; Brady, Solomon, Neu, Siberry, & Parekh, 2010; Hansen, Gunn, & Kaelber, 2007).

Most Doctors Fail to Diagnose Pediatric Hypertension

Blood pressure changes with height as a child grows, so there is not a single standard value

for pediatric BP as there is with adults; classifying pediatric BP is a two-step process using age- and

sex-specific standardized tables (Ogden et al., 2002). The most common reasons for failure to

diagnose elevated pediatric BP are failure to measure BP and height at the same visit, failure to use

the standardized tables to classify BP status, and pediatricians’ inability to define pediatric pre-

hypertension and hypertension (Bijlsma et al., 2014). Pediatricians also fail to diagnose elevated BP

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in children when it is less than 120/80 mm Hg (the adult “normal” value); if the patient is of normal

weight for height, older, or male; and if the family history does not include cardiovascular disease

(Brady et al., 2010; Hansen et al., 2007).

Reference tables must be used to correctly identify pediatric BP status because normal BP

values are incremental for every age and height and there are too many values to memorize. Pediatric

BP is not difficult to figure out: first, the sex-specific percentile of height-for-age is found, and then

the child’s BP reading is compared to normal BP for a child of the same height percentile, age, and

sex. Hypertension is diagnosed when the child’s BP reading is at or above the 95th percentile, and

pre-hypertension is diagnosed when it is at or above the 90th percentile or is below the 95th percentile

but over 120/80 mm Hg (either systolic BP is over 120 mm Hg or diastolic BP is over 80 mm Hg,

or both) (National High Blood Pressure Education Program Working Group on High Blood

Pressure in Children and Adolescents, 2004).

Pediatric Hypertension Estimates May Be Significantly Understated

Despite long-standing guidelines that recommend measuring BP at each well-child visit

(Lurbe et al., 2009; National High Blood Pressure Education Program Working Group, 2004), just

25% of pediatricians routinely measure BP in their patients, and only 35% of those who do take

measurements actually use the standardized tables to look up BP status (Bijlsma et al., 2014). This is

consistent with studies which found that 74% to 87% of pediatric hypertension cases were

undiagnosed before adulthood, even when the family history included hypertension (Bijlsma et al.,

2014; Brady et al., 2010; Hansen et al., 2007).

The risk of undiagnosed and untreated hypertension is higher for low-income, immigrant,

and minority youth, who typically have both limited preventive health care and more psychosocial

and environmental stressors (Gundersen, Mahatmya, Garasky, & Lohman, 2011; Robl et al., 2013).

Estimated prevalence of pediatric pre-hypertension is 4% to 15% and estimated prevalence of

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hypertension is 2% to 5% (McNiece et al., 2007; Sorof, Lai, Turner, Poffenbarger, & Portman,

2004), but these rates are for all ages, sexes, races and ethnicities, and do not account for differences

in socioeconomic status or other psychosocial risk factors. Specific prevalence rates for low-income

pediatric populations and separate rates for pre-teens and adolescents cannot be estimated with any

degree of confidence, however, some data specific to adolescents in North Carolina is available.

Analysis of nurse-measured height, weight, and BP for 573 adolescents (average age: 15.0

years) from a clinic serving low-income, ethnically diverse families in Guilford County, NC, found

that only 56.9% of adolescents had normal BP, while 25.7% had pre-hypertension and 17.5% had

hypertension. There were significant differences in BP between girls (n = 267) and boys (n = 306):

65.9% of girls had normal BP, 21.7% had pre-hypertension, and 12.3% had hypertension, but

among the boys, only 49.0% had normal BP, while 29.1% had pre-hypertension and 21.9% had

hypertension. Of note, BP status was not driven by weight: based on BMI percentiles, 59.5% of

adolescents were normal weight, 18.3% were overweight, and 22.2% were obese, with virtually

identical percentages of girls and boys in each weight category (Ewald, Bond, & Haldeman, 2017).

NC Medicaid Managed Care Can Save Money By Diagnosing Pediatric Hypertension

Early diagnosis and treatment of pediatric hypertension is both realistic and achievable, and

is particularly timely and relevant as NC transitions to a Medicaid Managed Care format. Early

diagnosis and treatment can prevent or limit development of hypertension-associated cardiovascular

and other chronic diseases, which would save money by reducing NC Medicaid long-term treatment

costs. Early diagnosis and treatment would be easy to implement and should have economic benefits

for PHPs because reducing pediatric hypertension will help with controlling high blood pressure in

Medicaid beneficiaries aged 18 to 85, which is one of the priority quality performance measures that

will be used to evaluate PHP’s performance and improvement (North Carolina Department of

Health and Human Services, 2018, p. 19). For Medicaid recipients, early diagnosis and treatment

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would have both immediate and long-term health benefits, improve their overall quality of life, and

lessen the lifelong financial burden faced by those with chronic diseases.

How to Approach Pediatric Hypertension Screening?

Option 1: Maintain the Status Quo and Make No Changes to Quality Measures

This option assumes that all Medicaid pediatricians are following the guidelines for pediatric

BP screening at every well-child visit, including using the standardized tables to look up measured

BP values, and therefore does not make any changes to NC Medicaid, PHP, or provider processes,

quality measures, or reporting requirements. While this option is the simplest and does not require

any additional time or effort on the part of NC Medicaid, PHPs, or providers, in light of the finding

that only 13% to 26% of pediatricians follow existing guidance, it is highly unlikely that all Medicaid

pediatricians are fully compliant. Given that none of the 4 existing quality measures that track

pediatric visits specifically measure compliance with pediatric BP screening guidelines (numbers 34,

38, 39, and 40 on pp. 24-25; North Carolina Department of Health and Human Services, 2018),

there is no incentive to comply, so this option will most likely ensure the status quo: Medicaid

pediatric patients will continue to have undiagnosed and untreated hypertension, greater risk for

chronic diseases and higher medical costs in adulthood, and a lifetime of financial burdens.

Option 2: Gather 3 Years of Data Before Deciding About Changes to Quality Measures

This option asks PHPs and providers, beginning in 2020, to follow existing guidelines for

measuring and documenting pediatric BP at every well-child visit, including using the standardized

tables to look up measured BP values (which is considered standard of care), and to report their

findings for three years to NC Medicaid, but it does not make any immediate changes to PHP or

provider quality measures and does not penalize them for non-compliance. Assuming adequate

voluntary compliance, this option allows NC Medicaid to do two things: establish baseline

prevalence and incidence rates for pediatric hypertension in low-income NC youth, which currently

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do not exist, and determine whether rates are high enough that there is a need to include a new

quality measure that would tie financial compensation to compliance with pediatric BP screening,

including documentation of assessment and any needed treatment. If added later, a BP-specific

quality measure would ensure that Medicaid pediatric patients with hypertension continue to get

early diagnosis and treatment, and that PHPs and providers who continue to comply with pediatric

screening guidelines receive financial compensation for their efforts.

Option 3: Require Pediatric Hypertension Screening and Add a New Quality Measure

This option, which assumes that most Medicaid pediatricians are not following the guidelines

for pediatric BP screening at every well-child visit, requires PHPs and providers to begin following

the guidelines for measuring and documenting BP in 2020 and adds a BP-specific quality measure to

ensure that PHPs and providers receive financial compensation for their time and efforts. Assuming

that prevalence rates for pediatric hypertension are higher in low-income Medicaid patients than the

national rates would suggest, this option requires PHPs and providers to report their findings to NC

Medicaid, and requires NC Medicaid to establish baseline pediatric hypertension prevalence and

incidence rates as well as benchmarks and target rates for future performance. While this option

requires additional time and effort initially on the part of NC Medicaid, PHPs, and providers,

consistently early diagnosis and treatment of pediatric hypertension will generate long-term savings

for NC Medicaid, provide financial compensation to PHPs and providers for achieving quality

measures, and reduce the lifelong health consequences and associated financial burden typically

faced by patients with undiagnosed and untreated pediatric hypertension.

Recommendation

The third option is the best overall, because it unambiguously supports early diagnosis of

pediatric hypertension, and is the only one that puts the needs of pediatric patients first. Early and

accurate diagnosis and treatment—or the lack thereof—will have the greatest impact on children’s

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lives, and therefore must take priority over any short-term inconvenience. For PHPs and providers

who are already in compliance, the only impacts will be the reporting requirement and the quality

measure compensation, and for those not in compliance now, any temporary inconvenience will be

offset by improved metrics for patient care and health outcomes, as well as compensation.

Regular and repeated BP measurement is even more important than BMI screening, because

hypertension can occur with no obvious outer symptoms and BP status cannot be judged simply by

looking at a child. Standardized tables for BP status already exist, and NC Medicaid should put the

tables online and require providers’ use. Use of the BP tables should be a criterion for the new BP

quality measure, just as assessment of BMI percentile is a component of the existing BMI quality

measure (number 3 on p. 15; North Carolina Department of Health and Human Services, 2018).

Governor Cooper needs to direct the NC Department of Health and Human Services to

make early diagnosis and treatment of pediatric hypertension a priority and to make compliance with

BP screening guidelines mandatory for all NC Medicaid PHPs and providers. The NC Department

of Health and Human Services needs to create a new quality measure to evaluate whether BP status

is assessed and documented by PHPs or providers during the measurement year, and develop the

baseline, benchmark, and target criteria to determine if a PHP or provider is achieving necessary

improvements in patient health outcomes over time. The children most at risk of undiagnosed

pediatric hypertension due to low income are those most likely to be served by the NC Medicaid

program. Early diagnosis and treatment of pediatric hypertension is entirely within the scope of the

new NC Medicaid managed care program, if the political will exists to ensure compliance.

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References

Bijlsma, M. W., Blufpand, H. N., Kaspers, G. J., & Bokenkamp, A. (2014). Why pediatricians fail to

diagnose hypertension: A multicenter survey. Journal of Pediatrics, 164(1), 173-177.

Brady, T. M., Solomon, B. S., Neu, A. M., Siberry, G. K., & Parekh, R. S. (2010). Patient-, provider-,

and clinic-level predictors of unrecognized elevated blood pressure in children. Pediatrics,

125(6), e1286-e1293.

Ewald, D. R., Bond, S. H., & Haldeman, L. A. (2017). Hypertension in low-income adolescents.

Global Pediatric Health, 4, 2333794X17741819. doi:10.1177/2333794x17741819

Gundersen, C., Mahatmya, D., Garasky, S., & Lohman, B. (2011). Linking psychosocial stressors and

childhood obesity. Obesity Review, 12(5), e54-e63.

Hansen, M. L., Gunn, P. W., & Kaelber, D. C. (2007). Underdiagnosis of hypertension in children

and adolescents. Journal of the American Medical Association, 298(8), 874-879.

Lauer, R. M., & Clarke, W. R. (1989). Childhood risk factors for high adult blood pressure: The

Muscatine study. Pediatrics, 84(4), 633-641.

Lurbe, E., Cifkova, R., Cruickshank, J. K., Dillon, M. J., Ferreira, I., Invitti, C., . . . Zanchetti, A.

(2009). Management of high blood pressure in children and adolescents: Recommendations

of the European Society of Hypertension. Jorunal of Hypertension, 27(9), 1719-1742.

McNiece, K. L., Poffenbarger, T. S., Turner, J. L., Franco, K. D., Sorof, J. M., & Portman, R. J.

(2007). Prevalence of hypertension and pre-hypertension among adolescents. Pediatrics,

150(6), 640-644.e641.

National High Blood Pressure Education Program Working Group on High Blood Pressure in

Children and Adolescents. (2004). The fourth report on the diagnosis, evaluation, and

treatment of high blood pressure in children and adolescents. Pediatrics, 114(2), 555-576.

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North Carolina Department of Health and Human Services. (2018). Medicaid managed care

proposed concept paper: Provider health plan quality performance and accountability (pp. 1-31).

Ogden, C. L., Kuczmarski, R. J., Flegal, K. M., Mei, Z., Guo, S., Wei, R., . . . Johnson, C. L. (2002).

Centers for Disease Control and Prevention 2000 growth charts for the United States:

Improvements to the 1977 National Center for Health Statistics version. Pediatrics, 109(1),

45-60.

Robl, M., de Souza, M., Schiel, R., Gellhaus, I., Zwiauer, K., Holl, R. W., & Wiegand, S. (2013). The

key role of psychosocial risk on therapeutic outcome in obese children and adolescents:

Results from a longitudinal multicenter study. Obesity Facts, 6(3), 297-305.

Sorof, J. M., Lai, D., Turner, J., Poffenbarger, T., & Portman, R. J. (2004). Overweight, ethnicity,

and the prevalence of hypertension in school-aged children. Pediatrics, 113(3), 475-482.

Tu, W., Eckert, G. J., DiMeglio, L. A., Yu, Z., & Jung, J. (2011). Intensified effect of adiposity on

blood pressure in overweight and obese children. Hypertension, 58(5), 818-824.

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