The Improving Renal Outcomes Collaborative: Blood Pressure Measurement in Transplant Recipients

Abstract

Background and objectives: Hypertension is highly prevalent in pediatric kidney transplant recipients and contributes to cardiovascular death and graft loss. Improper blood pressure (BP) measurement limits the ability to control hypertension in this population. Here, we report multicenter efforts from the Improving Renal Outcomes Collaborative (IROC) to standardize and improve appropriate BP measurement in transplant patients.

Methods: Seventeen centers participated in structured quality improvement activities facilitated by IROC, including formal training in quality improvement methods. The primary outcome measure was the proportion of transplant clinic visits with appropriate BP measurement according to published guidelines. Prospective data were analyzed over a 12-week pre-intervention period and a 20-week active intervention period for each center and then aggregated as of the program-specific start date. We used control charts to quantify improvements across IROC centers. We applied thematic analysis to identify patterns and common themes of successful interventions.

Results: We analyzed data from 5392 clinic visits. At baseline, BP was measured and documented appropriately at 11% of visits. Center-specific interventions for improving BP measurement included educating clinic staff, assigning specific team member roles, and creating BP tracking tools and alerts. Appropriate BP measurement improved throughout the 20-week active intervention period to 78% of visits.

Conclusions: We standardized appropriate BP measurement across 17 pediatric transplant centers using the infrastructure of the IROC learning health system and substantially improved the rate of appropriate measurement over 20 weeks. Accurate BP assessment will allow further interventions to reduce complications of hypertension in pediatric kidney transplant recipients.

FIGURE 1

The IROC learning health system. Pins represent locations of IROC member centers as of March 2019; the dark blue pins identify centers that contributed data for this study. The star identifies Cincinnati Children’s Hospital Medical Center as the coordinating center for IROC. The table details the location and number of visits contributed by each center. AL, Alabama; AZ, Arizona; CA, California; CO, Colorado; GA, Georgia; IA, Iowa; IL, Illinois; IN, Indiana; IU, Indiana University; MD, Maryland; MI, Michigan; MN, Minnesota; MO, Missouri; NY, New York; PA, Pennsylvania; UAB, The University of Alabama at Birmingham; UCLA, University of California, Los Angeles; WA, Washington.

FIGURE 2

Standardized BP measurement protocol for outpatient clinic. A, Measurement. B, Treatment. Option 1 included an oscillometric screening that was confirmed by using a manual reading if uncontrolled (>90th percentile for age and/or height via the fourth report). Option 2 used universal manual readings to classify BP. Uncontrolled BP triggered a treatment pathway developed at each center.

FIGURE 3

Control chart (p-chart) of appropriate BP measurement across 17 centers. A, Baseline period. B, Active intervention period. Mean BP was measured appropriately at an average of 11% of clinic visits at baseline. During the active intervention period, totaling 20 weeks after interventions were deployed, the mean rate of appropriate BP measurement increased to 78% of visits. Toward the end of the active intervention, there was special-cause variation noted on the control chart. The special-cause signal was 4 out of 5 successive points >1 σ from the mean on the same side of the centerline.

FIGURE 4

SPC chart (p-chart) illustrating subgroup analysis for the percentage of clinic visits with appropriate BP measurement. A, Baseline period for all centers. B, Active intervention for low-volume centers. C, Active intervention for medium-volume centers. D, Active intervention for high-volume centers. Data from all centers were grouped together for the 12-week baseline period. Results during the 20-week active intervention are compared between low-, medium-, and high-volume centers.

FIGURE 5

SPC chart illustrating subgroup analysis for the percentage of visits with appropriate BP measurement. A, Baseline period for all centers. B, Active intervention with general QIF version. C, Active intervention with IROC-specific QIF version. Data from all centers were grouped for the 12-week baseline period. Results during the 20-week active intervention were compared between centers completing general (n = 11) versus IROC-specific (n = 6) versions of the QIF course.

FIGURE 6

Thematic analysis of center-specific interventions to increase appropriate BP measurement (small boxes) yielded 4 interrelated latent themes for success: achieving buy-in from stakeholders, optimizing clinic workflow and efficiency, adequately equipping clinic, and training staff in appropriate BP measurement. Italic font denotes bridging themes. ^a High-consensus themes. MD, medical doctor.

FIGURE 7

Practice pattern modification was reinforced and perpetuated via teaching and learning cycles between sites and their assigned small groups and between sites and the IROC network. A Web-based clinical data registry now also provides real-time benchmarking data for each site.