Development of a Hypertension Electronic Phenotype for Chronic Disease Surveillance in Electronic Health Records: Key Analytic Decisions and Their Effects

Abstract

Introduction: Modernizing chronic disease surveillance with electronic health record (EHR) data may provide better data to improve hypertension prevention and control, but no consensus exists for an EHR-based surveillance definition for hypertension. The Multi-State EHR-Based Network for Disease Surveillance (MENDS) pilot surveillance system was used to develop and test an electronic phenotype for hypertension.

Methods: We used MENDS data from 1,671,279 patients in Louisiana to examine the effect of different analytic decisions on estimates of hypertension prevalence. Decisions included 1) whether to restrict surveillance to patients with recent blood pressure measurements, 2) varying the number and recency of encounters to define the population at risk of hypertension, 3) how to define hypertension (diagnosis codes, antihypertensive medication, blood pressure measurements, or combinations of these), and 4) how to handle multiple blood pressure measurements on the same day. Results were compared with independent estimates of hypertension prevalence in Louisiana from the Behavioral Risk Factor Surveillance System (BRFSS).

Results: Applying varying criteria resulted in hypertension prevalence estimates ranging from 19.7% to 59.3%. A hypertension surveillance strategy that includes a population with at least 1 clinical encounter with measured blood pressure in the previous 2 years and identifies hypertension using all available data (≥1 diagnosis code, ≥1 antihypertensive medication, and ≥2 elevated blood pressure values ≥140/90 mm Hg on separate days) generated estimates in line with population-based survey data. This definition estimated the crude 2019 hypertension prevalence in the state of Louisiana as 43.4% (age-adjusted, 41.0%), comparable with the crude BRFSS estimate of 39.7% (age adjusted, 37.1%).

Conclusion: Applying different criteria to define hypertension using EHR data has a large effect on hypertension prevalence estimates. The proposed electronic phenotype generates hypertension prevalence estimates that align with independent estimates from BRFSS.

Figure

Contribution of 3 criteria for hypertension case definition to an estimated overall hypertension prevalence of 43.4% in Louisiana, 2019. The denominator for estimating prevalence was the population of patients with ≥1 blood pressure measurement in 2018 or 2019 and 3 criteria for hypertension case identification (a combination of ≥1 diagnosis code, 2 elevated blood pressures, and antihypertensive medication). Data source: Research Action for Health Network (REACHnet) (17), operated by the Louisiana Public Health Institute, 1 of the 5 data contributors participating in the Multi-State EHR-Based Network for Disease Surveillance (MENDS) pilot chronic disease surveillance system (11).