{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,3]],"date-time":"2026-05-03T01:38:49Z","timestamp":1777772329022,"version":"3.51.4"},"reference-count":37,"publisher":"Oxford University Press (OUP)","issue":"5","license":[{"start":{"date-parts":[[2026,3,17]],"date-time":"2026-03-17T00:00:00Z","timestamp":1773705600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"funder":[{"DOI":"10.13039\/100000133","name":"Agency for Healthcare Research and Quality","doi-asserted-by":"publisher","award":["R18HS027402"],"award-info":[{"award-number":["R18HS027402"]}],"id":[{"id":"10.13039\/100000133","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,5,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>Elevated blood pressure (BP) and hypertension are often overlooked in pediatric care. We adapted a pediatric hypertension clinical decision support (CDS) for a primarily rural health system and compared CDS impact across varied implementation approaches.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>In this cluster randomized trial, 40 primary care clinics were randomized 1:1:1 to CDS with high-intensity implementation, CDS with low-intensity implementation, or usual care (UC). Low-intensity implementation was limited to online training. High-intensity CDS implementation included in-person and online training, monthly check-ins and feedback regarding CDS use. Patients 6-17 years with BP measured at a primary care visit from August 1, 2022 to January 31, 2024 were eligible. Outcomes were remeasurement of elevated BP during a visit and recognition of hypertension within 6 months of meeting criteria. Analyses adjusted for clustered study design and patient characteristics.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Of 9155 patients with an elevated BP, remeasurement during the visit occurred for 51.5% at high-intensity, 23.6% at low-intensity, and 6.2% at UC clinics. Among 578 patients with incident hypertension, recognition was 42.8% at high-intensity, 24.5% at low-intensity and 14.4% at UC clinics. Patients attending high or low-intensity CDS clinics were more likely than those at UC to have elevated BP remeasured (adjusted odds ratio [aOR] 8.70; 95% CI 5.68-13.3) and to have their hypertension clinically recognized (aOR 2.94; 1.00-8.60). High-intensity implementation was more effective than low-intensity implementation for repeat BP measurement (aOR 3.45; 1.88-6.33) and hypertension recognition (aOR 2.31; 1.08-4.98).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>CDS improved pediatric BP care in a primarily rural health system while effectiveness varied by implementation approach.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/jamia\/ocag031","type":"journal-article","created":{"date-parts":[[2026,2,24]],"date-time":"2026-02-24T12:36:57Z","timestamp":1771936617000},"page":"1000-1008","source":"Crossref","is-referenced-by-count":0,"title":["Implementation of a clinical decision support tool for hypertension in a rural health system"],"prefix":"10.1093","volume":"33","author":[{"given":"Elyse O","family":"Kharbanda","sequence":"first","affiliation":[{"name":"HealthPartners Institute , Minneapolis, MN 55440,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stephen E","family":"Asche","sequence":"additional","affiliation":[{"name":"HealthPartners Institute , Minneapolis, MN 55440,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0775-8255","authenticated-orcid":false,"given":"Inih","family":"Essien","sequence":"additional","affiliation":[{"name":"HealthPartners Institute , Minneapolis, MN 55440,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Clayton I","family":"Allen","sequence":"additional","affiliation":[{"name":"Essentia Health , Duluth, MN 55805,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Laura A","family":"Freitag","sequence":"additional","affiliation":[{"name":"Essentia Institute for Rural Health , Duluth, MN 55805,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Heidi L","family":"Ekstrom","sequence":"additional","affiliation":[{"name":"HealthPartners Institute , Minneapolis, MN 55440,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kay A","family":"Kromrey","sequence":"additional","affiliation":[{"name":"HealthPartners Institute , Minneapolis, MN 55440,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Abhilash","family":"Muthineni","sequence":"additional","affiliation":[{"name":"HealthPartners Institute , Minneapolis, MN 55440,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Daniel M","family":"Saman","sequence":"additional","affiliation":[{"name":"Consultant , Lexington, KY 40513,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Vijayakumar","family":"Thirumalai","sequence":"additional","affiliation":[{"name":"HealthPartners Institute , Minneapolis, MN 55440,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Patrick J","family":"O\u2019Connor","sequence":"additional","affiliation":[{"name":"HealthPartners Institute , Minneapolis, MN 55440,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Catherine P","family":"Benziger","sequence":"additional","affiliation":[{"name":"Essentia Health , Duluth, MN 55805,","place":["United States"]},{"name":"University of Minnesota Medical School, Duluth Campus , Duluth, MN 55812,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2026,3,17]]},"reference":[{"key":"2026042913024662300_ocag031-B1","doi-asserted-by":"crossref","first-page":"531","DOI":"10.1161\/HYPERTENSIONAHA.117.09444","article-title":"Influence of child and adult elevated blood pressure on adult arterial stiffness: the cardiovascular risk in Young Finns Study","volume":"70","author":"Aatola","year":"2017","journal-title":"Hypertension"},{"key":"2026042913024662300_ocag031-B2","doi-asserted-by":"crossref","first-page":"1877","DOI":"10.1056\/NEJMoa2109191","article-title":"Childhood cardiovascular risk factors and adult cardiovascular events","volume":"386","author":"Jacobs","year":"2022","journal-title":"N Engl J Med"},{"key":"2026042913024662300_ocag031-B3","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1161\/CIRCULATIONAHA.113.001614","article-title":"Combined effects of child and adult elevated blood pressure on subclinical atherosclerosis: the International Childhood Cardiovascular Cohort Consortium","volume":"128","author":"Juhola","year":"2013","journal-title":"Circulation"},{"key":"2026042913024662300_ocag031-B4","doi-asserted-by":"crossref","first-page":"1766","DOI":"10.1097\/HJH.0b013e32832e8cfa","article-title":"Relation of blood pressure and body mass index during childhood to cardiovascular risk factor levels in young adults","volume":"27","author":"Rademacher","year":"2009","journal-title":"J Hypertens"},{"key":"2026042913024662300_ocag031-B5","doi-asserted-by":"crossref","first-page":"d643","DOI":"10.1136\/bmj.d643","article-title":"Association of blood pressure in late adolescence with subsequent mortality: cohort study of Swedish male conscripts","volume":"342","author":"Sundstrom","year":"2011","journal-title":"BMJ"},{"key":"2026042913024662300_ocag031-B6","doi-asserted-by":"crossref","first-page":"1774","DOI":"10.1001\/jama.2018.13551","article-title":"Association of blood pressure classification in young adults using the 2017 American College of Cardiology\/American Heart Association Blood Pressure guideline with cardiovascular events later in life","volume":"320","author":"Yano","year":"2018","journal-title":"JAMA"},{"key":"2026042913024662300_ocag031-B7","doi-asserted-by":"crossref","first-page":"1224","DOI":"10.1161\/HYPERTENSIONAHA.118.12334","article-title":"Relation of blood pressure in childhood to self-reported hypertension in adulthood","volume":"73","author":"Urbina","year":"2019","journal-title":"Hypertension"},{"key":"2026042913024662300_ocag031-B8","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1542\/peds.2017-1904","article-title":"Clinical practice guideline for screening and management of high blood pressure in children and adolescents","volume":"140","author":"Flynn","year":"2017","journal-title":"Pediatrics"},{"key":"2026042913024662300_ocag031-B9","doi-asserted-by":"crossref","first-page":"e415","DOI":"10.1542\/peds.2012-1292","article-title":"Prehypertension and hypertension in community-based pediatric practice","volume":"131","author":"Lo","year":"2013","journal-title":"Pediatrics"},{"key":"2026042913024662300_ocag031-B10","doi-asserted-by":"crossref","first-page":"784","DOI":"10.1111\/jch.12173","article-title":"The prevalence of primary pediatric prehypertension and hypertension in a real-world managed care system","volume":"15","author":"Koebnick","year":"2013","journal-title":"J Clin Hypertens (Greenwich)"},{"key":"2026042913024662300_ocag031-B11","doi-asserted-by":"crossref","first-page":"e20151662","DOI":"10.1542\/peds.2015-1662","article-title":"Change in weight status and development of hypertension","volume":"137","author":"Parker","year":"2016","journal-title":"Pediatrics"},{"key":"2026042913024662300_ocag031-B12","doi-asserted-by":"crossref","first-page":"E271","DOI":"10.1002\/oby.20080","article-title":"Longitudinal associations between BMI, waist circumference, and cardiometabolic risk in US youth: monitoring implications","volume":"21","author":"Jago","year":"2013","journal-title":"Obesity (Silver Spring)"},{"key":"2026042913024662300_ocag031-B13","doi-asserted-by":"crossref","first-page":"818","DOI":"10.1161\/HYPERTENSIONAHA.111.175695","article-title":"Intensified effect of adiposity on blood pressure in overweight and obese children","volume":"58","author":"Tu","year":"2011","journal-title":"Hypertension"},{"key":"2026042913024662300_ocag031-B14","doi-asserted-by":"crossref","first-page":"874","DOI":"10.1001\/jama.298.8.874","article-title":"Underdiagnosis of hypertension in children and adolescents","volume":"298","author":"Hansen","year":"2007","journal-title":"JAMA"},{"key":"2026042913024662300_ocag031-B15","doi-asserted-by":"crossref","DOI":"10.1542\/peds.2016-2195","article-title":"Diagnosis and medication treatment of pediatric hypertension: a retrospective cohort study","volume":"138","author":"Kaelber","year":"2016","journal-title":"Pediatrics"},{"key":"2026042913024662300_ocag031-B16","doi-asserted-by":"crossref","DOI":"10.1542\/peds.2017-2954","article-title":"Clinical decision support for recognition and management of hypertension: a randomized trial","volume":"141","author":"Kharbanda","year":"2018","journal-title":"Pediatrics"},{"key":"2026042913024662300_ocag031-B17","first-page":"1142","article-title":"TeenBP: development and piloting of an EHR-linked clinical decision support system to improve recognition of hypertension in adolescents","volume":"3","author":"Kharbanda","year":"2015","journal-title":"EGEMS (Wash DC)"},{"key":"2026042913024662300_ocag031-B18","doi-asserted-by":"crossref","first-page":"107293","DOI":"10.1016\/j.cct.2023.107293","article-title":"Adapting a clinical decision support system to improve identification of pediatric hypertension in a rural health system: design of a pragmatic trial","volume":"132","author":"Benziger","year":"2023","journal-title":"Contemp Clin Trials"},{"key":"2026042913024662300_ocag031-B19"},{"key":"2026042913024662300_ocag031-B20","doi-asserted-by":"crossref","first-page":"E12","DOI":"10.5888\/pcd16.180528","article-title":"Estimated change in prevalence and trends of childhood blood pressure levels in the United States after application of the 2017 AAP guideline","volume":"16","author":"Al Kibria","year":"2019","journal-title":"Prev Chronic Dis"},{"key":"2026042913024662300_ocag031-B21","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1016\/j.acap.2017.07.004","article-title":"Evaluation of an electronic clinical decision support tool for incident elevated BP in adolescents","volume":"18","author":"Kharbanda","year":"2018","journal-title":"Acad Pediatr"},{"key":"2026042913024662300_ocag031-B22","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1542\/peds.2010-0150","article-title":"Geographic maldistribution of primary care for children","volume":"127","author":"Shipman","year":"2011","journal-title":"Pediatrics"},{"key":"2026042913024662300_ocag031-B23","doi-asserted-by":"crossref","first-page":"200","DOI":"10.1111\/jrh.12769","article-title":"Rural-urban differences in access to care among children and adolescents in the United States","volume":"40","author":"Crouch","year":"2024","journal-title":"J Rural Health"},{"key":"2026042913024662300_ocag031-B24","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1016\/j.jacc.2024.09.1215","article-title":"Rural-urban differences in cardiovascular mortality in the United States, 2010-2022","volume":"85","author":"Marinacci","year":"2025","journal-title":"J Am Coll Cardiol"},{"key":"2026042913024662300_ocag031-B25","doi-asserted-by":"crossref","first-page":"233","DOI":"10.1089\/chi.2014.0085","article-title":"Urban-rural differences in childhood and adolescent obesity in the United States: a systematic review and meta-analysis","volume":"11","author":"Johnson","year":"2015","journal-title":"Child Obes"},{"key":"2026042913024662300_ocag031-B26","doi-asserted-by":"crossref","first-page":"E92","DOI":"10.5888\/pcd20.230136","article-title":"Rural-urban differences in overweight and obesity, physical activity, and food security among children and adolescents","volume":"20","author":"Crouch","year":"2023","journal-title":"Prev Chronic Dis"},{"key":"2026042913024662300_ocag031-B27","doi-asserted-by":"crossref","first-page":"2410","DOI":"10.1001\/jama.2018.5158","article-title":"Differences in obesity prevalence by demographics and urbanization in US children and adolescents, 2013-2016","volume":"319","author":"Ogden","year":"2018","journal-title":"JAMA"},{"key":"2026042913024662300_ocag031-B28","doi-asserted-by":"crossref","first-page":"E216","DOI":"10.1503\/cmaj.090578","article-title":"Effect of point-of-care computer reminders on physician behaviour: a systematic review","volume":"182","author":"Shojania","year":"2010","journal-title":"CMAJ"},{"key":"2026042913024662300_ocag031-B29","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1186\/s13012-015-0209-1","article-title":"A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project","volume":"10","author":"Powell","year":"2015","journal-title":"Implement Sci"},{"key":"2026042913024662300_ocag031-B30","doi-asserted-by":"crossref","first-page":"259","DOI":"10.1007\/s11906-024-01298-0","article-title":"Screening and management of pediatric high blood pressure-challenges to implementing the clinical practice guideline","volume":"26","author":"Hanevold","year":"2024","journal-title":"Curr Hypertens Rep"},{"key":"2026042913024662300_ocag031-B31","doi-asserted-by":"crossref","first-page":"2501","DOI":"10.1161\/HYPERTENSIONAHA.124.23532","article-title":"Pediatric high blood pressure recognition associated with electronic decision support: a cohort analysis","volume":"81","author":"Zachariah","year":"2024","journal-title":"Hypertension"},{"key":"2026042913024662300_ocag031-B32","doi-asserted-by":"crossref","first-page":"e237043","DOI":"10.1001\/jamanetworkopen.2023.7043","article-title":"Adherence to the 2017 clinical practice guidelines for pediatric hypertension in safety-net clinics","volume":"6","author":"Carroll","year":"2023","journal-title":"JAMA Netw Open"},{"key":"2026042913024662300_ocag031-B33","doi-asserted-by":"crossref","first-page":"506","DOI":"10.1016\/j.acap.2023.07.006","article-title":"Pediatric high blood pressure follow-up guideline adherence in a Massachusetts Health Care System","volume":"24","author":"Goulding","year":"2024","journal-title":"Acad Pediatr"},{"key":"2026042913024662300_ocag031-B34","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1111\/jch.14148","article-title":"Under-recognition of pediatric hypertension diagnosis: examination of 1 year of visits to community health centers","volume":"23","author":"Moin","year":"2021","journal-title":"J Clin Hypertens (Greenwich)"},{"key":"2026042913024662300_ocag031-B35","doi-asserted-by":"crossref","first-page":"484","DOI":"10.1111\/chd.12469","article-title":"The effect of an electronic health record-based tool on abnormal pediatric blood pressure recognition","volume":"12","author":"Twichell","year":"2017","journal-title":"Congenit Heart Dis"},{"key":"2026042913024662300_ocag031-B36","doi-asserted-by":"crossref","DOI":"10.1542\/peds.2019-3778","article-title":"Persistent hypertension in children and adolescents: a 6-year cohort study","volume":"146","author":"Kaelber","year":"2020","journal-title":"Pediatrics"},{"key":"2026042913024662300_ocag031-B37","doi-asserted-by":"crossref","first-page":"163","DOI":"10.1016\/j.acap.2019.08.010","article-title":"Improving hypertension recognition in adolescents, a small but important first step in cardiovascular disease prevention","volume":"20","author":"Kharbanda","year":"2020","journal-title":"Acad Pediatr"}],"container-title":["Journal of the American Medical Informatics Association"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/jamia\/article-pdf\/33\/5\/1000\/67379739\/ocag031.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/jamia\/article-pdf\/33\/5\/1000\/67379739\/ocag031.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,29]],"date-time":"2026-04-29T17:02:56Z","timestamp":1777482176000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/jamia\/article\/33\/5\/1000\/8526084"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,17]]},"references-count":37,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2026,3,17]]},"published-print":{"date-parts":[[2026,5,1]]}},"URL":"https:\/\/doi.org\/10.1093\/jamia\/ocag031","relation":{},"ISSN":["1067-5027","1527-974X"],"issn-type":[{"value":"1067-5027","type":"print"},{"value":"1527-974X","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,5]]},"published":{"date-parts":[[2026,3,17]]}}}