title: Underlying Rationale and Approach to Treat Hypertension in Adolescents by Physicians of Different Specialty.
abstract: OBJECTIVE
  To describe the underlying clinical decision-making rationale among general pediatricians, family physicians, pediatric cardiologists and pediatric nephrologists in their approach to an adolescent with hypertension.
  
  
  METHODS
  We conducted semi-structured phone interviews with a convenience sample of physicians from the above-mentioned 4 specialties. Each participant was asked to "think aloud" regarding their approach to a hypothetical patient - 12 year old boy with persistent hypertension for 6 months. Standardized open-ended questions about potential factors that could affect physicians' diagnosis and treatment strategies (e.g., patient age) were used. Interviews were audio-recorded; transcribed verbatim; transcripts were independently coded by 2 investigators; emergent themes identified and inter-coder agreement achieved. Thematic analysis was performed based on grounded theory.
  
  
  RESULTS
  Nineteen participants included 5 general pediatricians, 5 pediatric cardiologists, 5 pediatric nephrologists and 4 family physicians. Five themes emerged: 1) Accuracy of blood pressure measurement and hypertension diagnosis, 2) Shift in the epidemiology of pediatric hypertension from secondary to primary hypertension, 3) Patient characteristics considered in the decision to initiate workup, 4) Obesity-centered choice of diagnostic tests and lifestyle modifications, and 5) Variable threshold for initiating antihypertensive pharmacotherapy vs. referral to hypertension specialists.
  
  
  CONCLUSIONS
  There is variation across primary care and specialty physicians who provide care for children and adolescents with hypertension. Key areas of variability include the willingness to initiate antihypertensive medications, the use of diagnostic tests (e.g., ambulatory blood pressure monitoring), and the perceived need for specialty referral. Further study is needed to assess whether different treatment paradigms result in differential patient outcomes.
authors.affiliation: Division of General Pediatrics, Child Health Evaluation and Research (CHEAR) Unit, University of Michigan, USA.
authors.forename: Esther Y
authors.initials: EY
authors.lastname: Yoon
authors.affiliation: Division of General Pediatrics, Child Health Evaluation and Research (CHEAR) Unit, University of Michigan, USA ; Wayne State University School of Medicine, USA.
authors.forename: Julie S
authors.initials: JS
authors.lastname: Weber
authors.affiliation: Division of General Pediatrics, Child Health Evaluation and Research (CHEAR) Unit, University of Michigan, USA.
authors.forename: Brigitte
authors.initials: B
authors.lastname: McCool
authors.affiliation: Division of Pediatric Cardiology, University of Michigan, USA.
authors.forename: Albert
authors.initials: A
authors.lastname: Rocchini
authors.affiliation: Division of Pediatric Nephrology, University of Michigan, USA.
authors.forename: David
authors.initials: D
authors.lastname: Kershaw
authors.affiliation: Division of General Pediatrics, Child Health Evaluation and Research (CHEAR) Unit, University of Michigan, USA.
authors.forename: Gary
authors.initials: G
authors.lastname: Freed
authors.affiliation: School of Pharmacy, University of Michigan, USA.
authors.forename: Frank
authors.initials: F
authors.lastname: Ascione
authors.affiliation: Division of General Pediatrics, Child Health Evaluation and Research (CHEAR) Unit, University of Michigan, USA.
authors.forename: Sarah
authors.initials: S
authors.lastname: Clark
keywords: Adolescents; Clinical decision-making; Hypertension; Hypertension specialists; Primary care physicians; Specialty differences