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Underdiagnosis of Hypertension in Children and

Adolescents
Matthew L. Hansen; Paul W. Gunn; David C. Kaelber
Online article and related content
current as of January 17, 2009.

JAMA. 2007;298(8):874-879 (doi:10.1001/jama.298.8.874)


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Diagnosing Hypertension in Children and Adolescents


Johan M. van Schalkwyk et al. JAMA. 2008;299(2):168.

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ORIGINAL CONTRIBUTION

Underdiagnosis of Hypertension in Children


and Adolescents
Matthew L. Hansen, MD
Paul W. Gunn, BS
David C. Kaelber, MD, PhD

Context Pediatric hypertension is increasing in prevalence with the pediatric obesity


epidemic. Diagnosis of hypertension in children is complicated because normal and
abnormal blood pressure values vary with age, sex, and height and are therefore difficult to remember.

Objectives To determine the frequency of undiagnosed hypertension and prehypertension and to identify patient factors associated with this underdiagnosis.

YPERTENSION, WITH AN ESTI-

mated prevalence of
between 2% and 5%,1,2 is a
common chronic disease in
children. Pediatric hypertension may
be secondary to another disease process or it may be essential hypertension. Secondary hypertension is more
common in children than in adults,
and common causes of hypertension
in children include renal disease,
coarctation of the aorta, and endocrine
disease.3 However, as with adults, the
majority of children and adolescents
with mild to moderate hypertension
have primary hypertension in which a
cause is not identifiable. Hypertension
in children has been shown to correlate with family history of hypertension, low birth weight, and excess
weight.2,4,5 With the increasing prevalence of childhood weight problems,6,7
increased attention to weight-related
health conditions including hypertension is warranted. 8 Several lines of
evidence suggest that blood pressure
in US children and adolescents is
increasing in parallel with weight.9-11
Although long-term sequelae such as
myocardial infarction, heart failure,
stroke, and kidney disease rarely
manifest in children, hypertension
during childhood has been shown to
be an independent risk factor for
hypertension in adulthood, and to be
associated with early markers of cardiovascular disease, including left ventricular hypertrophy, intima-media
thickness, arterial compliance, atherosclerosis, and diastolic dysfunction.12-19

Design, Setting, and Participants A cohort study of 14 187 children and adolescents aged 3 to 18 years who were observed at least 3 times for well-child care between
June 1999 and September 2006 in the outpatient clinics in a large academic urban medical system in northeast Ohio. For children and adolescents who met criteria for hypertension or prehypertension at 3 or more well-child care visits, the proportion with a hypertension-related International Classification of Diseases, Ninth Revision code in the
diagnoses list, problem list, or past medical history list of any visit was determined.
Main Outcome Measures Proportion of children and adolescents with 3 or more
elevated age-adjusted and height-adjusted blood pressure measurements at wellchild care visits and with a diagnosis of hypertension or prehypertension documented
in the electronic medical record. Multivariate logistic regression identified patient factors associated with a correct diagnosis.
Results Of 507 children and adolescents (3.6%) who had hypertension, 131 (26%)
had a diagnosis of hypertension or elevated blood pressure documented in the electronic
medical record. Patient factors that increased the adjusted odds of a correct diagnosis
were a 1-year increase in age over age 3 (odds ratio [OR], 1.09; 95% confidence interval
[CI], 1.03-1.16), number of elevated blood pressure readings beyond 3 (OR, 1.77; 95%
CI, 1.21-2.57), increase of 1% in height-for-age percentile (OR, 1.02; 95% CI, 1.011.03), having an obesity-related diagnosis (OR, 2.61; 95% CI, 1.49-4.55), and number
of blood pressure readings in the stage 2 hypertension range (OR, 1.68; 95% CI, 1.292.19). Of 485 children and adolescents (3.4%) who had prehypertension, 55 (11%) had
an appropriate diagnosis documented in the electronic medical record. Patient factors that
increased the adjusted odds of being diagnosed with prehypertension included a 1-year
increase in age over age 3 (OR, 1.21; 95% CI, 1.09-1.34) and number of elevated blood
pressure readings beyond 3 (OR, 3.07; 95% CI, 2.20-4.28).
Conclusions Hypertension and prehypertension were frequently undiagnosed in this
pediatric population. Patient age, height, obesity-related diagnoses, and magnitude
and frequency of abnormal blood pressure readings all increased the odds of diagnosis.
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JAMA. 2007;298(8):874-879

Although pediatric clinicians are generally familiar with the possibility of hypertension, recognizing it in their patients is not simple. Consensus
guidelines define hypertension during
childhood as blood pressure that is, on
3 different visits, measured at or higher
than the 95th percentile for age, sex,
and height.20 Prehypertension is defined similarly at 3 or more visits, but

874 JAMA, August 22/29, 2007Vol 298, No. 8 (Reprinted)

Author Affiliations: School of Medicine, Case Western


Reserve University, Cleveland, Ohio (Drs Hansen and
Kaelber and Mr Gunn); Department of Emergency Medicine, Oregon Health and Science University School of
Medicine, Portland (Dr Hansen); and the Departments
of Internal Medicine and Pediatrics, MetroHealth Medical Center, Cleveland, Ohio, and the Center for Information Technology Leadership, Partners Healthcare, and
the Departments of Internal Medicine and Pediatrics,
Harvard Medical School, Boston Childrens Hospital,
Brigham and Womens Hospital, and Massachusetts
General Hospital, Boston, Massachusetts (Dr Kaelber).
Corresponding Author: David C. Kaelber, MD, PhD,
18 Upton St, Cambridge, MA 02139 (dkaelber
@partners.org).

2007 American Medical Association. All rights reserved.

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UNDERDIAGNOSIS OF HYPERTENSION IN CHILDREN

as average blood pressure at or higher


than the 90th percentile for age, sex,
and height, or more than 120/80
mm Hg but less than the 95th percentile.20 Based on these definitions, numerous normal and abnormal cutoffs
exist, which are difficult for pediatric
clinicians to remember. For example,
the 95th blood pressure percentile for
a 15-year-old girl in the 75th percentile for height is 129/84 mm Hg, but the
95th blood pressure percentile for an
8-year-old boy in the 10th percentile for
height is 112/76 mm Hg. Although normal and abnormal blood pressure value
tables and electronic programs exist, it
may be difficult for pediatric clinicians to integrate these tools into their
work flow. Therefore, our hypothesis
is that many children with hypertension or prehypertension are never diagnosed.
Our study was undertaken to determine the frequency of undiagnosed hypertension and prehypertension in 3to 18-year-old children within a large,
academic, urban medical system.
METHODS
Patients

This was a cohort study of all children


and adolescents (N = 14 187) who received at least 3 well-child care visits,
based on CPT (Current Procedural Terminology) codes between June 1999 and
September 2006 at a large tertiary care
health system in northeast Ohio. A child
had to have at least 3 well-child care visits while aged 3 to 18 years to be included in the cohort. The age criteria coincide with the National Heart, Lung,
and Blood Institutes National High
Blood Pressure Education Program
Working Group on High Blood Pressure in Children and Adolescents recommendations for routine blood pressure screening in children.20
Clinicians

The health care system in which this


study was conducted had approximately 600 staff clinicians and 300 resident physicians in training annually during the study period. Pediatric clinicians
included family practitioners, pediatri-

cians (general pediatricians and combined internists and pediatricians), and


a few nurse practitioners. These pediatric clinicians made up about onesixth of the staff and practice in 10 facilities in urban and suburban Cleveland,
Ohio. Our study included patients who
had supervised visits with resident physicians in family practice, general pediatrics, and combined internal medicine and pediatrics training programs,
which made up about one-fifth of the
physicians in training.
Data Collection

The health care system has used an electronic medical record system (EPIC,
Epicare, Epic Systems Corp, Madison,
Wisconsin) in the outpatient clinics
since 1999. All visit information including vital signs, clinician notes, laboratory and imaging test results, all orders (including prescriptions), and all
billing (including diagnoses) are recorded in the electronic medical record. Clinicians can easily view data from
prior visits. No paper records are
maintained.
For our study, we looked at patient
race/ethnicity, age, sex, weight, height,
and blood pressure readings for all
well-child care visits for each participant during the study period. Race/
ethnicity was self-identified by the patient, guardian, or both as part of the
patients routine clinical care and was assessed because of possible differences in
prevalence or underdiagnosis of hypertension based on race. In addition, we
obtained data on visit diagnosis codes,
family history of hypertension codes,
past medical history codes, and problem list codes for each participant from
all visits, not just well-child care visits.
Any well-child care visits without a recorded blood pressure were excluded
(6%). Visits were also excluded if the patients recorded height for the visit was
less than 30.5 cm or more than 213.4 cm
or if the recorded weight was less than
1.5 kg or more than 300 kg. Height and
weight measurements outside of these
parameters were considered to have been
entered in error. This correction eliminated less than 0.1% of the visits, indi-

2007 American Medical Association. All rights reserved.

cating that the data are largely free of


mistakenly entered data.
Blood pressure measurements in the
electronic medical record were recorded during the normal course of
clinical care. Standard nursing blood
pressure measurement protocols were
used. 21 The normal procedure included intake blood pressure taken by
a nurse or medically trained assistant
using an automatic, appropriately sized
blood pressure cuff. These values were
compared with a table of normal blood
pressure values. Abnormal blood pressure readings were repeated by the
nurse or medically trained assistant with
a manual blood pressure cuff, with continued abnormal readings to be brought
to the attention of the pediatric clinician. A full range of automatic and
manual blood pressure cuff sizes were
available to the nurse or medically
trained assistants for the initial blood
pressure measurements and to the pediatric clinicians to confirm those measurements. Medically trained assistants, nurses, and clinicians were to
input the most accurate blood pressure into the electronic medical record. We had no way to independently
assess the accuracy of the blood pressure measurements in the electronic
medical record or the degree to which
the blood pressure procedures were followed. Clinicians were not routinely
provided access to paper-based or electronic blood pressure references but
were left to develop their own practice
patterns or references for pediatric
blood pressure.
The protocol for our study received
full approval through an expedited review by the institutional review board
of MetroHealth Medical Center.
Statistical Analysis

Descriptive statistics, including ageadjusted height and weight percentiles, were calculated for each participant visit using the most recent Centers
for Disease Control and Prevention
growth charts.22 The age-adjusted and
height-adjusted expected systolic and
diastolic blood pressures were estimated for each participant visit accord-

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UNDERDIAGNOSIS OF HYPERTENSION IN CHILDREN

Table 1. Population Demographics for the Entire Study Population and Subgroups Used in Analysis
Entire Sample
(N = 14 187)

Prehypertension
(n = 485)

Diagnosed
With Prehypertension
(n = 55)

Hypertension
(n = 507)

Diagnosed
With Hypertension
(n = 131)

Age, mean (SD), y


Weight-for-age percentile, mean (SD)

8.8 (3.8)
66 (28.4)

11.9 (3.7)
77 (24.9)

13.0 (3.5)
86 (18.3)

9.5 (3.8)
75 (28.3)

10.6 (3.8)
87 (21.1)

Height-for-age percentile, mean (SD)


Female sex, %
African American race, %
Hispanic/Latino ethnicity, %

60 (29.0)
49
50
12

65 (28.7)
36
57
11

68 (27.2)
42
62
9

58 (29.6)
56
59
12

69 (26.3)
55
63
12

ing to the National High Blood Pressure Education Program Working


Group on High Blood Pressure in Children and Adolescents guidelines. 20
Blood pressure percentiles for each participant visit were then calculated based
on the expected blood pressures. Stage
1 hypertension was defined as 3 or more
visits with systolic or diastolic blood
pressure measurements greater than or
equal to the 95th percentile for sex, age,
and height, and less than the 99th percentile plus 5 mm Hg. Stage 2 hypertension was defined as 3 or more visits
with systolic or diastolic blood pressure measurements greater than the
99th percentile plus 5 mm Hg. Prehypertension was defined as an average
systolic or diastolic blood pressure percentile between the 90th and 95th percentiles or greater than 120/80 mm Hg.
Using this definition, we defined a patient as prehypertensive if he/she had
3 systolic or diastolic blood pressure
readings between the 90th and 95th
percentile or greater than 120/80
mm Hg.
Patients were considered to have been
diagnosed with hypertension if the problem list, list of diagnoses, or past medical history list from any visit contained
1 of the following International Classification of Diseases, Ninth Revision
(ICD-9) codes related to hypertension:
elevated blood pressure without hypertension (code 796.2); hypertension (code
401.xx); hypertension, not otherwise
specified (code 401.9); hypertension,
benign (code 401.1); and hypertension
(code 997.91) or heart disease due to
hypertension, not otherwise specified
(code 402.9). We first calculated the
prevalence of prehypertension, stage 1
hypertension, and stage 2 hyperten-

sion in the cohort. Then, for those


patients who met criteria for hypertension (stage 1 or stage 2) or prehypertension, the fraction with a diagnosis of
hypertension present in the electronic
medical record was determined.
Multivariate logistic regression analysis was performed to determine the association between various factors and
having a hypertension or elevated blood
pressure diagnosis in the electronic
medical record. The following factors
were included in the regression models: age, number of elevated blood pressure readings beyond 3, weight-forage percentile, height-for-age percentile,
male sex, African American race, Hispanic/Latino ethnicity, presence of an
obesity-related diagnosis, and family
history of hypertension. The following ICD-9 codes were used to define an
obesity-related diagnosis: obesity, not
otherwise specified (code 278.00); overweight (code 278.02); overweight for
pediatric patient (code 278.002); and
weight gain, abnormal (code 283.1). In
addition, the number of blood pressures in the stage 2 hypertension range
was included in the regression model
for those children and adolescents with
hypertension. Models were selected
based on our a priori hypotheses of factors, which may have been associated
with having a diagnosis of hypertension. We report the adjusted odds ratios (ORs) and 95% confidence intervals for the regression results.
To assess the accuracy of the problem lists, visit diagnosis lists, and past
medical history lists, we also performed
a manual review of the electronic medical records from 50 randomly selected
patients with undiagnosed hypertension. All well-child care visits from the

876 JAMA, August 22/29, 2007Vol 298, No. 8 (Reprinted)

electronic medical records of these patients were manually searched for mention of elevated blood pressure or
hypertension.
SAS version 9.13 was used for all data
processing and analysis.23
RESULTS
Study inclusion criteria were met by
14 187 participants, with a total of
53 911 patient visits. At the most recently recorded visit for all participants, mean (SD) age was 8.8 (3.8)
years, mean weight-for-age percentile
was the 66th percentile, mean heightfor-age percentile was the 60th percentile, 50% of the participants were African American, and 49% were female
(TABLE 1).
Criteria for hypertension were met by
507 children (3.6%). Of the children
with hypertension, only 131 (26%) had
a diagnosis of hypertension or elevated
blood pressure documented in the electronic medical record. Hence, 376 of 507
participants (74%) had undiagnosed hypertension. Elevated blood pressure
without hypertension (ICD-9 code
796.2) was the only code present in 51
of the 131 diagnosed with hypertension; therefore, only 80 of the 507 participants (15.8%) had a true hypertension diagnosis in the electronic medical
record. In addition, 17 of the 507 participants (3%) with hypertension had
stage 2 hypertension, and 10 of these 17
(59%) had an elevated blood pressure
or hypertension-related diagnosis present in the electronic medical record.
Therefore, 7 of the 17 participants (41%)
had undiagnosed stage 2 hypertension.
Family history of hypertension was
documented in 18% of the 507 patients
with hypertension. Criteria for prehy-

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UNDERDIAGNOSIS OF HYPERTENSION IN CHILDREN

pertension were met by 485 children


(3.4%). Of these children, 55 (11%) had
a diagnosis of hypertension or elevated
blood pressure documented in the electronic medical record.
Results of multivariate logistic regression analysis performed for the cohorts with hypertension and prehypertension are shown in TABLE 2. Patient
characteristics significantly associated
with having a diagnosis of hypertension included a 1-year increase in age
over age 3, number of elevated blood
pressure readings beyond 3, increase of
1% in height-for-age percentile, having an obesity-related diagnosis, and the
number of blood pressure readings in
the stage 2 hypertension range. The OR
for height-for-age percentile would be
interpreted as a 1.9% increase in the
odds of having a diagnosis of hypertension for a 1% increase in height-forage percentile. This can be approximately extrapolated as a 19% increase
in the odds of diagnosis for a 10% increase in height-for-age percentile. Factors not significantly associated with
having a diagnosis of hypertension in
the electronic medical record included weight-for-age percentile, African American race or Hispanic/Latino
ethnicity, sex, and family history of hypertension.
Patient characteristics significantly
associated with having a diagnosis of
prehypertension included a 1-year increase in age over age 3 and number of
elevated blood pressure readings beyond the required 3. Factors not significantly associated with having an elevated blood pressurerelated diagnosis
included height-for-age percentile,
weight-for-age percentile, sex, African American race or Hispanic/Latino
ethnicity, and family history of hypertension (Table 2).
On manual review of 50 randomly selected charts of patients with undiagnosed hypertension, the pediatric clinician made a note of an abnormal
blood pressure in the text of the electronic medical record clinic note, without making the equivalent notation in
the problem list, past medical history,
or visit diagnosis list, in 4 charts (8%).

Table 2. Logistic Regression Analysis of Factors Associated With Having a Correct Diagnosis
of Hypertension and Prehypertension in Children Aged 3 to 18 Years
Odds Ratio (95% CI) a
Variable
Demographic factors
Age, per 1-y increase over age 3 y
Male sex
African American race
Hispanic/Latino ethnicity
Anthropometric factors
Weight-for-age percentile, per 1% increase
Height-for-age percentile, per 1% increase
Obesity-related diagnosis
Clinical factors
No. of elevated blood pressure readings
beyond 3
No. of blood pressure readings in stage 2
hypertension range
Family history of hypertension

Hypertension

Prehypertension

1.09 (1.03-1.16)
1.15 (0.73-1.80)
1.04 (0.62-1.75)
1.31 (0.61-2.83)

1.21 (1.09-1.34)
1.20 (0.61-2.36)
1.20 (0.59-2.45)
0.75 (0.22-2.53)

1.00 (0.98-1.01)
1.02 (1.01-1.03)
2.61 (1.49-4.55)

1.02 (0.99-1.04)
1.00 (0.99-1.02)
1.90 (0.90-4.00)

1.77 (1.21-2.57)

3.07 (2.20-4.28)

1.68 (1.29-2.19)

NA

1.21 (0.70-2.11)

1.28 (0.60-2.76)

Abbreviations: CI, confidence interval; NA, not applicable.


a Listed odds ratios were adjusted for variables in the same column during logistic regression analysis.

Including these additional chart notations as correct identification and assuming an equivalent documentation
rate across all charts, the diagnosis rate
for hypertension would increase from
25.8% to 31.8% and, for prehypertension, from 11.3% to 18.6%.
COMMENT
Our study documents the underdiagnosis of pediatric hypertension and prehypertension in a large pediatric population during an extended period of time.
The prevalence of hypertension in our
study is consistent with other studies in
which the reported prevalence of hypertension in children ranges from 2%
to 5%.1,2 Although the data to make the
diagnosis were present in the patients
records, pediatric clinicians did not appropriately identify hypertension and
prehypertension in these children. This
low diagnosis rate could be accounted
for by 2 primary factors: (1) lack of
knowledge of normal blood pressure
ranges and (2) lack of awareness of a patients previous blood pressure readings. Because normal blood pressure in
children is a function of age, sex, and
height percentile, clinicians typically
cannot remember normal blood pressures for the wide range of children observed in the typical primary care setting. Although tables exist with normal

2007 American Medical Association. All rights reserved.

values, using these references for every


blood pressure during well-child care
visits could be time consuming. Additionally, even if a particular blood pressure is found to be abnormally high, investigating prior blood pressure readings
is often difficult because the prior blood
pressure readings, as well as the age and
height percentile of the child at the time
of those readings, need to be found.
We found that several patient factors were associated with increased adjusted odds that hypertension or prehypertension would be recognized.
Specifically, older and taller children
were more likely to have their abnormal blood pressure identified. The normal blood pressure range for children
increases with age and height. Therefore, older and taller children with high
blood pressure are more likely to have
their blood pressure be more than
120/80 mm Hg, which is above the normal blood pressure value for adults. The
knowledge of this normal adult blood
pressure among pediatric clinicians may
account for the increase in abnormal
blood pressure identification in these
patients.
Some risk factors for abnormal blood
pressure increased the chance of identification of abnormal blood pressure.
Presence of an obesity-related diagnosis was significantly associated with an

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UNDERDIAGNOSIS OF HYPERTENSION IN CHILDREN

increased adjusted odds of hypertension diagnosis among patients with hypertension and, although not significant, a similar trend was noticed in
patients with prehypertension. These
trends probably occur because pediatric clinicians look more carefully for abnormal blood pressure in overweight
children, since abnormal blood pressure is a common comorbid condition
occurring in upward of 30% of overweight children.20 A positive family history of hypertension, however, did not
increase the adjusted odds of identification of abnormal blood pressure in
either group. This is probably related to
the fact that, except for the visit at which
the family history is obtained, the clinician is not generally aware of the positive family history and therefore does not
factor this into the care of the child.
The frequency and magnitude of abnormal blood pressure readings also
correlated with increased adjusted odds
of identification of abnormal blood
pressure. As the relative magnitude of
the abnormal blood pressure increased, indicated by the presence of increased numbers of blood pressure
readings in the stage 2 hypertension
range, the adjusted odds of diagnosis
also increased. One reason for this could
again be that as the abnormal blood
pressure approaches and surpasses the
normal cutoff for adults of 120/80
mm Hg, the pediatric clinician recognizes the blood pressure as abnormal.
Additionally, as the number of abnormal blood pressure readings increased,
the adjusted odds of diagnosis also increased, which is most likely because
the pediatric clinician has more opportunities to recognize the abnormal
blood pressure.
One potential limitation of our study
is that it did not examine clinician characteristics that may be related to the rate
of appropriate abnormal blood pressure diagnosis. Given the duration of the
study period and the involvement of resident physicians, generally more than 1
clinician was involved in the visits for
each patient. Also, any number of relatively unique clinician characteristics
(years of experience, training status,

training background, percentage of practice time, patient panel characteristics)


could affect diagnosis rates. Our study
was designed only to investigate the overall diagnosis rates and patient characteristics affecting diagnosis rates.
Another potential limitation of our
study is our reliance on the problem
lists, past medical history lists, and visit
diagnosis lists as the gold standard for
the positive identification of a child with
abnormal blood pressure. However, our
manual review showed few charts with
only text notations of an abnormal
blood pressure. In the era of decreasing continuity of clinicians and increasing use of electronic medical records,
one may argue that a pure text comment should not be considered sufficient documentation of a diagnosis.
In our study, blood pressure measurement followed routine clinical procedures as opposed to more rigorous
measurement techniques. Although
there may be more accurate ways to
measure blood pressure, the blood pressure measurement protocols we used
are similar to those in many institutions. We do not have data on how frequently blood pressures were correctly obtained; however, we do know
that among children aged 3 to 18 years
observed in our system, 94% of wellchild care visits had a blood pressure
documented. Our results may not be
generalizable to other practice settings with single or smaller groups of
clinicians in which different blood pressure measurement techniques are used.
Diagnoses of hypertension and prehypertension were based on blood pressure readings taken at the well-child care
visits. We thought this was appropriate
for 2 reasons. We did not want to include visits in which blood pressure
readings may have been artificially elevated secondary to acute conditions,
such as pain or asthma exacerbation,
rather than true hypertension and current consensus guidelines call for screening blood pressure measurement at wellchild care visits from ages 3 to 18 years.20
Reliance on well-child care visits alone
for blood pressure measurements decreased the potential sample size of our

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study, as all children had to have at least


3 well-child care visits to be included in
our cohort. In addition, bias may have
been introduced by potentially selecting a population more likely to get wellchild care. However, the group of patients not included due to having less
than 3 primary care visits had less than
2% difference in mean age, height percentile, weight percentile, and percentage female compared with the study
group.
Although the blood pressures used in
our study were from well-child care visits only, the ICD-9 codes used to determine whether a child was diagnosed
came from all visits. For example, if a
diagnosis code for hypertension or elevated blood pressure was associated
with a nephrology visit or a nonwellchild primary care visit, it would be included in the analysis. Some practitioners may have rechecked a patients
elevated blood pressure at a separate
nonwell-child care visit. In this case,
the blood pressure measurement from
the recheck visit would not be included in our analysis but any ICD-9
abnormal blood pressure codes would.
A child with hypertension based on
ICD-9 codes who did not have 3 abnormal readings during well-child care
visits would not be counted among the
507 children with a diagnosis of hypertension.
In our population, we also investigated the diagnosis of hypertension in
children without 3 well-child care visits with abnormal blood pressures.
There were 900 children in our cohort
who had at least 3 abnormal blood pressure measurements during all outpatient visits in the study period but did
not have 3 abnormal blood pressure
measurements at well-child care visits. Of these 900 children, only 155 had
an ICD-9associated abnormal blood
pressure code, leading to a diagnosis
rate in this population of 17.2%. Some
cases exist in which clinicians may be
more likely to look for abnormal blood
pressure readings and diagnosis of
hypertension, such as follow-up abnormal blood pressure visits and obstetricgynecologic visits. However, in well-

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UNDERDIAGNOSIS OF HYPERTENSION IN CHILDREN

child care visits, clinicians should be


focused on screening and prevention of
diseases including hypertension and
most nonwell-child care visits are for
specific issues that would not focus the
clinicians attention to the patients
blood pressure. Additionally, there may
be acute circumstances, such as pain or
asthma exacerbation, in which the
blood pressure could be acutely high
from a normal baseline and so it would
be inappropriate to diagnose the child
with chronic hypertension at that time.
The fact that these 900 cases would also
make the prevalence of hypertension in
our population 9.9% (1407/14 187), up
to double that of published prevalence in other studies of normal children,1,2 supports the idea that some of
the abnormal blood pressures using this
expanded criterion could represent
false-positive findings.
All patients in our study whom we
labeled with hypertension had elevated blood pressure at 3 separate wellchild care visits and met current consensus criteria for a diagnosis of
hypertension. Our study represents true
underdiagnosis of hypertension as these
patients hypertension was not recognized by clinicians throughout our
health care system.
Identification of elevated blood pressure in children meeting prehypertension or hypertension criteria is important because of the increasing prevalence of pediatric weight problems and
because secondary hypertension is more
common in children than adults, requiring identification and appropriate
work-up.19 If abnormal blood pressure is not identified by a patients pediatric clinician, it may be years before the abnormal blood pressure is
detected, leading to end-organ damage. Because effective treatments for abnormal blood pressure exist, these longterm sequelae can be avoided with early
diagnosis.
Although this study identifies the
problem of undiagnosed hypertension in children, it also points to the potential of electronic medical records to
help address this issue. The relatively
poor identification of abnormal blood

pressure could be remedied by a clinical decision support algorithm built into


an electronic medical record that would
automatically review current and prior
blood pressures, ages, heights, and sex
to determine if abnormal blood pressure criteria had been met. The algorithm could indicate if any abnormal
blood pressure ICD-9 codes already existed and prompt the pediatric clinician that the child appears to have undiagnosed abnormal blood pressure. In
addition, the clinical decision support
algorithm could provide guidelinebased evaluation, treatment, and parent/
patient education materials to the clinician.
CONCLUSION
Hypertension and prehypertension are
well-defined, prevalent, asymptomatic, chronic conditions in children and
adolescents. Based on the data in this
study, these conditions appear to be frequently undiagnosed by pediatric clinicians. Early, appropriate diagnosis is important because established evaluation
guidelines and effective treatment for abnormal blood pressure exist.
Author Contributions: Drs Hansen and Kaelber had
full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Hansen, Gunn, Kaelber.
Acquisition of data: Kaelber.
Analysis and interpretation of data: Hansen, Gunn,
Kaelber.
Drafting of the manuscript: Hansen, Gunn, Kaelber.
Critical revision of the manuscript for important intellectual content: Hansen, Gunn, Kaelber.
Statistical analysis: Hansen, Kaelber.
Administrative, technical, or material support: Kaelber.
Study supervision: Kaelber.
Financial Disclosures: None reported.
Previous Presentation: Presented in part at the Pediatric Academic Societies Annual Meeting; May 5, 2007;
Toronto, Ontario, Canada.
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