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Invited commentary: raising a high-pressure alarm about pediatric hypertension
1Division of Critical Care, Department of Pediatrics at Nemours Children's Hospital, Wilmington, Delaware, United States.
Insights
Pediatric hypertension is likely more common than previously thought. Direct blood pressure measurements in electronic health records reveal higher rates than diagnosis codes suggest, highlighting a need for better detection and management.
Area of Science:
- Pediatric Medicine
- Cardiovascular Epidemiology
- Health Informatics
Background:
- Hypertension in children and adolescents is under-diagnosed.
- Current epidemiologic estimates may be inaccurate due to reliance on billing codes.
- Elevated blood pressure in youth poses long-term cardiovascular health risks.
Purpose of the Study:
- To compare the prevalence of pediatric hypertension using direct blood pressure measurements versus diagnosis codes.
- To assess the accuracy of electronic health records in identifying pediatric hypertension.
- To highlight the need for improved hypertension detection in pediatric populations.
Main Methods:
- Utilized the US Food and Drug Administration's Sentinel System, analyzing 3.75 million pediatric healthcare visits.
- Compared a "clinical cohort" (direct blood pressure measurements from EHRs) with a "claims-based cohort" (diagnosis codes).
- Included both inpatient and outpatient visits for data extraction.
Main Results:
- Direct assessment of blood pressure measurements suggests a higher prevalence of hypertension in children and adolescents than previously estimated using claims codes.
- Electronic health record data offers a more comprehensive view of pediatric hypertension prevalence.
- Potential for misclassification bias exists within electronic health records.
Conclusions:
- Relying solely on ICD-9-CM/ICD-10-CM codes underestimates pediatric hypertension.
- Direct clinical data from EHRs is crucial for accurate epidemiologic estimates.
- Improved identification of pediatric hypertension can enhance long-term cardiovascular health outcomes.
Abstract:
Hypertension is a common "silent killer" in adult medicine, but epidemiologic estimates of elevated blood pressure in children and adolescents are challenged by under-diagnosis and resultant low utilization of relevant administrative or billing codes. In the article by Horgan et al (Am J Epidemiol 2025;194(2):407-419), children and adolescents with hypertension and elevated blood pressure were identified using direct assessment of blood pressure measurements available in the electronic health record from both inpatient and outpatient visits ("clinical cohort") in comparison to diagnosis codes ("claims-based cohort"). The study population included 3.75 million pediatric healthcare visits available in the US Food and Drug Administration's Sentinel System. While the study applied a relatively novel methodology to interrogate available clinical data within the EHR to better understand the prevalence of pediatric hypertension and raised concern for a higher occurrence of hypertension among children and adolescents than previously realized using claims codes, the utility of the prevalence estimates may be limited by the potential for misclassification bias inherent in electronic health records data. However, these data raise important concerns about relaying solely on ICD-9-CM/ICD-10-CM codes to quantify the epidemiology of pediatric hypertension and highlight opportunities to address elevated blood pressure in children that could improve long-term cardiovascular health.
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Monitoring Both Arms:
Monitoring BP in both arms during the initial assessment is advisable, as the systolic value may differ by five to ten mm Hg between arms. For subsequent BP assessments, use the arm with the higher reading.