Patient-, provider-, and clinic-level predictors of unrecognized elevated blood pressure in children

OBJECTIVE: The goal was to determine patient-, provider-, and cliniclevel predictors of unrecognized elevated blood pressure (BP) in children. We hypothesized that being of healthy weight, having a BP of <120/80 mm Hg, and being seen by a less experienced provider would result in decreased recognition. METHODS: A cross-sectional study of clinic visits for children 3 to 20 years of age at an urban, pediatric primary care practice between January 1, 2006, and June 30, 2006, was performed. Children with elevated systolic or diastolic BP (≥90th percentile or ≥120/80mm Hg) were included. Recognition was defined as having any of the following documented: repeat BP measurement, elevated-BP/hypertension diagnosis, plan to recheck BP, or initiation of hypertension evaluation. Multivariate logistic regression analysis was used to identify characteristics associated with underrecognition. RESULTS: Elevated BP occurred in 779 (39%) of 2000 visits. Of 726 cases included in the analysis, 87% were not recognized by providers. Patient-level predictors of underrecognition included systolic BP of <120 mm Hg (odds ratio: 7.7 [95% confidence interval: 3.2-18.6]), diastolic BP of <80 mm Hg (odds ratio: 2.4 [95% confidence interval: 1.1-5.0]), decreasing BMI z score, male gender, older age, lack of family history of cardiovascular disease, and negative medical history findings. Being seen by a nurse practitioner and being seen by a less-experienced provider also were significant predictors. CONCLUSIONS: Most BP elevations were not recognized by providers. Poor recognition was most influenced by the absence of obviously elevated BP, obesity, and family history of cardiovascular disease.