Failure to confirm high blood pressures in pediatric care—quantifying the risks of misclassification

Abstract

Pediatric practice guidelines call for repeating an elevated office blood pressure (BP) at the same visit, but there are few data available to support this recommendation. We compared the visit results in children aged 3 to 17 years with a BP reading ≥95th percentile (n = 186 732) based on the initial BP and the mean of two BP readings, using electronic medical records from 2012-2015. Failure to repeat an initial BP reading ≥95th percentile would lead to a false "hypertensive" visit result in 54.1% of children who would require follow-up visits. After an initial visit result indicating hypertension, hypertension stage I or stage II was sustained in 2.3% and 11.3% of youth during their next visits, respectively. In conclusion, only approximately half of the pediatric patients would be correctly classified based on their initial BP. The recommendation to repeat high BP during the same visit needs to be emphasized because it saves unnecessary follow-up visits. | INTRODUCTIONHigh blood pressure (BP) is a major contributing risk factor for heart failure, heart attack, stroke, and chronic kidney disease and accounts for an estimated 18% of cardiovascular deaths in the United States. Initial BP readings can be high for various reasons including measurement error. Hence, BP readings should be repeated during the same visit and the mean of BP readings used as the visit result. 19Repeating a high BP during the same visit can prevent misclassification of a patient's visit result. This has implications for clinical practice because it is recommended that follow-up visits should be scheduled after a visit with a BP ≥95th percentile to confirm or rule out hypertension. Misclassification of a patient's visit result as hypertensive may result in unnecessary follow-up visits, which are a burden for both the patient and the healthcare system. However, studies are needed to quantify the magnitude of misclassification arising from the failure to repeat an initial high BP reading.To estimate the benefit of adhering to standardized protocols for BP screening as recommended by the American Academy of Pediatrics and others, [15][16][17][18][19] we assessed the misclassification of pediatric patients as hypertensive based on an initial BP reading, which could be avoided by a repeated reading during the same visit. The classification of an individual's BP as normotensive or hypertensive during the same

Utility of blood pressure measurements at an initial screening visit to identify Chinese children and adolescents with hypertension

“…18 only, which would lead to unnecessary follow-up. 7 In the present study, we found that the mean value of the last two readings when three BP readings were recorded at a single visit was better than any individual reading to identify those children and adolescents with hypertension. Consistent with our findings, a previous study showed that BP decreases greatly between the first two measurements but less so between the second and third measurements at a visit.…”

“…One major challenge is how to best balance the increased rate of false positives using limited BP mesurements. 7,8 Among adults, single BP measurement at a visit might not be enough to define hypertension, 17 especially for people with a higher initial BP reading. 18 only, which would lead to unnecessary follow-up.…”

Racial Differences in Rates of Change of Childhood Body Mass Index and Blood Pressure Percentiles

“…8 BP measurement in children can be neither accurate nor precise, with data suggesting that substantial misclassification can result from reliance on single values. 21 That we did not identify clear differences in BP percentile patterns may not be surprising given these issues. Further study is necessary to determine whether tracking SBP percentiles could help identify critical periods when racial differences emerge.…”

Optimizing the implementation of a population panel management intervention in safety-net clinics for pediatric hypertension (The OpTIMISe–Pediatric Hypertension Study)

“…Diagnosis of HTN is further dependent upon taking multiple BP readings, whose interval of repetitive measurements is dependent upon the initial readings themselves. About 48.2% of stage I HTN diagnoses are correct, and only 35.0% of stage II HTN diagnoses are correct [39]. Thus, follow-up appointments must be carefully coordinated to assure accuracy.…”