Pediatric Hypertension Gaps: Longitudinal Analysis and Social Drivers of Health

Background: Pediatric hypertension (HTN) remains underdiagnosed despite established guidelines. Prior studies evaluating social drivers of health (SDOH) relied on diagnostic codes or single-visit blood pressure (BP) measurements, limiting identification of persistent BP elevation. We evaluated longitudinal BP patterns and associated SDOH among children with continuity of care. Methods: We conducted a retrospective cohort study of children aged 6-17 years with [≥]3 primary care visits between 2017 and 2024 within a large healthcare network. BP was classified according to guidelines. Multivariable logistic regression evaluated associations between persistent abnormal BP ([≥]3 abnormal readings, would meet guideline-based diagnosis for HTN) and stage 1/2 HTN with demographic, clinical, and neighborhood-level factors, including Area Deprivation Index (ADI), Child Opportunity Index (COI), and insurance instability. Results: Among 71,683 children, 2,911 (4.2%) had persistent abnormal BP, whereas only 848 (1.2%) had a documented HTN diagnosis. Obesity, age [≥]13 years, male sex, prematurity, and insurance instability were associated with abnormal BP and stage 1/2 HTN. Higher ADI quartiles were associated with increased odds of abnormal BP (Q3: OR 2.48) and stage 1/2 HTN (Q3: OR 4.89). Higher COI socioeconomic opportunity was associated with lower odds of abnormal BP, whereas higher educational opportunity was associated with higher odds; these associations were not observed for stage 1/2 HTN. Conclusions: Among children with continuity of care, substantial gaps in HTN recognition persist despite repeated opportunities for diagnosis. SDOH factors remained associated with BP abnormalities, supporting the need for system-level and community-based strategies to improve HTN detection.