Adherence to Guideline-Recommended Testing in Youth With Hypertension: 2014–2024

The 2017 American Academy of Pediatrics (AAP) hypertension guidelines recommend diagnostic testing in youth with incident hypertension to identify secondary causes, detect target organ damage, and screen for comorbidities.1 However, adherence to guideline-recommended testing is unknown.We performed a retrospective cohort study using aggregated, deidentified electronic health record (EHR) data in the TriNetX US Research No Date Shift Network, a repository of more than 87 million patients from 51 US health care organizations. Research using TriNetX was deemed exempt by the MetroHealth System Institutional Review Board.In November 2025, we queried TriNetX for youth aged 1–17 years with an ambulatory visit between 2014 and 2024 with a new International Classification of Diseases, Tenth Revision (ICD-10) code for primary hypertension (I10). We excluded youth with a history of any ICD-10 encounter diagnosis code for a hypertension-related disorder (I10, I11, I12, I13, I15, I16, or I1A). Race and ethnicity were extracted from the EHR because of known disparities in access to care.2We determined the prevalence of laboratory testing, ambulatory blood pressure (BP) monitoring (ABPM), echocardiogram, and renal ultrasonography following the 2017 guidelines from 2018 to 2024 based on procedure codes within 6 months after the initial encounter diagnosis code for primary hypertension in youth who never had the test previously (Supplemental Table 1).3 We performed sensitivity analyses by evaluating testing in youth at any time in the past until 6 months after the initial encounter diagnosis code and in youth with at least 3 encounter diagnosis codes for primary hypertension. We calculated the prevalence of testing overall and stratified by age group (1–5 years and 6–17 years), as the guideline-directed workup depends on age.1 We assessed for trends in testing from 2014 to 2024 using the Cochran-Armitage test.Of 9 695 678 youth with ambulatory visits between 2018 and 2024, 49 833 (0.5%) had an incident encounter diagnosis code for primary hypertension (mean, 12.1 [SD, 4.6] years; 38.8% female, 50.0% White, 23.7% Black, and 18.4% Hispanic; median body mass index, 96.2 percentile [IQR, 33.9]). Among youth without prior diagnostic testing, the most frequent tests in the 6 months after the initial encounter diagnosis code for hypertension were echocardiogram (21.1%), urinalysis (19.9%), and serum electrolytes and creatinine (17.7%) (Figure 1A). The prevalence of other guideline-concordant tests included renal ultrasonography in 12.2% of youth aged 1–5 years, ABPM in 7.7% of youth aged 6–17 years, and lipid profile in 8.1% of all youth. For the 15 157 youth with at least 3 ICD encounter diagnosis codes for hypertension from 2018 to 2024, diagnostic testing was completed more frequently, yet most youth did not undergo all guideline-recommended tests (Figure 1C). From 2014 to 2024, there was a significant increase in ABPM from 5.7% to 11.9% (P < .001) and electrolyte and creatinine testing from 12.0% to 19.5% (P < .001) (Figure 2).In this large sample of youth with a new encounter diagnosis code for primary hypertension, the prevalence of guideline-recommended testing was low. The 2017 guideline recommends the following tests: urinalysis, chemistry panel, and lipid profile for all youth with hypertension; ABPM for those able to tolerate the procedure; renal ultrasonography in children aged less than 6 years; echocardiogram when considering pharmacologic treatment; and additional testing based on history and physical examination.1 These recommendations were a change from the 2004 Fourth Report, which had recommended echocardiogram and renal ultrasonography for all youth with hypertension and had not yet recommended universal ABPM.4 Despite the changing recommendations, we found that echocardiogram remained the most frequently ordered test. Furthermore, the prevalence of renal ultrasonography was unchanged and uptake of ABPM, although doubled, remained limited (<12%). The continued use of echocardiogram and renal ultrasonography may be supported by recent literature showing that echocardiogram detects left ventricular hypertrophy in 33%–41% of youth at initial hypertension diagnosis5,6 and that renal ultrasonography has the highest diagnostic yield for secondary hypertension.5Our work builds on prior studies showing suboptimal diagnostic evaluations for pediatric hypertension. In a Canadian study on practice patterns before and after the 2016 Hypertension Canada7 and 2017 AAP guidelines,1 there was no significant change in ordering of serum electrolytes, creatinine, or lipid profiles, with rates ranging from 16% to 19% in the immediate pre- and postguideline periods.8 In a US primary care–based collaborative, only 11% of youth with high BP documented had appropriate laboratory testing.9 Forgoing guideline-recommended tests may miss secondary hypertension, which can be the first sign of a systemic disease and for which treatment is often different from primary hypertension. Likewise, forgoing ABPM may lead to unnecessary workups for white coat hypertension.Study limitations include use of ICD-10 codes to define hypertension and lack of information about the ordering clinician’s specialty. Given that pediatric hypertension is often unrecognized,10 we expect the prevalence of testing to be even lower if we defined hypertension using BP instead of ICD-10 codes. Nevertheless, our results highlight the need to explore multilevel barriers to guideline-adherent testing for hypertension, including access to testing, provider knowledge, patient preferences, insurance, and cost. Future guidelines may consider incorporating implementation strategies to promote guideline-based testing in clinical practice.