Background: The American Academy of Pediatrics 2017 clinical practice guidelines (CPG) call for regular blood pressure (BP) screening in children ≥3 years. However, it is unknown to what extent the BP screening CPG has been implemented or if such implementation has been equitable.

Methods: Cross-sectional data from January 1-December 31, 2018 were extracted from electronic health records from the largest health care system in Central Massachusetts. Outpatient visits for children aged 3-to-17-years without a prior hypertension diagnosis were included. Adherence was defined by the BP screening CPG recommending ≥1 BP screening per year for children of a healthy body mass index ((BMI) <85%) and at every encounter for children who are overweight (BMI ≥85%). Independent variables included social determinant of health indicators at the child-level (insurance, language, child opportunity index) and clinic-level (urban/rural, Medicaid population). Covariates included child’s age, gender, race/ethnicity, and BMI, as well as clinic’s specialty (pediatrics/family medicine), patient panel size, and number of providers. We used direct estimation to calculate prevalence estimates and multivariable mixed effects logistic regression to determine the odds of undergoing CPG adherent BP screening.

Findings: We identified 44,947 visits for 19,787 children (median age 11 years) across 7 pediatric and 20 family medicine clinics in 2018. The prevalence of CPG adherent BP screening was 83%. In the multivariable adjusted model, children with private insurance (adjusted odds ratio (aOR) 1.22, 95% CI 1.09-1.35) and those seen in clinics with a lower Medicaid population (aOR 1.02, 95% CI 1.0-1.05 per 1% decrease) were more likely to undergo CPG adherent screening. CPG adherent screening was also more likely among older children, those with BMI <85%, those in family medicine clinics, and those in clinics with more providers.

Implications for D&I Research: Despite overall high adherence to pediatric BP CPG indicating relatively successful implementation, our findings suggest that this implementation is not equitable. Adherence was lower for children who are more likely to be impoverished, have higher social needs, and benefit from preventive screenings (BMI ≥85%, publicly insured, and treated in Medicaid predominant clinics). Future implementation efforts should address structural factors, especially those related to insurance and pediatric practice to achieve more equitable implementation.