New Study Shows Efficacy of Creating Normative BP Values from EHR
Using real-world blood pressure (BP) measurements to identify pediatric patients at risk of hypertension-related cardiovascular disease in adulthood showed feasibility and cost-effectiveness in a recent study.
Mark Mitsnefes, MD, MS, director of the Clinical and Translational Research Center at Cincinnati Children’s, was one of the authors of the multi-center study, published in the December 2023 issue of The Lancet’s eBioMedicine journal.
“We know hypertension in childhood can lead to cardiovascular problems in adulthood, like myocardial infarction and stroke, but the way we currently identify hypertension in pediatric patients is based on normative data compiled from research studies largely conducted decades ago,” Mitsnefes says.
To see if normative values could be created from real-world data, Mitsnefes and a team of researchers from eight large health systems gathered the electronic health records (EHR) of more than 8 million children—derived from the health systems and aggregated by PEDSnet, a multi-institutional pediatric health system network—and filtered them to narrow the sample size.
The study’s participating health systems included:
- Cincinnati Children’s Hospital
- Children’s Hospital Colorado
- Children’s Hospital of Philadelphia
- Lurie Children’s Hospital of Chicago
- Nationwide Children’s Hospital
- Nemours Children’s Health
- Seattle Children’s Hospital
- Stanford Medicine Children’s Health
Inclusion criteria targeted children between the ages of 3 and 17 years, and those with a body mass index (BMI) of lower than the 85th percentile. The resulting study analyzed around 1 million BP measurements from nearly 300,000 children—a significantly larger sample size than the current database of normative BP values, which was compiled from roughly 60,000 to 70,000 measurements taken from around 50,000 pediatric patients between the 1970s and 1990s.
Benefits of Real-World Data
Not only is the EHR database much larger than the current one, Mitsnefes says, it’s also much more diverse because it includes records of patients from across the country. And, while the existing value database only reflects auscultation measurements, the EHR database includes both auscultation and oscillometric device-derived BP measurements, which about half of today’s providers use. It also reflects the modern guidance of taking an average of two BP measurements instead of one.
Another issue the EHR database helps to correct is taking measurements in real-life circumstances. The current normative values were taken from 11 research studies completed in controlled environments, Mitsnefes says.
"When we do research studies, we’re particular about everything, from how long we wait in between measurements to making sure the patient’s back and legs are supported,” he says. “But in the real world, for example, the child may be talking or not sitting still, and those things can affect blood pressure. “Limitations of the historical data are why we decided to ask the question of whether we could create normative values from real-world blood pressure measurements taken from pediatric patients during regular visits to their provider.”
Significance for Clinical Practice
In addition to concluding that real-world BP measurements could be used effectively to create normative values in children, the study highlighted other important implications, including higher cutoff points for normative values using EHR.
“We found that in our study, generated cutoff points to define hypertension were a few points (2-4 mmHg) higher than current normative values, especially in children between the ages of 3 and 7,” Mitsnefes says. “That means we’re probably overestimating the real prevalence of high blood pressure in that age group right now.”
Adjusting the range could lead to fewer follow-up appointments, specialist referrals and treatments, Mitsnefes says, which also could mean cost savings. Another potential for cost savings with the EHR database is the ability to update it regularly, such as every 10 years.
Also, the researchers provided statistical data, from codes to full tables, so others can replicate the study at any time—or compare the two sets of data to determine which works best for their specific needs.
Still, there are limitations to the study: “We don’t know how many of the blood pressure measurements were done by auscultation versus with a digital device,” Mitsnefes says. “But we know that this real-world data represents how we practice, and we see important implications for applying it to clinical care.”
This study was funded by the Preserving Kidney Function in Children with Chronic Kidney Disease (PRESERVE) grant.
(Published February 2026)
