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The American Journal of Managed Care August 2014
Personalized Preventive Care Reduces Healthcare Expenditures Among Medicare Advantage Beneficiaries
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Impact of Hypertension on Healthcare Costs Among Children
Todd P. Gilmer, PhD; Patrick J. O'Connor, MD, MPH; Alan R. Sinaiko, MD; Elyse O. Kharbanda, MD, MPH; David J. Magid, MD, MPH; Nancy E. Sherwood, PhD; Kenneth F. Adams, PhD; Emily D. Parker, MD, PhD; and Karen L. Margolis, MD, MPH
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Impact of Hypertension on Healthcare Costs Among Children

Todd P. Gilmer, PhD; Patrick J. O'Connor, MD, MPH; Alan R. Sinaiko, MD; Elyse O. Kharbanda, MD, MPH; David J. Magid, MD, MPH; Nancy E. Sherwood, PhD; Kenneth F. Adams, PhD; Emily D. Parker, MD, PhD; and Karen L. Margolis, MD, MPH
This study demonstrates a major influence of prehypertension and hypertension on healthcare costs in a large cohort of children, independent of body mass index.
Table 3 shows that the standardized cost differentials between categories narrowed when controlling for additional comorbidity using the CDPS score. The differential in total costs between HT and normotensive children declined by $383 (SE = $90) to $852 (SE = $53), and the cost differential between preHT and normotensive children declined by $67 (SE = $18) to $141 (SE = $9) (P <.001 each) when adjusting for additional comorbidity using CDPS. The differentials in total cost for children above the 95th percentile of BMI and children between the 85th and 95th percentiles compared to children below the 85th percentile declined by $67 (SE = $19, P <.001) and $64 (SE = $48, P = .192), respectively, to $48 (SE = $11, P <.001) and $68 (SE = $15, P <.001) when adjusting for additional comorbidity using CDPS.

Table 4 shows estimates of outpatient utilization associated with preHT and HT. There were statistically significant increases in all measures of utilization except for laboratory testing. Utilization was at least 50% higher in HT than normal BP children in all categories, except for laboratory testing (P <.001 each), with the large percentage increases observed for renal ultrasound, echocardiogram, and chest x-ray. However, these procedures were performed at a relatively low rate, and all diagnostic and evaluation procedures with the exception of urinalysis were conducted in fewer than 10% of children with HT. We reviewed the types of specialist consultations, but could not identify any specific pattern to differentiate visits among the BP categories.


The present study shows the strong incremental effects of both preHT and HT, independent of BMI and comorbidity, on healthcare costs in children. Although BMI status also was significantly associated with cost, the major influence on cost in this large cohort of children was BP status. It should be noted that the percent of children with preHT was higher than previously reported.38 Because the definition for preHT requires only a single BP measurement, the requirement of 3 separate clinic BP measurements for inclusion in this study increased the number with preHT.

An important factor in this analysis is that hypertension was identified primarily from review of EHRs, with only 17% recognized by the clinic physicians. The lack of recognition of HT by providers using computerized medical record systems has been reported previously,39 as has the extent of the underrecognition.40 However, there was no significant difference in cost associated with the EHR method, as opposed to physician recognition and diagnosis. Thus, there may be something inherent in the presence of hypertension or prehypertension that leads to increased outpatient and emergency department visits, specialist consultations, increased diagnostic and evaluation procedures, and their associated costs; or medical issues resulting in more frequent clinic visits with greater number of BP measurements resulting in a larger number of diagnoses of preHT or HT. This may account for the significantly greater use of cardiac studies and chest x-rays in the subjects with hypertension.

Elevated BP in adults has been shown to be associated with substantial increased costs in 3 national data sets.41-43 Studies of adults have further shown that both obesity and hypertension are independent determinants of costs.44 In contrast, little attention has been devoted to the costs or to strategies to address elevated BP in children or adolescents. Given the strong relationship between elevated BP and healthcare costs, a case could be made to health plans and payers to consider implementing strategies to manage healthcare utilization of children with elevated BP. These strategies might include improved primary care, case management, health behavior interventions, family education, or other interventions.45-47

In contrast to prior studies, costs of healthcare services in this study were not significantly different between overweight (BMI ≥85th percentile to < 95th percentile) and obese (BMI ≥95th percentile) children controlling for BP status. Studies assessing healthcare utilization and cost related to overweight or obesity previously have not been able to adjust for BP status due to lack of BP data. By including both BMI and BP status in the analyses, this study has been able to extend previous findings by showing that the effect of BMI is lower than previously reported and is confounded by the associated impact of preHT and HT.

These findings are relevant to ongoing clinical and public policy discussions. First, they suggest that greater attention should be paid to elevated BP in children and adolescents as a driver of healthcare costs. Second, elevated BP has a significant effect on cost independent from elevated BMI and other comorbid conditions. Third, studies that do not account for the impact of BP level on utilization may overestimate the effect of BMI on utilization and costs.

There are limitations that should be considered in the interpretation of these data. First, despite the large, racially and ethnically diverse study population, these results may not be generalizable to costs of care in non–insurance-driven healthcare systems. However, it is currently challenging to conduct this type of study and capture detailed clinical and cost data outside the highly integrated healthcare systems included in this study. Second, it is possible that some allopathic care was obtained outside the insurance system, although prior studies suggest that this is well under 5% of total allopathic care. Third, although we adjusted for comorbidity using CDPS, there may be some residual differences in comorbidities by BP status. Finally, the results from this study do not imply causality between hypertension and the increased cost of patient care. However, the data clearly show an association between BP and healthcare costs in youth.

In summary, this study provides for the first time an estimate of the impact of BP and BMI status on healthcare utilization and cost in children and adolescents. Results suggest that costs attributable to overweight or obesity may be systematically overestimated in studies that do not adjust for BP status, and that BP status has a major independent association with utilization and costs of healthcare in youth. While we do not have the data to examine whether lowering BP in those with elevated BP would reduce their healthcare cost, it seems reasonable to suggest this may occur.

Author Affiliations: Department of Family and Preventive Medicine, University of California, San Diego (TPG); HealthPartners Institute for Education and Research, Minneapolis, MN (PJO, EOK, NES, KFA, KLM); Department of Pediatrics, University of Minnesota, Minneapolis (ARS); Institute for Health Research, Kaiser Permanente Colorado, Denver (DJM).

Funding Source: Funding was provided by the National Institutes of Health grant R01HL093345 from the National Heart, Lung, and Blood Institute.
Author Disclosures:
The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (TPG, PJO, ARS, EOK, KLM); acquisition of data (PJO, KLM); analysis and interpretation of data (TPG, PJO, ARS, EOK, DJM, NES, KFA, EDP, KLM); drafting of the manuscript (TPG, PJO, ARS); critical revision of the manuscript for important intellectual content (TPG, PJO, ARS, EOK, DJM, NES, KFA, EDP, KLM); statistical analysis (TPG); provision of study materials or patients (PJO); obtaining funding (PJO, ARS, NES); administrative, technical, or logistic support (TPG); supervision (TPG, POC).

Address correspondence to: Todd Gilmer, PhD, Department of Family and Preventive Medicine, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92092-0622. E-mail:
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