Background: Gaps in care (GIC) are common for patients with congenital heart disease (CHD) and can lead to worsening clinical status, unplanned hospitalization, and mortality. Understanding of how social determinants of health (SDOH) contribute to GIC in CHD is incomplete. We hypothesize that SDOH, including Child Opportunity Index (COI), are associated with GIC in patients with significant CHD. Methods and Results: A total of 8554 patients followed at a regional specialty pediatric hospital with moderate to severe CHD seen in cardiology clinic between January 2013 and December 2015 were retrospectively reviewed. SDOH factors including race, ethnicity, language, and COI calculated based on home address and zip code were analyzed. GIC of >3.25 years were identified in 32% (2709) of patients. GIC were associated with ages 14 to 29 years ( P <0.001), Black race or Hispanic ethnicity ( P <0.001), living ≥150 miles from the hospital ( P =0.017), public health insurance ( P <0.001), a maternal education level of high school or less ( P <0.001), and a low COI ( P <0.001). Multivariable analysis showed that GIC were associated with age ≥14 years, Black race or Hispanic ethnicity, documenting <3 caregivers as contacts, mother's education level being high school or less, a very low/low COI, and insurance status (C statistic 0.66). Conclusions: One‐third of patients followed in a regional referral center with significant CHD experienced a substantial GIC (>3.25 years). Several SDOH, including a low COI, were associated with GIC. Hospitals should adopt formal GIC improvement programs focusing on SDOH to improve continuity of care and ultimately overall outcomes for patients with CHD.

Background: Lifelong continuity of care is essential for patients with congenital heart disease (CHD) to maximize health outcomes; unfortunately, gaps in care (GIC) are common. Trends in GIC and of social determinants of health factors contributing to GIC are poorly understood. Methods and Results: This retrospective cohort study included patients with CHD, aged 0 to 34 years, who underwent surgery between January 2003 and May 2020, followed up at a pediatric subspeciality hospital. Patients were categorized as having simple, moderate, and complex CHD based on 2018 American Heart Association and American College of Cardiology guidelines. Social determinants of health, such as race, ethnicity, language, insurance status, and Child Opportunity Index, based on home address zip code, were analyzed. Of 2012 patients with CHD, a GIC of ≥3 years was identified in 56% (n=1119). The proportion of patients with GIC per year increased by 0.51% ( P <0.001). Multivariable longitudinal models showed that the odds of GIC were higher for patients who were ≥10.5 years old, had simple CHD, lived out of state, lived farther from care site, received public insurance, had less protection with additional insurance plans, and with low Child Opportunity Index. A separate model for patients with only moderate/complex CHD showed similar findings. Race and ethnicity were not associated with the odds of experiencing GIC over time. Conclusions: GIC have increased over time for patients with CHD. Social determinants of health, like insurance, access, and neighborhood opportunity, are key risk factors for increasing GIC. Efforts to reduce GIC in patients with CHD should focus on addressing the impact of specific social determinants of health.

Importance: Despite published guidelines and a prevalence of pediatric hypertension of approximately 3%, less than 25% of affected children are identified, with 60% not receiving any intervention despite detection. Understanding the knowledge and perceptions of parents or caregivers and health care teams is crucial to identify factors that may contribute to these unacceptably low detection rates.Objective: To examine the knowledge and perceptions of parents and health care teams regarding pediatric hypertension to identify common themes contributing to low hypertension detection.Design, Setting, and Participants: This qualitative study, interviewed parents of children diagnosed with hypertension who did not follow up within 1 year after diagnosis and health care clinicians (medical assistants, nurses, managers, pediatricians, and nurse practitioners) across 10 clinics in Delaware and Pennsylvania between November 1, 2022, and March 31, 2023.Main Outcomes and Measures: With the use of an inductive thematic approach, codes were developed and themes identified by multidisciplinary research investigators.Results: A total of 38 stakeholders (mean [range] age, 43 [25-64] years; 33 [86%] female), including 13 parents and 25 health care clinicians, were interviewed. The parent sample was diverse based on race (5 [46%] Black, 5 [38%] White, and 3 [23%] other race), ethnicity (5 [38%] Hispanic and 8 [62%] non-Hispanic), and Child Opportunity Index (5 [38%] very low or low, 3 [23%] moderate, and 5 [38%] high or very high). Parents and clinicians demonstrated awareness of the significance of pediatric hypertension. Parents thought blood pressure checks were important; however, clinicians often had competing priorities during annual visits. Both groups expressed skepticism about high blood pressure readings, attributing them to situational factors or white coat syndrome. Parents and clinicians shared concerns about medication use and preferred lifestyle change. Parents advocated for further testing, whereas clinicians exhibited varying perspectives on additional diagnostics, emphasizing targeted testing strategies and cautious medication approaches.Conclusions and Relevance: In this qualitative study of parents and clinicians, both groups were skeptical of blood pressure readings and expressed concerns about medication use, with a preference for lifestyle changes over medication. Improving detection may require better measurement tools, reassurance about medications, and clear communication on the role of nonpharmacologic treatments, while future interventions should incorporate the perspectives of both parents and clinicians to develop practical strategies for managing pediatric hypertension.

Importance: Pediatric hypertension remains underrecognized despite its high prevalence (approximately 5%) and long-term cardiovascular implications. Although guidelines for screening and diagnosis exist, less than 25% of affected children are diagnosed, and more than half do not receive timely follow-up care. Clinician-specific implementation barriers and directly informed strategies, which may alleviate this gap, are insufficiently described. Objective: To identify clinician-reported barriers and actionable recommendations to improve pediatric hypertension detection and follow-up in primary care using the Consolidated Framework for Implementation Research. Design, Setting, and Participants: Semistructured qualitative interviews were conducted between November 1, 2022, and March 31, 2023, with health care clinicians at 10 pediatric primary care clinics. Clinics were purposefully selected based on outpatient follow-up care gaps for patients 1 year or more after initial hypertension diagnosis and the Child Opportunity Index based on clinic address. Exposures: Transcripts were analyzed thematically and mapped to Consolidated Framework for Implementation Research domains and constructs to identify modifiable barriers and stakeholder-informed recommendations. Main Outcomes and Measures: Clinician-identified barriers and recommended strategies for improving pediatric hypertension detection and follow-up. Results: A total of 25 health care clinicians were interviewed (mean [range] age, 45.1 [28.0-64.0] years; 22 [88%] female). A total of 10 themes emerged; 5 major barriers to hypertension detection were identified that directly aligned with 5 themes for recommendations. Clinicians described (1) lack of standardized clinical pathways, with the recommendation to implement role-specific pathways for blood pressure measurement and follow-up; (2) insufficient training and confidence among clinicians and staff, addressed by competency-based and continuous training programs; (3) electronic medical record systems that did not support blood pressure trend analysis or decision-making, with the recommendation to redesign and optimize integration; (4) variable access to properly maintained and sized equipment, with the recommendation to ensure reliable availability and calibration; and (5) fragmented referral and communication with subspecialists, addressed by establishing structured, shared communication and referral systems. Conclusions and Relevance: This qualitative study demonstrated that improving pediatric hypertension detection requires targeted strategies that address clinician-level implementation barriers. Stakeholder-informed recommendations offer a roadmap to operationalize clinical guidelines that can improve hypertension detection.

Pediatric hypertension (HTN) affects 3%–5% of children in the United States, yet only 25% are diagnosed and 60% lack recommended follow‐up care. Skepticism about elevated blood pressure (BP) readings and reluctance to use antihypertensive medications by parents and clinicians highlight the need for stakeholder‐informed strategies to address these challenges. This study examined parents’ perceived needs, their recommended strategies to improve HTN detection, and contextual health system challenges. Parents and clinicians from 10 pediatric primary care clinics participated in semi‐structured qualitative interviews. Only parents of children with documented stage 2 BP readings and a HTN diagnosis, but with gaps in care of 1 year or longer, were included. Participants were recruited from clinics in diverse communities. Thematic analysis identified major themes and recommendations guided by the Consolidated Framework for Implementation Research (CFIR). A total of 38 stakeholders participated, including 13 parents and 25 healthcare clinicians. Parents reported limited discussions in the clinic around pediatric HTN, logistical barriers related to social determinants of health, including financial burdens and insurance issues, and scheduling conflicts. Clinicians cited systemic constraints such as time limitations, staffing shortages, and insufficient resources to address social determinants of health‐related needs. Parents recommended strategies, including enhanced education on pediatric HTN, flexible scheduling, telehealth, remote BP monitoring, and improved care coordination, to overcome barriers and align with systemic improvements. Parent‐recommended strategies can address pediatric HTN detection challenges. However, aligning these strategies with systemic constraints is essential for effective, stakeholder‐informed improvements in HTN detection.