Date of Award

January 2021

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Robert B. Schonberger

Second Advisor

Paul Heerdt

Abstract

SAME-DAY REFERRAL OF PATIENTS WITH ELEVATED PREOPERATIVE BLOOD PRESSURE TO PRIMARY CARE PROVIDERSShaunte Butler, Natalie Holt, Feng Dai, Catherine Quick, Jeffrey D. Kravetz, Albert Perrino Jr., Robert B. Schonberger. Department of Anesthesiology, Yale University, School of Medicine, New Haven, CT.

Although recent studies show that elevated blood pressures as measured during the preoperative evaluation are often predictive of true hypertension, it is not yet known what interventions during the preoperative evaluation may result in modifications of longitudinal blood pressure trajectories. We herein report the results of a quality improvement project at a preoperative evaluation clinic that aimed to improve hypertension treatment via same-day primary care referral of a sample of surgical patients with elevated blood pressures. Timing of hypertension follow-up and subsequent blood pressure changes in the referred group were compared to a highly similar group of hypertensive patients who underwent standard preoperative evaluations without same-day primary care referral during the same time period at the same facility.

Between June 1, 2018 and June 1, 2019, patients with elevated blood pressure at a Department of Veterans Affairs preoperative clinic were enrolled in this quality improvement initiative. These patients are typically assigned in a pseudo-random fashion to one of two primary care groups (Firm A vs. Firm B). In collaboration with Firm A clinicians, Firm A patients who presented to the preoperative testing clinic with elevated blood pressure were referred for a same day visit to primary care. In contrast Firm B patients received standard preoperative care. Charts for both groups were reviewed after 12 months to assess for changes in hypertension treatment and blood pressure.

75 patients in Firm A and 60 patients in Firm B demonstrated preoperative clinic blood pressures in the hypertensive range. There were no differences in age, sex, race, Hispanic ethnicity, body mass index (BMI), Charlson Comorbidity Index, history of smoking, or history of hypertension. 91% of hypertensive patients in Firm A were referred for same-day visit to primary care and 41.2% of those referred complied with the recommendation. There were no differences between the groups in changes in systolic blood pressure (SBP) or diastolic blood pressure (DBP) within 3, 6, 9, or 12 months. However, those in Firm A that complied with the intervention were more likely than Firm A patients that did not follow the intervention and Firm B patients to receive hypertension treatment intensification within 3, 6, and 9 months (p<0.001, p<0.01, and p<0.05, respectively).

In conclusion, among patients presenting for preoperative evaluation with elevated blood pressures, approximately 41% demonstrate willingness to attend same-day primary care referral for hypertension evaluation. Patients who accepted such primary care referral demonstrated increased rates of treatment intensification but did not demonstrate a difference in changes in blood pressure compared to the standard care group. Future studies should include more patients to increase the power to detect clinically significant differences in blood pressure changes and systematically survey patients and primary care providers to explore the reasons for low adherence rates to the intervention and barriers for antihypertensive treatment intensification.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 10/12/2023

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