Feasibility of a randomized hypertension screening initiative in the perioperative setting

Sofia I Diaz, Luying Yan, Feng Dai, Bin Zhou, Matthew M Burg, Robert B Schonberger, Sofia I Diaz, Luying Yan, Feng Dai, Bin Zhou, Matthew M Burg, Robert B Schonberger

Abstract

Objectives: This study sought to assess feasibility of a randomized trial of blood pressure intervention (home blood pressure monitoring vs. counseling) in the preoperative clinic and the baseline rates of primary care follow-up after such interventions.

Methods: A prospective randomized feasibility study was performed at Yale New Haven Hospital Preadmission Testing Clinic. A sample of 100 adults, with elevated blood pressure, were recruited during their preadmission visit, and randomized 1:1 to receive brief BP counseling and an educational brochure versus additionally receiving a home BP monitor (HBPM) with a mailed report of their home readings. At 60-day post-surgery telephone follow-up, investigators asked whether participants had primary-care follow-up; had new/adjusted hypertension treatment; and felt satisfied with the study.

Results: There were 51 patients in the counseling group and 49 in the HBPM group. Of 46 patients in the HBPM group who returned their monitors, 36 (78%) were hypertensive at home. At 60 days post-surgery, 31 (61%) patients in the counseling group and 30 (61%) in the HBPM group were reached by telephone with the remaining followed by EHR. Thirty-six (71%) patients in the counseling group and 36 (73%) in the HBPM group had seen their primary care provider. Seventeen of 36 (47%) in the counseling group and 18 of 31 (58%) in the HBPM group received new or adjusted hypertension medications. Sixty-one participants answered questions regarding their satisfaction with the study with 52 (85%) reporting that they felt moderately to very satisfied.

Conclusions: This feasibility study suggests that interventional blood pressure trials in the preoperative clinic are feasible, but telephone follow-up leads to significant gaps in outcome ascertainment.

Trial registration: Clinicaltrials.gov, NCT03634813 . Registered 16 of August 2018.

Keywords: Home blood pressure monitoring; Hypertension; Preoperative blood pressure screening.

Conflict of interest statement

Dr. Schonberger reports owning stock in Johnson & Johnson. Dr. Schonberger reports that his institution receives funding from Merck, Inc. on a study with which he is involved.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Post-operative questionnaire. PCP, primary care physician; BP, blood pressure; HBPM, home blood pressure monitoring
Fig. 2
Fig. 2
Flow chart depicting allocation of randomized participants and main results. HBPM, home blood pressure monitor; PCP, primary care physician; EHR, electronic health record
Fig. 3
Fig. 3
Home blood pressure monitor cutoffs. Cutoff used was mean systolic HBP ≥ 135 mmHg or mean diastolic HBP ≥ 85 mmHg. HBP, home blood pressure; SBP, systolic blood pressure; DBP, diastolic blood pressure
Fig. 4
Fig. 4
Percentage of patients with changes in their blood pressure treatment at 60 days of follow-up. Both the counseling and HBPM group had an even distribution regarding treatment. HTN, hypertension; HBPM, home blood pressure monitoring group
Fig. 5
Fig. 5
60-day follow-up satisfaction questionnaire. Satisfaction scores measured with a 5-point Likert scale. Values given in number of patients that answered each individual question. HBPM, home blood pressure monitor

References

    1. Aronson S. Moving toward a cardiovascular perioperative enhancement team. J Cardiothorac Vasc Anesth. 2016;30(4):1067–1075. doi: 10.1053/j.jvca.2016.03.016.
    1. Aronson S, Westover J, Guinn N, Setji T, Wischmeyer P, Gulur P, Hopkins T, Seyler TM, Lagoo-Deendayalan S, Heflin MT, Thompson A, Swaminathan M, Flanagan E. A perioperative medicine model for population health: an integrated approach for an evolving clinical science. Anesth Analg. 2018;126(2):682–690. doi: 10.1213/ANE.0000000000002606.
    1. Bosworth HB, Powers BJ, Olsen MK, McCant F, Grubber J, Smith V, Gentry PW, Rose C, van Houtven C, Wang V, Goldstein MK, Oddone EZ. Home blood pressure management and improved blood pressure control: results from a randomized controlled trial. Arch Intern Med. 2011;171(13):1173–1180. doi: 10.1001/archinternmed.2011.276.
    1. Cahan A, Ben-Dov IZ, Mekler J, Bursztyn M. The role of blood pressure variability in misdiagnosed clinic hypertension. Hypertension Res. 2011;34(2):187–192. doi: 10.1038/hr.2010.190.
    1. Coleman A, Freeman P, Steel S, Shennan A. Validation of the Omron MX3 Plus oscillometric blood pressure monitoring device according to the European Society of Hypertension international protocol. Blood Pressure Monit. 2005;10(3):165–168. doi: 10.1097/00126097-200506000-00009.
    1. Grimm RH, Jr, Cohen JD, Smith WM, Falvo-Gerard L, Neaton JD. Hypertension management in the Multiple Risk Factor Intervention Trial (MRFIT). Six-year intervention results for men in special intervention and usual care groups. Arch Intern Med. 1985;145(7):1191–1199. doi: 10.1001/archinte.1985.00360070061010.
    1. Levine DM, Landon BE, Linder JA. Quality and experience of outpatient care in the United States for adults with or without primary care. JAMA Intern Med. 2019;179(3):363–372. doi: 10.1001/jamainternmed.2018.6716.
    1. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, AlMazroa MA, Amann M, Anderson HR, Andrews KG, Aryee M, Atkinson C, Bacchus LJ, Bahalim AN, Balakrishnan K, Balmes J, Barker-Collo S, Baxter A, Bell ML, Blore JD, Blyth F, Bonner C, Borges G, Bourne R, Boussinesq M, Brauer M, Brooks P, Bruce NG, Brunekreef B, Bryan-Hancock C, Bucello C, Buchbinder R, Bull F, Burnett RT, Byers TE, Calabria B, Carapetis J, Carnahan E, Chafe Z, Charlson F, Chen H, Chen JS, Cheng ATA, Child JC, Cohen A, Colson KE, Cowie BC, Darby S, Darling S, Davis A, Degenhardt L, Dentener F, Des Jarlais DC, Devries K, Dherani M, Ding EL, Dorsey ER, Driscoll T, Edmond K, Ali SE, Engell RE, Erwin PJ, Fahimi S, Falder G, Farzadfar F, Ferrari A, Finucane MM, Flaxman S, Fowkes FGR, Freedman G, Freeman MK, Gakidou E, Ghosh S, Giovannucci E, Gmel G, Graham K, Grainger R, Grant B, Gunnell D, Gutierrez HR, Hall W, Hoek HW, Hogan A, Hosgood HD, III, Hoy D, Hu H, Hubbell BJ, Hutchings SJ, Ibeanusi SE, Jacklyn GL, Jasrasaria R, Jonas JB, Kan H, Kanis JA, Kassebaum N, Kawakami N, Khang YH, Khatibzadeh S, Khoo JP, Kok C, Laden F, Lalloo R, Lan Q, Lathlean T, Leasher JL, Leigh J, Li Y, Lin JK, Lipshultz SE, London S, Lozano R, Lu Y, Mak J, Malekzadeh R, Mallinger L, Marcenes W, March L, Marks R, Martin R, McGale P, McGrath J, Mehta S, Memish ZA, Mensah GA, Merriman TR, Micha R, Michaud C, Mishra V, Hanafiah KM, Mokdad AA, Morawska L, Mozaffarian D, Murphy T, Naghavi M, Neal B, Nelson PK, Nolla JM, Norman R, Olives C, Omer SB, Orchard J, Osborne R, Ostro B, Page A, Pandey KD, Parry CDH, Passmore E, Patra J, Pearce N, Pelizzari PM, Petzold M, Phillips MR, Pope D, Pope CA, III, Powles J, Rao M, Razavi H, Rehfuess EA, Rehm JT, Ritz B, Rivara FP, Roberts T, Robinson C, Rodriguez-Portales JA, Romieu I, Room R, Rosenfeld LC, Roy A, Rushton L, Salomon JA, Sampson U, Sanchez-Riera L, Sanman E, Sapkota A, Seedat S, Shi P, Shield K, Shivakoti R, Singh GM, Sleet DA, Smith E, Smith KR, Stapelberg NJC, Steenland K, Stöckl H, Stovner LJ, Straif K, Straney L, Thurston GD, Tran JH, van Dingenen R, van Donkelaar A, Veerman JL, Vijayakumar L, Weintraub R, Weissman MM, White RA, Whiteford H, Wiersma ST, Wilkinson JD, Williams HC, Williams W, Wilson N, Woolf AD, Yip P, Zielinski JM, Lopez AD, Murray CJL, Ezzati M. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2224–2260. doi: 10.1016/S0140-6736(12)61766-8.
    1. Mallick S, Kanthety R, Rahman M. Home blood pressure monitoring in clinical practice: a review. Am J Med. 2009;122(9):803–810. doi: 10.1016/j.amjmed.2009.02.028.
    1. Myers MG, Godwin M, Dawes M, Kiss A, Tobe SW, Grant FC, Kaczorowski J. Conventional versus automated measurement of blood pressure in primary care patients with systolic hypertension: randomised parallel design controlled trial. BMJ. 2011;342(feb07 1):d286. doi: 10.1136/bmj.d286.
    1. National Heart, Lung, and Blood Institute; National Institutes of Health; US Department of Health and Human Services; “Your Guide to Lowering Blood Pressure”(url: as Accessed Nov 2018).
    1. Ostchega Y, Yoon S, Hughes J, Louis T. Services USDoHaH, editor: Centers for Disease Control and Prevention; National Center for Health Statistics. 2008. Hypertension awareness, treatment, and control - continued disparities in adults: United States 2005-2006.
    1. Pfister C-L, Govender S, Dyer RA, et al. A multicenter, cross-sectional quality improvement project: the perioperative implementation of a hypertension protocol by anesthesiologists. Anesth Analg. 2020;131(5):1401–1408. doi: 10.1213/ANE.0000000000004966.
    1. Roerecke M, Kaczorowski J, Myers MG. Comparing automated office blood pressure readings with other methods of blood pressure measurement for identifying patients with possible hypertension: a systematic review and meta-analysis. JAMA Intern Med. 2019;179(3):351–62. 10.1001/jamainternmed.2018.6551.
    1. Schonberger RB. Rebranding the perioperative surgical home: lessons from the Duke experience. J Cardiothorac Vasc Anesth. 2016;30(4):1064–1066. doi: 10.1053/j.jvca.2016.03.143.
    1. Schonberger RB, Burg MM, Holt NF, Lukens CL, Dai F, Brandt C. The relationship between day-of-surgery and primary care blood pressure among Veterans presenting from home for surgery. Is there evidence for anesthesiologist-initiated blood pressure referral? Anesth Analg. 2012;114(1):205–214. doi: 10.1213/ANE.0b013e318239c4c1.
    1. Schonberger RB, Dai F, Brandt CA, Burg MM. Balancing model performance and simplicity to predict postoperative primary care blood pressure elevation. Anesth Analg. 2015;121(3):632–641. doi: 10.1213/ANE.0000000000000860.
    1. Schonberger RB, Nwozuzu A, Zafar J, Chen E, Kigwana S, Monteiro MM, Charchaflieh J, Sophanphattana S, Dai F, Burg MM. Elevated preoperative blood pressures in adult surgical patients are highly predictive of elevated home blood pressures. J Am Soc Hypertens. 2018;12(4):303–310. doi: 10.1016/j.jash.2018.01.012.
    1. Stamler J, Neaton JD, Wentworth DN. Blood pressure (systolic and diastolic) and risk of fatal coronary heart disease. Hypertension. 1989;13(5 Suppl):I2–12. doi: 10.1161/01.hyp.13.5_suppl.i2.
    1. Tanabe P, Persell SD, Adams JG, McCormick JC, Martinovich Z, Baker DW. Increased blood pressure in the emergency department: pain, anxiety, or undiagnosed hypertension? Ann Emerg Med. 2008;51(3):221–229. doi: 10.1016/j.annemergmed.2007.10.017.
    1. Tsuji I, Imai Y, Nagai K, et al. Proposal of reference values for home blood pressure measurement: prognostic criteria based on a prospective observation of the general population in Ohasama, Japan. Am J Hypertension. 1997;10:409–418.
    1. Victor RG, Lynch K, Li N, Blyler C, Muhammad E, Handler J, Brettler J, Rashid M, Hsu B, Foxx-Drew D, Moy N, Reid AE, Elashoff RM. A cluster-randomized trial of blood-pressure reduction in black barbershops. N E J Med. 2018;378(14):1291–1301. doi: 10.1056/NEJMoa1717250.
    1. Voils CI, Maciejewski ML, Hoyle RH, Reeve BB, Gallagher P, Bryson CL, Yancy WS. Initial validation of a self-report measure of the extent of and reasons for medication nonadherence. Med Care. 2012;50(12):1013–1019. doi: 10.1097/MLR.0b013e318269e121.
    1. Whelton PK, Carey RM, Aronow WS, Casey de Jr, Collins KJ, Dennison Himmelfarb C, DePalma S, Gidding S, Jamerson KA, Jones DW, MacLaughlin E, Muntner P, Ovbiagele B, Smith SC Jr, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA Sr, Williamson JD, Wright JT Jr 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Hypertension. 2018;71(6):1269–1324. doi: 10.1161/HYP.0000000000000066.
    1. Xu W, Goldberg SI, Shubina M, Turchin A. Optimal systolic blood pressure target, time to intensification, and time to follow-up in treatment of hypertension: population based retrospective cohort study. BMJ. 2015;350(feb05 9):h158. doi: 10.1136/bmj.h158.

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