Same-Day Primary Care Referral Versus Usual Care for Patients With Elevated Blood Pressures Seen in a Preoperative Clinic

TL;DR

A study tested same-day primary care referrals for patients with high blood pressure seen before surgery, finding faster treatment adjustments but no immediate improvement in blood pressure control.

Contribution

This study introduces a pragmatic approach to hypertension management through same-day primary care referrals in preoperative settings.

Findings

Same-day referrals led to faster hypertension treatment intensification compared to usual care.

Blood pressure levels remained similar between groups at 3, 6, 9, and 12 months.

91% of patients were correctly referred, but only 41.2% attended the same-day primary care visit.

Abstract

Background

While several studies have suggested that anesthesia and surgical care episodes provide an opportunity to improve the diagnosis and treatment of hypertension, few studies have implemented and tested pragmatic care coordination efforts for this population. The present study aimed to examine the effects of same-day primary care referral vs. usual care on outpatient hypertension treatment among patients with elevated preoperative clinic blood pressure (BP).

Methodology

With institutional review board approval of the project as a quality improvement (QI) initiative not requiring consent, we conducted a prospective QI project comparing same-day preoperative primary care referral vs. usual care within comparable cohorts of US Veterans presenting to a preoperative evaluation clinic with elevated BP for whom treatment assignment was based on prior primary care clinic affiliation. Outpatient BP, antihypertensive medications, and antihypertensive dosages at the initial visit and for one year after the initial preoperative clinic visit were followed in the electronic health record.

Results

Between June 1, 2018, and June 1, 2019, one of the two on-site primary care groups (Firm A) at our facility agreed to accommodate same-day BP referrals. Patients in the second primary care group received standard preoperative care (Firm B). Charts for the pseudo-randomized cohort of Firm A and B patients were compared after 12 months to assess for changes in BP and hypertension treatment. Firm A and B patients were similar in demographics. Overall, 68 (91%) Firm A patients were correctly referred for primary care appointments. Moreover, 28 of 68 (41.2%) patients adhered to the same-day referral recommendation, with the remainder declining to attend the primary care visit. BPs were similar between Firm A and Firm B groups at 3, 6, 9, and 12 months post-intervention. Firm A adherent patients (i.e., those attending the referral) received hypertension treatment intensification sooner than Firm A non-adherent and Firm B patients (median (interquartile range) days to intensification = 21 (0.5-103.5) vs. 154 (45.5-239) and 170 (48-220), respectively; p = 0.038 and p = 0.048, respectively).

Conclusions

Our protocol achieved a high degree of same-day primary care referral (91%) in hypertensive patients presenting at the preoperative clinic. Although this limited study did not demonstrate improved BP control in patients who received same-day primary care, this group did show increased rates of rapid treatment intensification which may infer improved long-term health outcomes. Further work examining logistical barriers to patients attending same-day referrals is warranted.

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