Integrating Perioperative Care into the Treatment of Hypertension

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DESCRIPTION (provided by applicant): Candidate: Dr. Robert B. Schonberger is a board certified anesthesiologist and Assistant Professor in the Department of Anesthesiology at the Yale School of Medicine. His long-term career goal is to conduct research that aims to transform the perioperative healthcare encounter into an integrated effort at overall health promotion, disease prevention, and longitudinal care of surgical patients. His immediate research goals are 1) to establish a clinical prediction model for predicting elevated postoperative ambulatory clinic blood pressure for use by anesthesiologists to guide referral decisions, 2) to identify risk-factor for post surgical failure of preventive care follow-up, and 3) to prospectively validate the clinicl prediction model's ability to identify ambulatory surgical patients with poor blood pressure control. As he transitions to independence, Dr. Schonberger aims in the future to conduct patient-oriented perioperative interventions to improve the treatment of hypertension. Dr. Schonberger has brought together mentors from the fields of primary care, health services research, hypertension research, informatics, anesthesiology, clinical trials design, and epidemiology that have a shared commitment to the success of this research enterprise and to the development of the candidate into an independent investigator. As part of his career development, Dr. Schonberger will pursue specific training in clinical informatics and health services research, clinical trials design, and epidemiology/ biostatistics in order to attain the skills necessary to become an independent clinician-scientist. Environment: The Yale University School of Medicine and the Veterans Administration (VA) Healthcare System in West Haven, Connecticut provide robust and complementary resources to faculty pursuing clinical research. Together these centers will provide the clinical research and training resources necessary for Dr. Schonberger's research and professional development. Structured didactics for Dr. Schonberger will include a Masters degree program focusing on clinical research, affiliated coursework audited through the Robert Wood Johnson Clinical Scholars program, and the Summer Institute on Randomized Behavioral Clinical Trials sponsored by the NHLBI and the NIH Office of Behavioral and Social Sciences Research. Clinical research resources will include the diverse population of a large, urban surgery center, an affiliated primary care center, a local office of telehealth with experience implementing and tracking home blood pressure measurements, the informatics infrastructure of the Yale Center for Medical Informatics, statistical support from the Yale Center for Analytical Sciences at the Yale School of Public Health, and the national database resources of the VA Connecticut, a designated informatics center within the U.S. Veterans Administration. Research: This K23 Mentored Patient-Oriented Research Career Development Award proposes a series of three studies to establish the scientific foundations for anesthesiologist-initiated blood pressure screening and subsequent primary care referral of ambulatory surgical patients. Outside the perioperative period, the data are manifest that despite increasingly large sums of money spent on healthcare, a significant number of patients with hypertensive disease in the United States remain either undiagnosed or undertreated for their hypertension. Given the several factors that are known to cause perioperative blood pressure changes, there are currently no widely accepted parameters for blood pressure screening and follow-up specifically tailored to the perioperative period. The first study of the present award aims to develop, by means of a national electronic medical record (EMR)-based cohort, a perioperative clinical prediction model for identifying undiagnosed and poorly controlled hypertension among ambulatory surgical patients. This same EMR-based cohort will then be used for a second study that will identify the characteristics of ambulatory surgical patients at high-risk for loss to preventive care follow-up. The third study will be a prospective validation of the perioperative blood pressure referral model developed in Study 1 and will also include a patient assessment focused on the identification of experiential factors that contribute to poor blood pressure control in this study population. By aiming to decrease the long-term cardiovascular disease burden caused by undiagnosed or undertreated hypertension among ambulatory surgical patients, this project is consistent with the National Heart Lung and Blood Institute's stated mission to support research aimed at the prevention and treatment of cardiovascular disease.