Association of a Remote Blood Pressure Monitoring Program With Postpartum Adverse Outcomes

Risk factors for emergency department visits and readmissions for postpartum hypertension

OBJECTIVE

Postpartum hypertension accounts for 15 to 20% of postpartum Emergency Department (ED) visits and readmissions in the United States. Postpartum readmission is a quality metric and target of quality improvement as it indicates poor control of hypertension and can portend increased morbidity. We aim to evaluate risk factors for postpartum ED visits and readmissions for hypertension.

METHODS

This was a retrospective cohort study of all birthing patients with peripartum hypertension at a single tertiary care center over a 5-year period (2017-2022). Inclusion criteria were age 18 years or above, existing diagnosis of chronic hypertension or hypertensive disease of pregnancy diagnosed during the intrapartum or postpartum course, and both delivery and ED visit or readmission at the study institution. Maternal baseline and intrapartum characteristics were chart abstracted. Primary outcome was ED visit or readmission (EDR) for postpartum hypertension. Patients who had EDR within 42 days of delivery were compared to those who underwent routine outpatient surveillance. For all analyses, p values were two-way, and the level of statistical significance was set at p < 0.05.

RESULTS

Of 16,162 patients who gave birth during the study period, 2403 (14.9%) patients met the definition of peripartum hypertension. 218 (9.1%) presented to the ED or were readmitted for hypertension. Risk factors for EDR were as follows: maternal age ≥40 years (22.9% vs 15.3%, p = 0.003), prenatal aspirin use (6.9% vs 3.9%, p = 0.039), cesarean delivery (42.7% vs 35.8%, p = 0.044), chronic hypertension (37.2% vs 31.6%, p = 0.029), preeclampsia with severe features (32.6% vs 15.6%, p < 0.001), postpartum hemorrhage (22.9% vs 12.0%, p < 0.001), and intrapartum need for intravenous anti-hypertensives (23.9% vs 3.3%, p < 0.001). Factors at discharge that increased risk of EDR included prescription of anti-hypertensives at discharge (27.5% vs 8.6%, p < 0.001) and having >50% elevated blood pressures within the 24 h prior to discharge (16.5% vs 11.9%, p = 0.046). In a multivariable logistic regression controlling for prenatal aspirin use, mode of delivery, postpartum hemorrhage, and chorioamnionitis, a higher risk of EDR remained for maternal age ≥40 years (aOR, 1.56; 95% confidence interval (CI), 1.11-2.20; p = 0.011), PO anti-hypertensives at discharge (aOR, 4.05; 95% CI, 2.86-5.73; p < 0.001), preeclampsia with severe features (aOR, 2.50; 95% CI, 1.83-3.42; p < 0.001), and history of IV anti-hypertensive exposure (aOR, 9.30; 95% CI, 6.20-13.95; p < 0.001).

CONCLUSIONS

Maternal age of 40 years and above, chronic hypertension, preeclampsia with severe features, prescription of anti-hypertensives on discharge, and elevated blood pressures leading up to discharge are associated with postpartum ED visits or readmissions for hypertension. Risk factor identification can aid in the development of predictive tools to determine high risk groups and interventions to reduce ED visits and readmissions.

Postpartum remote blood pressure monitoring and risk of hypertensive-related readmission: systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To assess the efficacy of remote blood pressure monitoring to prevent readmission due to complications of hypertensive disorders of pregnancy.

METHODS

The search was conducted using MEDLINE, EMBASE, Web-of-Sciences, Scopus, ClinicalTrial.gov, OVID and Cochrane-Library as electronic databases from the inception of each database to November 2023. Selection criteria included randomized controlled trials of postpartum individuals randomized to remote blood pressure monitoring or telehealth strategies vs. routine-care. The primary outcome was postpartum readmission, defined as postpartum hospital admission after discharge. Secondary maternal outcomes included stroke, eclampsia, ICU-admission, maternal death, emergency department visit, ascertainment of a blood pressure measurement within 7-10 days after delivery, attendance of the 4-6-week postpartum visit. The summary measures were reported as relative risk (RR) or as mean difference (MD) with 95 % confidence intervals (CI).

RESULTS

Four RCTs including 714 individuals randomized to either telematic reporting of blood pressure measurements (n=356, 49.8 %) or standard postpartum care (n=358, 50.1 %). There were no significant differences in the rate of hospital readmission due to hypertensive related causes (5.3 % vs. 11.8 %). However, emergency department visit rate differed significantly among the two groups (9.0 % vs. 4.4 %). With regards to postpartum follow up, blood pressure assessment at 10 days postpartum and 4-6-week postpartum visit attendance rate were similar. No included RCT provided data on maternal secondary outcome like pulmonary edema, stroke, maternal death, and ICU admission.

CONCLUSIONS

Remote blood pressure monitoring is not superior to standard care to prevent hypertensive related readmission and increases emergency department visits.

Remote blood pressure monitoring in women at risk of or with hypertensive disorders of pregnancy: A systematic review and meta-analysis

BACKGROUND

Remote blood pressure monitoring refers to an organized framework that either allows clinicians to review home-based blood pressure readings and institute management, or provide participants with clear instructions for contacting care teams when blood pressure readings are out of prespecified targets. With widespread uptake of telemonitoring and mobile health in recent years, such models of care have been increasingly described in the literature.

OBJECTIVES

This study aimed to review remote blood pressure monitoring in pregnant and postpartum women who are at high-risk for or have an established diagnosis of hypertensive disorders of pregnancy, and its effect on maternal and fetal outcomes, healthcare utilization and psychosocial outcomes.

SEARCH STRATEGY

PubMed, Medline, Embase, Cochrane Library, Web of Science and CINAHL databases were searched electronically in June 2024 to their inception.

STUDY SELECTION CRITERIA

Included studies compared remote blood pressure monitoring with standard care. Remote blood pressure monitoring was pre-defined as any framework for measuring blood pressure remotely in pregnancy, with organized review by clinicians. Published full-text and study abstracts describing randomized controlled trials and observational studies were included. The study population was pregnant women at high-risk for developing pre-eclampsia or postpartum (<6 weeks) women with an established diagnosis of a hypertensive disorder of pregnancy. Remote blood pressure monitoring undertaken in the antenatal and postnatal periods were analyzed separately.

DATA COLLECTION AND ANALYSIS

This systematic review was conducted according to the Preferred Reporting Item for Systematic Reviews and Meta-Analyses statement. Screening of records and data extraction were independently performed. Data were extracted and analyzed using Review Manager software (version 5.4; Cochrane Collaboration, Copenhagen, Denmark). Risk of bias and quality assessment was performed independently using the Risk Of Bias In Non-randomized Studies-of Interventions (ROBINS-I) assessment tool and the Cochrane Risk of Bias 2 (RoB2) tool.

MAIN RESULTS

A total of 18 studies with 28 094 patients were included. Antenatal remote blood pressure monitoring reduces antenatal outpatient visits, antenatal hospital admissions for any cause, and antenatal hospital admissions specifically for hypertension. Importantly, there was no increase in adverse maternal and fetal outcomes, including the likelihood of cesarean section deliveries or induction of labor due to hypertension, composite maternal outcome, growth restriction, neonatal intensive care unit admissions, gestational age at delivery and the composite fetal outcome. Psychosocial outcomes were also not significantly different between the remote blood pressure monitoring and usual care groups. Postpartum remote blood pressure monitoring in women with an established hypertensive disorder of pregnancy led to greater compliance with blood pressure follow-up within 10 days, with no increase in unscheduled hypertension-related presentations, postpartum readmissions or outpatient antihypertensive prescription.

CONCLUSIONS

Utilizing a model of remote blood pressure monitoring which incorporates organized review and management by clinicians, may reduce antenatal outpatient visits and admissions, without increasing adverse fetal and maternal outcomes, in pregnant women who require frequent monitoring of their blood pressure. In postpartum women with a hypertensive disorder of pregnancy, remote blood pressure monitoring can improve guideline recommended follow-up within 10 days. However, the meta-analysis was hampered by study heterogeneity and a paucity of high-quality evidence. Further randomized controlled trials are needed to confirm the findings of this review and provide recommendations.

Hypertension in Pregnancy and Postpartum: Current Standards and Opportunities to Improve Care

Hypertension in pregnancy contributes substantially to maternal morbidity and mortality, persistent hypertension, and rehospitalization. Hypertensive disorders of pregnancy are also associated with a heightened risk of cardiovascular disease, and timely recognition and modification of associated risk factors is crucial in optimizing long-term maternal health. During pregnancy, there are expected physiologic alterations in blood pressure (BP); however, pathophysiologic alterations may also occur, leading to preeclampsia and gestational hypertension. The diagnosis and effective management of hypertension during pregnancy is essential to mitigate maternal risks, such as acute kidney injury, stroke, and heart failure, while balancing potential fetal risks, such as growth restriction and preterm birth due to altered uteroplacental perfusion. In the postpartum period, innovative and multidisciplinary care solutions that include postpartum maternal health clinics can help optimize short- and long-term care through enhanced BP management, screening of cardiovascular risk factors, and discussion of lifestyle modifications for cardiovascular disease prevention. As an adjunct to or distinct from postpartum clinics, home BP monitoring programs have been shown to improve BP ascertainment across diverse populations and to lower BP in the months after delivery. Because of concerns about pregnant patients being a vulnerable population for research, there is little evidence from trials examining the diagnosis and treatment of hypertension in pregnant and postpartum individuals. As a result, national and international guidelines differ in their recommendations, and more studies are needed to bolster future guidelines and establish best practices to achieve optimal cardiovascular health during and after pregnancy. Future research should focus on refining treatment thresholds and optimal BP range peripartum and postpartum and evaluating interventions to improve postpartum and long-term maternal cardiovascular outcomes that would advance evidence-based care and improve outcomes worldwide for people with hypertensive disorders of pregnancy.

Telehealth to Address Preventable Maternal Deaths: A Call to Action

Over 80% of maternal deaths are preventable. Telehealth approaches can help address disparities by increasing access to quality maternal health care. In this position statement, we advocate for the utility of telehealth to address maternal mortality disparities, focusing specifically on the postpartum period, where most maternal deaths occur. Specifically, we describe how telehealth visits, mobile health applications, and wearable devices for remote patient monitoring can be used to promote the uptake of postpartum care and adherence to evidence-based treatment for the most common causes of maternal death (i.e., cardiovascular conditions and mental health-related conditions). We discuss challenges that must be overcome to ensure the broad and equitable reach of telehealth and identify specific action steps to address this pressing public health issue.

Postpartum Management of Hypertensive Disorders of Pregnancy in Six Large U.S. Hospital Systems: Descriptive Review and Identification of Clinical and Research Gaps

Hypertensive disorders of pregnancy (HDPs) are a key contributor to maternal morbidity and mortality. Several gaps in knowledge remain regarding best practices in the postpartum management of HDPs. In this review, we describe postpartum HDPs management among six large academic U.S. hospital systems: Medical College of Wisconsin, University of Pittsburgh, University of Wisconsin-Madison, Northwestern University, University of Minnesota, and Boston Medical Center. We identified that all six health systems discharge patients with HDPs diagnosed with a blood pressure (BP) cuff and use the same two antihypertensive medications, nifedipine and labetalol, as first- and second-line treatment of HDPs. Northwestern University routinely adds oral furosemide for 5 days for patients with BP that exceeds 150/100 mm Hg. Most hospital systems administer magnesium sulfate routinely when readmission for HDPs occurs. In contrast, there was variation in BP threshold for antihypertensive treatment initiation, use of remote BP monitoring program, use of a transition clinic, delivery or lack of education on long-term cardiovascular disease risk, and BP management through the first 6 weeks postpartum and beyond. Based on the clinical review, we identified clinical gaps and formulated considerations for research priorities in the field of postpartum HDPs management. KEY POINTS: · Several gaps in knowledge remain regarding best practices in postpartum management of HDPs.. · There is a variation in the BP threshold for antihypertensive treatment initiation.. · Data are lacking on the reduction in severe maternal morbidity (SMM) and racial disparities in SMM with remote monitoring..

Public health and system approach in eliminating disparities in hypertensive disorders and cardiovascular outcomes in non-Hispanic Black women across the pregnancy life course

Hypertension is one of the leading risk factors for cardiovascular disease. The ACC/AHA/Multisociety hypertension guideline covered all aspects of the recommendations for optimal blood pressure diagnosis and management to improve cardiovascular outcomes. Despite this, there remains a growing prevalence of hypertension within the United States, largely in non-Hispanic Black women at earlier stages of their life course. This highlights the evident racial disparities, but offers a targeted opportunity for improved outcomes. With hypertension increasingly seen in the antenatal and immediate postpartum period, and obstetrics societies weighing in on the need to alter pharmacotherapy initiation goals, national initiatives have purposefully targeted pregnant and postpartum women in an effort to improve outcomes. This same energy must also re-focus health care efforts across the entire health continuum. Public health and system strategies are in place to do so, with the strongest enforcing initiatives as early as childhood with a greater focus on primordial prevention.

Extended postpartum outcomes with systematic treatment of and management of postpartum hypertension program

OBJECTIVE

The purpose of this study was to examine the long-term effect of a quality improvement initiative at one-year post delivery.

STUDY DESIGN

This was a retrospective study of 1480 patients who delivered between October 2018 and June 2020 at the study institution and were enrolled in the Systematic Treatment and Management of PostPartum Hypertension Program (STAMPP). Patients received standardized cuffs, education, and follow-up. At the six-week postpartum follow-up, patients were again given instructions to establish follow-up.

MAIN OUTCOME MEASURES

The primary outcome was a visit with a primary care physician (PCP) or cardiologist between 6 weeks and 1 year postpartum.

RESULTS

A total of 939 (63 %) patients had some follow-up within twelve months. Of these, 113 (12 %) and 175 (19 %) had follow-up with cardiology and primary care providers, respectively. Patients with no follow-up were more likely to have public aid (73.9 % vs 60.3 %; p < 0.001). 77 % identified as Black, with only 12 % of this cohort following up with cardiology and 13 % with a PCP.

CONCLUSIONS

Despite specific counseling about long term follow-up, a minority of patients completed one year follow-up, notably amongst Black patients and those with public insurance. Further work is needed to optimize long-term follow-up after HDP to reduce the prevalence of cardiovascular disease, especially amongst high-risk patients.

Moving the needle: Quality improvement strategies to achieve guideline-concordant care of obstetric patients with severe hypertension

OBJECTIVES

To improve timely treatment and follow-up of birthing individuals with severe hypertension.

STUDY DESIGN

A quality improvement (QI) initiative was implemented at an academic tertiary care center in the United States of America for individuals with obstetric hypertensive emergencies. Statistical process control charts were utilized to track process measures and interventions tested through plan-do-study-act cycles. Measures were disaggregated by race and ethnicity to identify and improve disparities.

MAIN OUTCOME MEASURES

Treatment of hypertensive events within 60 min, receipt of blood pressure (BP) device at discharge and completed postpartum follow-up BP check within 7 days of discharge.

RESULTS

All process measures showed statistically significant improvements. The primary process measure, timely treatment of hypertensive emergencies, improved from 29 % to 76 %. Receipt of BP device improved from 37 % to 91 % and follow-up BP checks from 58 % to 81 %. No racial or ethnic disparities were noted at baseline or after interventions. Readmission rates within 6 weeks of delivery increased from 2.3 % to 6.1 % for the cohort with no severe morbidity or mortality events after discharge. Strategies associated with improvement included project launch with establishment of the "why," telehealth, simulation, a video display of quality metrics on the birthing unit, promoting BP cuff access, and automated orders.

CONCLUSIONS

This comprehensive QI initiative provides novel improvement strategies for the management of individuals with severe hypertensive disorders of pregnancy for the timely treatment of severe BP, attainment of home BP devices, and follow-up after discharge. Quality improvement methodology is practical and essential for achieving guideline-concordant care.

A rapid review of telehealth in women with recent de novo hypertensive disease of pregnancy

Hypertensive disorders of pregnancy pose significant risks to both maternal and fetal health. Postpartum hypertension, a common complication, often leads to emergency room (ER) visits or hospital readmissions. Despite the prevalence of these complications, there is a paucity of studies that focus on blood pressure monitoring in postpartum patients with de novo hypertensive disorders of pregnancy. This review aimed to address the gap by evaluating available evidence to compare telehealth monitoring with in-person visits in preventing ER visits and hospital readmissions among postpartum patients with de novo hypertensive disorders of pregnancy. The study identified relevant studies by conducting a rigorous search strategy (Medline/OVID, the Cochrane Library, Scopus, and research registries such as the International Clinical Trials Registry Platform [ICTRP] and clinical trials) directed by the clinical information specialist. Two reviewers independently screened titles and abstracts, resolving discrepancies with the assistance of a third reviewer. Data extraction followed standardized protocols, and risk of bias assessments were conducted using appropriate tools. This rapid review synthesized evidence from 11 studies on telehealth for women with recent de novo hypertensive disorders of pregnancy. Findings highlighted that telemonitoring led to earlier blood pressure documentation and intervention, reduced disparities in blood pressure measurement, decreased hypertension-related readmissions, higher rates of postpartum antihypertensive treatment initiation, and increased patient satisfaction. Telehealth emerges as a promising tool for managing postpartum hypertension among women with recent de novo hypertensive disorders of pregnancy.

Cardiovascular Risk Factor Management After Hypertensive Disorders of Pregnancy

Hypertensive disorders of pregnancy (HDP) are associated with significantly increased risk of developing future cardiovascular disease (CVD). Obstetricians play a crucial role in CVD prevention for postpartum women and birthing people with HDP because they are primarily responsible for immediate postpartum management and can assist with care transitions to other health care practitioners for long-term management of CVD risk factors. Standardized calculators can be used to evaluate long-term CVD risk, which can help guide intensity of treatment. Emerging technologies such as remote blood pressure monitoring demonstrate promise for improving outcomes among patients with HDP. After HDP, all patients should be advised of their increased CVD risk. A plan should be made to initiate lifestyle modifications and antihypertensive therapy to achieve optimal blood pressure control with a target of lower than 130/80 mm Hg, assess lipids within 2-3 years of delivery, and evaluate for development of type 2 diabetes. Other CVD risk factors such as nicotine use should similarly be identified and addressed. In this review, we summarize the essential components of managing CVD risk after a pregnancy complicated by HDP, including blood pressure monitoring, risk stratification tools, and evidence-based lifestyle recommendations.

Remote blood pressure management for postpartum hypertension: a cost-effectiveness analysis

BACKGROUND

Recognizing the importance of close follow-up after hypertensive disorders of pregnancy, many centers have initiated programs to support postpartum remote blood pressure management.

OBJECTIVE

This study aimed to evaluate the cost-effectiveness of remote blood pressure management to determine the scalability of these programmatic interventions.

STUDY DESIGN

This was a cost-effectiveness analysis of using remote blood pressure management vs usual care to manage postpartum hypertension. The modeled remote blood pressure management included provision of a home blood pressure monitor, guidance on warning symptoms, instructions on blood pressure self-monitoring twice daily, and clinical staff to manage population-level blood pressures as appropriate. Usual care was defined as guidance on warning symptoms and recommendations for 1 outpatient visit for blood pressure monitoring within a week after discharge. This study designed a Markov model that ran over fourteen 1-day cycles to reflect the initial 2 weeks after delivery when most emergency department visits and readmissions occur and remote blood pressure management is clinically anticipated to be most impactful. Parameter values for the base-case scenario were derived from both internal data and literature review. Quality-adjusted life-years were calculated over the first year after delivery and reflected the short-term morbidities associated with hypertensive disorders of pregnancy that, for most birthing people, resolve by 2 weeks after delivery. Sensitivity analyses were performed to assess the strength and validity of the model. The primary outcome was the incremental cost-effectiveness ratio, which was defined as the cost needed to gain 1 quality-adjusted life-year. The secondary outcome was incremental cost per readmission averted. Analyses were performed from a societal perspective.

RESULTS

In the base-case scenario, remote blood pressure management was the dominant strategy (ie, cost less, higher quality-adjusted life-years). In univariate sensitivity analyses, the most cost-effective strategy shifted to usual care when the cost of readmission fell below $2987.92 and the rate of reported severe range blood pressure with a response in remote blood pressure management was <1%. Assuming a willingness to pay of $100,000 per quality-adjusted life-year, using remote blood pressure management was cost-effective in 99.28% of simulations in a Monte Carlo analysis. Using readmissions averted as a secondary effectiveness outcome, the incremental cost per readmission averted was $145.00.

CONCLUSION

Remote blood pressure management for postpartum hypertension is cost saving and has better outcomes than usual care. Our data can be used to inform future dissemination of and support funding for remote blood pressure management programs.

Implementation of a Cell-Enabled Remote Blood Pressure Monitoring Program During the Postpartum Period at a Safety-Net Hospital

BACKGROUND

Postpartum hypertension is a risk factor for severe maternal morbidity; however, barriers exist for diagnosis and treatment. Remote blood pressure (BP) monitoring programs are an effective tool for monitoring BP and may mitigate maternal health disparities. We aimed to describe and evaluate engagement in a remote BP monitoring program on BP ascertainment during the first 6-weeks postpartum among a diverse patient population.

METHODS AND RESULTS

A postpartum remote BP monitoring program, using cell-enabled technology and delivered in multiple languages, was implemented at a large safety-net hospital. Eligible patients are those with hypertensive disorders before or during pregnancy. We describe characteristics of patients enrolled from January 2021 to May 2022 and examine program engagement by patient characteristics. Linear regression models were used to calculate mean differences and 95% CIs between characteristics and engagement metrics. We describe the prevalence of patients with BP ≥140/or >90 mm Hg. Among 1033 patients, BP measures were taken an average of 15.2 days during the 6-weeks, with the last measurement around 1 month (mean: 30.9 days), and little variability across race or ethnicity. Younger maternal age (≤25 years) was associated with less frequent measures (mean difference, -4.3 days [95% CI: -6.1 to -2.4]), and grandmultiparity (≥4 births) was associated with shorter engagement (mean difference, -3.5 days [95% CI, -6.1 to -1.0]). Prevalence of patients with BP ≥140/or >90 mm Hg was 62.3%, with differences by race or ethnicity (Black: 72.9%; Hispanic: 52.4%; White: 56.0%).

CONCLUSIONS

A cell-enabled postpartum remote BP monitoring program was successful in uniformly monitoring BP and capturing hypertension among a diverse, safety-net hospital population.

Postpartum blood pressure control and the rate of readmission

BACKGROUND

Postpartum hypertension is a major contributor to the rising maternal mortality rates in the United States, with nearly half of maternal deaths occurring after delivery. Previous studies have found evidence that the maximum blood pressure reading during labor and delivery admission can predict readmission; however, the optimal blood pressure to reduce the need for readmissions and additional medical treatment in the postpartum period is not known.

OBJECTIVE

This study aimed to investigate the relationship between postpartum blood pressure control at discharge and readmission within the first 6 weeks after delivery.

STUDY DESIGN

Data were obtained from Cosmos, an electronic health record-based, Health Insurance Portability and Accountability Act-defined limited dataset that includes more than 1.4 million birth encounters. All birthing parents with blood pressure data after delivery were included. Demographic information, medications, and readmissions were queried from the dataset. Patients were grouped into categories based on blood pressure readings in the 24 hours before discharge (≥160/110, ≥150/100, ≥140/90, ≥130/80, ≥120/80, and <120/80 mm Hg). The readmission rates across these groups were compared. Planned subanalyses included stratification by the use of antihypertensive medications and a sensitivity analysis using the highest blood pressure during admission. Covariates included maternal age, preexisting diabetes mellitus or lupus erythematosus, and body mass index.

RESULTS

The analysis included 1,265,766 total birth encounters, 391,781 (30.9%) in the referent group (120/80 mm Hg), 392,592 (31.0%) in the group with <120/80 mm Hg, 249,414 (19.7%) in the group with ≥130/80 mm Hg, 16,125 (1.3%) in the group with ≥140/90 mm Hg, 50,659 (4.0%) in the group with ≥150/100 mm Hg, and 20,196 (1.6%) in the group with ≥160/110 mm Hg. In the first 6 weeks after delivery, readmission rates increased with higher blood pressure readings. More than 5% of postpartum patients with the highest blood pressure readings (≥160/110 mm Hg) were readmitted. These patients were almost 3 times more likely to be readmitted than patients whose highest blood pressure reading fell into the referent group (120/80 mm Hg) (odds ratio [OR], 2.90; 95% confidence interval, 2.69-3.12). Patients with blood pressures of >150/100 mm Hg (odds ratio, 2.72; 95% confidence interval, 2.58-2.87), >140/90 mm Hg (odds ratio, 2.03; 95% confidence interval, 1.95-2.11), and >130/80 mm Hg (odds ratio, 1.43; 95% confidence interval, 1.37-1.49) all had higher odds of readmission, whereas patients with a blood pressure of <120/80 mm Hg had a lower odds of readmission (odds ratio, 0.78; 95% confidence interval, 0.75-0.81). Patients who had higher blood pressures during admission but had improved control in the 24 hours before discharge had lower rates of readmission than those whose blood pressures remained elevated. In all blood pressure categories, patients who received an antihypertensive prescription had higher rates of readmission.

CONCLUSION

In this large, national dataset, blood pressure control at discharge and readmission in the postpartum period were significantly correlated. Our data should inform postpartum hypertension treatment goals and the role of remote monitoring programs in improving maternal safety.

Postpartum Remote Blood Pressure Monitoring Using a Mobile App in Women with a Hypertensive Disorder of Pregnancy

BACKGROUND

Hypertensive disorders of pregnancy affect approximately 15% of pregnancies in the United States and are a leading cause of postpartum readmissions. Morbidity due to hypertension may be higher in the first several weeks postpartum. The ability to monitor blood pressure and intervene in the postpartum period is critical to reducing morbidity and mortality.

LOCAL PROBLEM

At WellSpan Health, hypertensive disorders were increasing and a leading cause of severe maternal morbidity and readmission.

INTERVENTIONS

A remote blood pressure monitoring app called BabyScripts™ myBloodPressure was implemented in September 2020. Prior to discharge postpartum, all patients with a diagnosis of a hypertensive disorder of pregnancy were given an automatic blood pressure cuff and instructions on how to monitor and track their blood pressure daily in the app.

RESULTS

A total of 1,260 patients were enrolled in the BabyScripts™ myBloodPressure module between September 2020 and July 2022 across five maternity hospitals. Of those enrolled 74% ( n = 938) entered seven or more blood pressures, and of those who entered at least one blood pressure 9% ( n = 107) entered at least one critical range blood pressure ( ≥ 150 mmHg systolic and or ≥ 100 mmHg diastolic).

CONCLUSION

Most women enrolled in the app were highly engaged and entered seven or more readings. Patients with critical blood pressures were identified; thus, the program has the potential to identify those at risk of severe complications. Barriers should be removed, and remote patient monitoring considered as a solution to improve postpartum assessment in patients with hypertensive disorders of pregnancy.

Development of a prediction model of postpartum hospital use using an equity-focused approach

BACKGROUND

Racial inequities in maternal morbidity and mortality persist into the postpartum period, leading to a higher rate of postpartum hospital use among Black and Hispanic people. Delivery hospitalizations provide an opportunity to screen and identify people at high risk to prevent adverse postpartum outcomes. Current models do not adequately incorporate social and structural determinants of health, and some include race, which may result in biased risk stratification.

OBJECTIVE

This study aimed to develop a risk prediction model of postpartum hospital use while incorporating social and structural determinants of health and using an equity approach.

STUDY DESIGN

We conducted a retrospective cohort study using 2016-2018 linked birth certificate and hospital discharge data for live-born infants in New York City. We included deliveries from 2016 to 2017 in model development, randomly assigning 70%/30% of deliveries as training/test data. We used deliveries in 2018 for temporal model validation. We defined "Composite postpartum hospital use" as at least 1 readmission or emergency department visit within 30 days of the delivery discharge. We categorized diagnosis at first hospital use into 14 categories based on International Classification of Diseases-Tenth Revision diagnosis codes. We tested 72 candidate variables, including social determinants of health, demographics, comorbidities, obstetrical complications, and severe maternal morbidity. Structural determinants of health were the Index of Concentration at the Extremes, which is an indicator of racial-economic segregation at the zip code level, and publicly available indices of the neighborhood built/natural and social/economic environment of the Child Opportunity Index. We used 4 statistical and machine learning algorithms to predict "Composite postpartum hospital use", and an ensemble approach to predict "Cause-specific postpartum hospital use". We simulated the impact of each risk stratification method paired with an effective intervention on race-ethnic equity in postpartum hospital use.

RESULTS

The overall incidence of postpartum hospital use was 5.7%; the incidences among Black, Hispanic, and White people were 8.8%, 7.4%, and 3.3%, respectively. The most common diagnoses for hospital use were general perinatal complications (17.5%), hypertension/eclampsia (12.0%), nongynecologic infections (10.7%), and wound infections (8.4%). Logistic regression with least absolute shrinkage and selection operator selection retained 22 predictor variables and achieved an area under the receiver operating curve of 0.69 in the training, 0.69 in test, and 0.69 in validation data. Other machine learning algorithms performed similarly. Selected social and structural determinants of health features included the Index of Concentration at the Extremes, insurance payor, depressive symptoms, and trimester entering prenatal care. The "Cause-specific postpartum hospital use" model selected 6 of the 14 outcome diagnoses (acute cardiovascular disease, gastrointestinal disease, hypertension/eclampsia, psychiatric disease, sepsis, and wound infection), achieving an area under the receiver operating curve of 0.75 in training, 0.77 in test, and 0.75 in validation data using a cross-validation approach. Models had slightly lower performance in Black and Hispanic subgroups. When simulating use of the risk stratification models with a postpartum intervention, identifying high-risk individuals with the "Composite postpartum hospital use" model resulted in the greatest reduction in racial-ethnic disparities in postpartum hospital use, compared with the "Cause-specific postpartum hospital use" model or a standard approach to identifying high-risk individuals with common pregnancy complications.

CONCLUSION

The "Composite postpartum hospital use" prediction model incorporating social and structural determinants of health can be used at delivery discharge to identify persons at risk for postpartum hospital use.

Ensuring safe and equitable discharge: a quality improvement initiative for individuals with hypertensive disorders of pregnancy

OBJECTIVE

To improve timely and equitable access to postpartum blood pressure (BP) monitoring in individuals with hypertensive disorders of pregnancy (HDP).

METHODS

A quality improvement initiative was implemented at a large academic medical centre in the USA for postpartum individuals with HDP. The primary aim was to increase completed BP checks within 7 days of hospital discharge from 40% to 70% in people with HDP in 6 months. Secondary aims included improving rates of scheduled visits, completed visits within 3 days for severe HDP and unattended visits. The balancing measure was readmission rate. Statistical process control charts were used, and data were stratified by race and ethnicity. Direct feedback from birthing individuals was obtained through phone interviews with a focus on black birthing people after a racial disparity was noted in unattended visits.

RESULTS

Statistically significant improvements were noted across all measures. Completed and scheduled visits within 7 days of discharge improved from 40% to 76% and 61% to 90%, respectively. Completed visits within 3 days for individuals with severe HDP improved from 9% to 49%. The unattended visit rate was 26% at baseline with non-Hispanic black individuals 2.3 times more likely to experience an unattended visit than non-Hispanic white counterparts. The unattended visit rate decreased to 15% overall with an elimination of disparity. A need for BP devices at discharge and enhanced education for black individuals was identified through patient feedback.

CONCLUSION

Timely follow-up of postpartum individuals with HDP is challenging and requires modification to our care delivery. A hospital-level quality improvement initiative using birthing individual and frontline feedback is illustrated to improve equitable, person-centred care.

Improving obstetric and perinatal outcomes with a remote patient monitoring program for hypertension in a large integrated care system

OBJECTIVE

To determine the effect of a remote patient monitoring program for hypertension (RPM HTN) in patients diagnosed with hypertensive disorders of pregnancy.

STUDY DESIGN

We used a matched retrospective cohort design to evaluate differences in obstetric and perinatal outcomes using data from electronic medical records. Patients enrolled in RPM HTN between November 1, 2019, and October 31, 2021, who delivered a pregnancy at ≥20 weeks gestation were compared to a cohort of patients matched by age, race, HTN and diabetes status, who delivered in the 48-month period before implementation of RPM HTN.

RESULTS

1030 patients were enrolled in RPM HTN and 937 were matched to historical controls. Five hundred and seventeen (50.2 %) were enrolled in the antepartum period and 513 (49.8 %) were enrolled postpartum. Patients in the RPM HTN cohort were more likely to have a post-hospital discharge blood pressure (BP) measured within the first 20 days after delivery (RR 1.56, 95 % CI: 1.47-1.65: p < 0.01) and were more likely to have that BP be normal (RR 1.43, 95 % CI: 1.31-1.55: p = 0.05). They were also more likely to be taking antihypertensives postpartum (RR 1.27, 95 % CI: 1.15-1.40; p < 0.01) and to be evaluated by an obstetric clinician within 20 days of delivery (RR 1.50, 95 % CI 1.42-1.58; p < 0.01).

CONCLUSIONS

A remote HTN monitoring program for 937 obstetric patients was associated with improved BP monitoring, better postpartum BP control, and improved linkages to clinician care after delivery, when compared to historical controls.

Opportunities in the Postpartum Period to Reduce Cardiovascular Disease Risk After Adverse Pregnancy Outcomes: A Scientific Statement From the American Heart Association

Adverse pregnancy outcomes are common among pregnant individuals and are associated with long-term risk of cardiovascular disease. Individuals with adverse pregnancy outcomes also have an increased incidence of cardiovascular disease risk factors after delivery. Despite this, evidence-based approaches to managing these patients after pregnancy to reduce cardiovascular disease risk are lacking. In this scientific statement, we review the current evidence on interpregnancy and postpartum preventive strategies, blood pressure management, and lifestyle interventions for optimizing cardiovascular disease using the American Heart Association Life's Essential 8 framework. Clinical, health system, and community-level interventions can be used to engage postpartum individuals and to reach populations who experience the highest burden of adverse pregnancy outcomes and cardiovascular disease. Future trials are needed to improve screening of subclinical cardiovascular disease in individuals with a history of adverse pregnancy outcomes, before the onset of symptomatic disease. Interventions in the fourth trimester, defined as the 12 weeks after delivery, have great potential to improve cardiovascular health across the life course.

Leveraging Digital Health to Improve the Cardiovascular Health of Women

Purpose of Review

In this review, we present a comprehensive discussion on the population-level implications of digital health interventions (DHIs) to improve cardiovascular health (CVH) through sex- and gender-specific prevention strategies among women.

Recent Findings

Over the past 30 years, there have been significant advancements in the diagnosis and treatment of cardiovascular diseases, a leading cause of morbidity and mortality among men and women worldwide. However, women are often underdiagnosed, undertreated, and underrepresented in cardiovascular clinical trials, which all contribute to disparities within this population. One approach to address this is through DHIs, particularly among racial and ethnic minoritized groups. Implementation of telemedicine has shown promise in increasing adherence to healthcare visits, improving BP monitoring, weight control, physical activity, and the adoption of healthy behaviors. Furthermore, the use of mobile health applications facilitated by smart devices, wearables, and other eHealth (defined as electronically delivered health services) modalities has also promoted CVH among women in general, as well as during pregnancy and the postpartum period. Overall, utilizing a digital health approach for healthcare delivery, decentralized clinical trials, and incorporation into daily lifestyle activities has the potential to improve CVH among women by mitigating geographical, structural, and financial barriers to care.

Summary

Leveraging digital technologies and strategies introduces novel methods to address sex- and gender-specific health and healthcare disparities and improve the quality of care provided to women. However, it is imperative to be mindful of the digital divide in specific populations, which may hinder accessibility to these novel technologies and inadvertently widen preexisting inequities.