The Green Journal Editor's Pick for the month of September is Clinical Outcomes Associated With a Remote Postpartum Hypertension Monitoring Program, a study from the Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, and Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
The study found that remote monitoring of postpartum hypertension was associated with fewer readmissions, increased adherence to national guidelines, and initiation of antihypertensive medications for individuals with hypertensive disorders of pregnancy (HDP).
Why it matters
Hypertension complicates 10-20% of pregnancies, and is a significant contributor to maternal mortality and morbidity, especially in the postpartum period when the majority of deaths occur.
It's also the most common cause of postpartum readmission. Worsening hypertension often doesn't manifest until after hospital discharge, and BP levels can also vary widely over the postpartum period, necessitating frequent medication titrations.
To manage these risks, ACOG recommends that individuals with HDP have their blood pressure measured at 10 days after delivery, but attendance rates at these recommended visits are low. Women that have just given birth and may have other children at home are not likely to prioritize a check-in, and in fact, less than 50% attend these in-office BP checks.
Black women are at higher risk than their White peers during this period. They are less likely to return to pre-pregnancy BP levels, and they are also less likely to attend a follow-up postpartum appointment. According to one study, visit adherence was 63.9% for Black patients compared with 88.7% for their non-Black peers.
Existing research
A recent systematic review shows that remote blood pressure monitoring improves blood pressure ascertainment in this vulnerable period.
In a study using Babyscripts, patients with remote monitoring had higher rates of postpartum blood pressure ascertainment compared with in-office surveillance (91.7% vs 58.4%), and remote monitoring also eliminated racial disparities observed at in-office checks. Black patients had lower rates of blood pressure ascertainment than White patients when assigned to in-office surveillance (41.2% vs 69.5%), but there was no difference in the remote management group (92.9% vs 92.9%). [1]
What this research adds
The connection between remote BP monitoring and BP ascertainment has been well-established, but its effect on outcomes has been less clear. This study affirms the downstream effects of RPM for blood pressure on clinical outcomes, demonstrating an association between remote BP monitoring and postpartum care utilization, attendance at a postpartum visit, and initiation of antihypertensive medications within 6 weeks postpartum.
These findings confirm results observed at LCMC Health, where use of Babyscripts' RPM was shown to drive higher compliance to postpartum care. Providers at LCMC Health found that offering continuous digital touchpoints and ongoing education and reminders during the postpartum period through Babyscripts drove up rates of postpartum visit attendance. In an analysis between Babyscripts users and a control group at LCMC Health, Babyscripts users were more than two times as likely to complete a postpartum visit in the first 30 days following delivery than the control group. By 60 days postpartum, 64% of Babyscripts users had completed a postpartum visit, compared to 44% of the control group. [2]
OTHER KEY HIGHLIGHTS and CONSIDERATIONS
- Improving BP ascertainment is critical for identifying hypertension, but needs to be combined with access to systems for medication initiation and escalation of care when needed. For example, with Babyscripts BP RPM, blood pressure monitoring is combined with exception-based reporting and care management services to ensure that risk identification receives the appropriate follow up.
- Patients in the study were required to manually input and communicate BP levels to their care team through SMS. Giving these rates of compliance, it's reasonable to assume that compliance would be equal or higher with a connected BP cuff that automatically communicates data to the healthcare team and reduces opportunities for human error.
- Although patients who participated had higher BP at the time of their delivery hospitalization and clinical evidence of more severe hypertensive disease, the program was associated with a return to early prenatal systolic BP by the 6 weeks postpartum. This improved BP control in the postpartum period has the potential to affect longer-term maternal cardiovascular health.
- Despite upfront costs to establish remote monitoring programs, recent analyses have demonstrated that these programs are cost saving at $93 per patient and remain cost effective when the postpartum readmission rate is 3.0% or higher with standard monitoring.
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