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Text message remote monitoring reduced racial disparities in postpartum blood pressure ascertainment

      Objective

      Nearly 50% of maternal morbidity and death occurs after delivery, one-third of which occurs in the first week after delivery.
      • Creanga A.A.
      • Syverson C.
      • Seed K.
      • Callaghan W.M.
      Pregnancy-related mortality in the United States, 2011–2013.
      The American College of Obstetricians and Gynecologists recommends close monitoring of patients with hypertensive disorders for the first 72 hours and again at 7–10 days after delivery, given the timing of peak blood pressures after delivery
      • Walters B.N.
      • Thompson M.E.
      • Lee A.
      • de Swiet M.
      Blood pressure in the puerperium.
      and the need for optimal blood pressure management in this period of increased risk of stroke and seizure.
      • Too G.
      • Wen T.
      • Boehme A.K.
      • et al.
      Timing and risk factors of postpartum stroke.
      We previously showed that a text message–based remote blood pressure monitoring program in the early postpartum period was more effective in obtaining these critical blood pressure values compared to in-person office visits in all at-risk women.
      • Hirshberg A.
      • Downes K.
      • Srinivas S.
      Comparing standard office-based follow-up with text-based remote monitoring in the management of postpartum hypertension: a randomised clinical trial.
      Non-Hispanic black women suffer a disproportionate amount of hypertensive-related morbidities and are 3 times more likely to die of preeclampsia than white women,
      • Shahul S.
      • Tung A.
      • Minhaj M.
      • et al.
      Racial disparities in comorbidities, complications, and maternal and fetal outcomes in women with preeclampsia/eclampsia.
      likely because of a combination of patient, community, provider, and systems factors. Our office-based follow-up experience is that nonblack women are twice as likely to return for an in-person blood pressure check shortly after discharge compared with black women (42.5% vs 24.1% attendance rate, respectively). Because early identification and treatment of women who are at risk for hypertension-related morbidities in the postpartum period may reduce maternal morbidity and mortality rates, we evaluated whether postpartum text-based remote blood pressure monitoring could reduce the disparity in postpartum blood pressure ascertainment.

      Study Design

      This was a planned secondary analysis of a randomized clinical trial that compared the effectiveness of text-based blood pressure monitoring to conventional in-person blood pressure visits for women with pregnancy-related hypertension in the early postpartum period.
      • Hirshberg A.
      • Downes K.
      • Srinivas S.
      Comparing standard office-based follow-up with text-based remote monitoring in the management of postpartum hypertension: a randomised clinical trial.
      Women were assigned randomly to either 2 weeks of twice daily text-based surveillance with the use of an automated platform and home blood pressure monitor or usual care in-person blood pressure check at their prenatal office 4–6 days after discharge. A standardized hypertension management algorithm was used by a Maternal Fetal Medicine physician in the text-messaging arm and the outpatient provider in the office arm. The primary outcome was ascertainment of blood pressure, defined as either office visit attendance or at least 1 blood pressure texted. Secondary outcomes included the need for hypertension-related readmission or oral antihypertensive medication. Women self-identified as black or nonblack race. We quantified racial disparity between black and nonblack with a risk ratio defined as the proportion with blood pressure ascertained in nonblack women divided by proportion ascertained in black participants. Poisson regression with a robust variance assumption was used to estimate risk ratios (RR) along with 95% confidence intervals (95% CI) for blood pressure ascertainment in nonblack vs black participants in each trial arm and to test for an interaction between blood pressure ascertainment and race by trial arm.

      Results

      In all, 206 women participated in the trial (103 women per arm). Seventy-one percent of women in usual care and 66% in the texting program were black. Nonblack women were twice as likely as black women return for a blood pressure visit within the usual care setting (70% vs 33%; RR, 1.95; 95% CI, 1.30–2.93; P<.001). The introduction of a text-messaging system resulted in >90% blood pressure ascertainment in both race groups (91% vs 93%; RR, 0.99; 95% CI, 0.87–1.11; P=.85). Compared with usual care, where nonblack women were twice as likely to comply with the American College of Obstetricians and Gynecologists recommendations, blood pressure ascertainment was similar between nonblack and black women in the texting arm, with a 50% reduction in racial disparity (ratio of RR, 0.51; 95% CI, 0.33–0.78; P=.002; Figure). There were no hypertension readmissions in the texting arm, whereas 4 readmissions (3 of 4 in black women) were observed in usual care. There was no difference in the percent of black women who required new antihypertensive medication or dose escalation by trial arm among those who had an outpatient blood pressure (19% text vs 21% office; P=.73).
      Figure thumbnail gr1
      FigurePostpartum blood pressure ascertainment by race and follow-up method
      CI, confidence interval; RR, relative risk.
      Hirshberg. Text messaging remote blood pressure monitoring. Am J Obstet Gynecol 2019.

      Conclusion

      Although nonblack women attended in-office (usual care) postpartum blood pressure checks twice as often as black women, the use of a text-based monitoring system resulted in overall higher compliance (>90%) in both race groups and no racial differences in blood pressure ascertainment. The postpartum period is fraught with high morbidity and significant barriers to in-person visits that disproportionately affect minority populations. Text messaging as the standard of care is a safe, patient-centered means for blood pressure surveillance in this time of increased morbidity. Text messaging allowed for ascertainment of critical information and likely would have led to medication initiation in an additional ≥20% black women who missed an office visit. Given that most strokes and maternal morbidity from pregnancy-related hypertension occur within 10 days of delivery, text messaging has the potential to be an innovative way to engage hypertensive women of all races equally shortly after delivery and may be further evaluated as a means to reduce disparities in other aspects of postpartum care.

      References

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        • Thompson M.E.
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        Timing and risk factors of postpartum stroke.
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        Comparing standard office-based follow-up with text-based remote monitoring in the management of postpartum hypertension: a randomised clinical trial.
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        • et al.
        Racial disparities in comorbidities, complications, and maternal and fetal outcomes in women with preeclampsia/eclampsia.
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