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Telehealth with remote blood pressure monitoring compared with standard care for postpartum hypertension

      Objective

      Hypertensive disorders of pregnancy (HDP) affect 10% of the pregnancies in the United States and are the most common diagnoses associated with postpartum hospital readmissions.
      American College of Obstetricians and Gynecologists
      Task force on hypertension in pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ task force on hypertension in pregnancy.
      ,
      • Mogos M.F.
      • Salemi J.L.
      • Spooner K.K.
      • McFarlin B.L.
      • Salihu H.H.
      Hypertensive disorders of pregnancy and postpartum readmission in the United States: national surveillance of the revolving door.
      According to the American College of Obstetricians and Gynecologists, a blood pressure (BP) follow-up should be completed 7–10 days postpartum for women with HDP, but 50%–70% of the women do not complete the follow-up.
      American College of Obstetricians and Gynecologists
      Task force on hypertension in pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ task force on hypertension in pregnancy.
      ,
      • Bryant A.S.
      • Haas J.S.
      • McElrath T.F.
      • McCormick M.C.
      Predictors of compliance with the postpartum visit among women living in healthy start project areas.
      The objective of this study was to evaluate whether postpartum home telehealth with remote BP monitoring could reduce the readmission rates during the first 6 weeks postpartum in women with HDP, when compared with standard outpatient care.

      Study Design

      We performed a nonrandomized controlled trial in which we compared the hospital readmission rates of the participants with HDP allocated to telehealth with remote BP monitoring group (intervention) with those of the standard outpatient care participants (control). In a 1:1 ratio, participants were allocated to the intervention group after consent was given, and the next eligible woman with a similar HDP was allocated to the control group when she declined the intervention or when she was not approached to participate in the intervention because of a lack of equipment or staff availability (Figure). The participants in the intervention group received a tablet and a Bluetooth BP monitor for daily transmission of vitals to a central database for 6 weeks.
      • Hoppe K.K.
      • Williams M.
      • Thomas N.
      • et al.
      Telehealth with remote blood pressure monitoring for postpartum hypertension: A prospective single-cohort feasibility study.
      Trained nurses relied on our previously published algorithm to guide the antihypertensive treatment initiation and titration.
      • Hoppe K.K.
      • Williams M.
      • Thomas N.
      • et al.
      Telehealth with remote blood pressure monitoring for postpartum hypertension: A prospective single-cohort feasibility study.
      The control participants were advised to follow standard care, which included a clinic visit 7–10 days and 6 weeks postpartum.
      American College of Obstetricians and Gynecologists
      Task force on hypertension in pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ task force on hypertension in pregnancy.
      The primary outcome variable was the number of hypertension-related hospital readmissions over the 6-week postpartum period. Our secondary outcome variables included hypertension-related postpartum emergency room (ER) or triage visits, the number of BPs acquired within 10 days of delivery, and the use of antihypertensives in the 6-week postpartum period. The rates of severe hypertensive episodes and increasing BPs that required treatment after discharge among the intervention group participants were also investigated. All the analyses were based on the intention-to-treat principle. We used a chi-square test for the dichotomous variables and a Wilcoxon rank sum test for the continuous variables. Two-tailed P values and 95% confidence intervals (CI) were reported in all cases. To account for potential confounding factors and effect modifications, a multivariable binary regression model was used to account for the baseline differences in the study groups for all outcomes. This study was approved by the Institutional Review Board (#017-003) on March 21, 2017.
      Figure thumbnail gr1
      FigureFlow diagram for study enrollment
      Hoppe. Telehealth with remote blood pressure monitoring for postpartum hypertension. Am J Obstet Gynecol 2020.

      Results

      Between April 2017 and June 2018, 428 women were enrolled in this study (214 in the intervention group and 214 in the control group; Figure). The intervention group had fewer hypertension-related readmissions compared with the controls (1 [0.5%] vs 8 [3.7%]; relative risk [RR], 0.12; 95% CI, 0.01–0.96). Significantly more women in the intervention group had minimum one BP measured within 10 days postpartum when compared with the controls (202 [94.4%] vs 129 [60.3%]; RR, 1.59; 95% CI, 1.36–1.77). There were no differences between the groups in the number of ER or triage visits or in the use of antihypertensives 6 weeks postpartum (Table). In the intervention arm, severe hypertension occurred in 56 (26.2%) women and 116 (54.2%) had increased BPs that required treatment after discharge.
      American College of Obstetricians and Gynecologists
      Task force on hypertension in pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ task force on hypertension in pregnancy.
      The median number of days to the first severe hypertension reading was 6.0 (interquartile range [IQR], 4.8–9.0) days and to the first BP level that necessitated treatment was also 6.0 (IQR, 5.0–9.0) days.
      TableOutpatient outcomes in telehealth vs standard outpatient care participants
      Telehealth (n=214)Standard outpatient care (n=214)P valueRR (95% CI)Adjusted P valueAdjusted RR (95% CI)
      Healthcare utilization through 6 wk
      Hypertension-related hospital readmissions
      Adjusted for the delivery mode, insurance status, antihypertension medication use at the time of hospital discharge, and the total number of postpartum admission days.
      , n (%)
      1(0.5)8(3.7).0370.13 (0.02–0.99).0450.12 (0.01–0.96)
      Hypertension-related emergency or triage room visits
      Adjusted for the delivery mode, insurance status, antihypertension medication use at the time of hospital discharge, and the total number of postpartum admission days.
      , n (%)
      11(4.6)13(6.0).8310.76 (0.38–1.85).8080.81 (0.36–1.80)
      Number of blood pressure reviews within 10 days of delivery
      Adjusted for the delivery mode, insurance status, antihypertension medication use at the time of hospital discharge, and the total number of postpartum admission days.
      , n (%)
      202(94.4)129(60.3)<.0011.56 (1.39–1.76)<.0011.59 (1.36–1.77)
      6 wk study endpoint
      Number of participants on antihypertensive treatment regimes
      Adjusted for the delivery mode, insurance status, antihypertension medication use at the time of hospital discharge, and the total number of postpartum admission days.
      , n (%)
      57(26.6)37(17.3).0271.54 (1.06–2.23).8661.03 (0.74–1.44)
      Data are expressed as mean, median (interquartile range), or n (%).
      Hoppe. Telehealth with remote blood pressure monitoring for postpartum hypertension. Am J Obstet Gynecol 2020.
      CI, confidence interval; RR, relative risk; SD, standard deviation.
      a Adjusted for the delivery mode, insurance status, antihypertension medication use at the time of hospital discharge, and the total number of postpartum admission days.

      Conclusion

      Telehealth with remote BP monitoring in combination with standardized management of postpartum hypertension was associated with a reduction in the number of readmissions when compared with standard outpatient care. Telehealth with remote BP monitoring offers a promising strategy for achieving higher number of postpartum BP acquisitions, early identification and treatment of uncontrolled hypertension, and ultimately reducing the number of hospital readmissions.

      References

        • American College of Obstetricians and Gynecologists
        Task force on hypertension in pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ task force on hypertension in pregnancy.
        Obstet Gynecol. 2013; 122: 1122-1131
        • Mogos M.F.
        • Salemi J.L.
        • Spooner K.K.
        • McFarlin B.L.
        • Salihu H.H.
        Hypertensive disorders of pregnancy and postpartum readmission in the United States: national surveillance of the revolving door.
        J Hypertens. 2018; 36: 608-618
        • Bryant A.S.
        • Haas J.S.
        • McElrath T.F.
        • McCormick M.C.
        Predictors of compliance with the postpartum visit among women living in healthy start project areas.
        Matern Child Health J. 2006; 10: 511-516
        • Hoppe K.K.
        • Williams M.
        • Thomas N.
        • et al.
        Telehealth with remote blood pressure monitoring for postpartum hypertension: A prospective single-cohort feasibility study.
        Pregnancy Hypertens. 2019; 15: 171-176