Preeclampsia is a pregnancy disorder characterized by high blood pressure (hypertension) and increased urine protein levels. Blood pressure in patients with pregnancy-related hypertension can take as long as three months to normalize and is likely to spike in the first ten days after delivery, putting new moms at risk for stroke, seizures, and organ failure.
In 2013, the American College of Obstetricians and Gynecologists (ACOG) issued guidelines to monitor postpartum blood pressure for this population at two points - once at 72 hours and again seven to 10 days after delivery. When ACOG released their recommendations, there was no guidance or best practice model for achieving the new standards.
When we started this work, the standard of care at the Hospital of the University of Pennsylvania (HUP) required new moms to return to the office to have their blood pressure taken at the designated touchpoints. Newly postpartum women often encounter barriers for in-person postpartum visit attendance. Show rates at these visits were less than 50 percent in the two years after the recommendation was made. Racial disparities in care also existed, with non-Black women almost twice as likely to attend this visit.
Hypertension was the leading cause of seven-day readmissions for obstetrics patients at HUP. Despite numerous efforts to improve show rates - including increasing the availability of appointments and issuing phone and text reminders, practices were not meeting ACOG guidelines.
Heart Safe Motherhood (HSM) is a first-of-its-kind text-based program for postpartum blood pressure monitoring. HSM enables patients to track their blood pressure from the comfort of their home and communicate with their care team without visiting a doctor’s office. Only patients with concerning blood pressures or symptoms may be asked to come in for an appointment.
The process works as follows:
- Inpatient physicians and nurse practitioners on labor and delivery and postpartum service identify and enroll at-risk women based on a set of eligibility criteria using diagnoses and vital signs.
- Participants are given a digital blood pressure monitor for at-home use. Training on how to use the monitor and education about the program occur prior to discharge.
- Upon discharge, an automated blood pressure monitoring protocol powered by Way to Health is enacted. Patients are prompted by twice-daily text messages to capture and share their blood pressure for ten days.
- Patients receive automated, real-time feedback to self-reported blood pressure readings based on a provider-determined algorithm.
- When blood pressures are high enough to necessitate intervention, the platform pushes real-time alerts to providers.
- Providers reach out for more information, start or adjust medication, or triage patients to in-person care, depending on the circumstances.
Through automation and exception handling, HSM makes it possible for one provider to manage the blood pressures of an entire hospital’s worth of enrolled deliveries in just a few hours a week.
HSM drives better maternal outcomes, improves patient experience, and reduces the total cost of care for women with pregnancy-related and chronic hypertension in the immediate postpartum period.
In 2017, we completed a randomized controlled trial comparing HSM to the usual care of one-time, office-based in-person blood pressure checks in the days after delivery discharge. We found an increase in our ability to obtain at least one blood pressure within ten days after discharge, with 92 percent of patients texting a blood pressure compared to 44 percent of patients attending their office visit. We met ACOG guidelines for blood pressure ascertainment at the two recommended time points in 80 percent of patients using HSM. Approximately 15 to 20 percent of women had elevated blood pressure requiring medication initiation or adjustment. There were no readmissions among HSM participants, and women enrolled in the program were more likely to attend their postpartum visit, a valuable touchpoint to evaluate physical and mental well-being after delivery and support contraception planning and breastfeeding. At scale, postpartum hypertension readmission rates at HUP dropped from 5 percent before HSM to 1 percent, and hypertension is no longer the leading cause of seven-day obstetrical readmissions.
A secondary analysis of the trial found that HSM eliminated the observed racial disparities in postpartum hypertension blood pressure ascertainment. Before the intervention, non-Black women were significantly more likely to attend an in-person blood pressure check than Black women, yet Black women were at higher risk of poor outcomes. With HSM, we were able to increase our ability to capture blood pressure for all patients while eliminating the previously observed racial disparities.
HSM is the standard of care for obstetrics patients at HUP, Pennsylvania Hospital, and Princeton Medical Center. Improved blood pressure ascertainment and reduction in hypertension-related readmissions have been observed at all three hospitals.
In response to COVID-19, we are supporting additional care teams to implement HSM to reduce the amount of time patients spend in the hospital and minimize follow-up visits in the early postpartum period. Knowing that patients can safely monitor their blood pressure at home has allowed for earlier discharge after delivery.