Women with hypertensive disorders of pregnancy (both preeclampsia and gestational hypertension) often continue to have high blood pressure after delivery, which can increase the risk of seizures, strokes and even maternal death in the postpartum period.

THE PROBLEM

UPMC and University of Pittsburgh Schools of the Health Sciences knew that understanding the trajectory of blood pressure decline after a hypertensive disorder of pregnancy might be important to preventing these complications. 

Prior work has relied on women coming into the office for a blood pressure check to determine how high blood pressure resolves in the postpartum period.

UPMC and the Pitt School of Medicine conducted a study in which they used data collected through a home blood pressure monitoring program to first determine the trajectory of postpartum blood decline. 

Second, given the disparities in maternal morbidity and mortality related to hypertensive disorders in the postpartum period, they investigated differences in postpartum blood pressure trajectory by race.

PROPOSAL

"Hypertension complicates 10-20% of pregnancies in the United States and is a significant contributor to maternal morbidity and mortality in the postpartum period," said Dr. Alisse Hauspurg, assistant professor at the Pitt School of Medicine, and a maternal-fetal medicine specialist at UPMC Magee. "Black women are at increased risk of hypertensive disorders of pregnancy and hypertension and cardiovascular etiologies more frequently contribute to morbidity and mortality among Black women compared with white women."

These differences are particularly notable in the postpartum period, she added.

"Our program uses a comprehensive and coordinated approach of clinical operations, EHR integration, mobile technology, best-practices algorithms and population health monitoring to address this key contributor to maternal morbidity and mortality."

Dr. Alisse Hauspurg, Pitt School of Medicine and UPMC Magee

"Despite this, prior studies and clinical management guidelines focus overwhelmingly on antepartum and intrapartum management, with relatively little emphasis placed on postpartum management," she explained. "One reason for the lack of management guidelines is our limited understanding of the postpartum blood pressure trajectory after delivery and hospital discharge. Thus we sought to better understand this trajectory and determine if it differed by race."

MEETING THE CHALLENGE

In the Women's Health Service Line at UPMC, staff have created a postpartum remote blood pressure monitoring program for women with hypertensive disorders of pregnancy for home monitoring and management of hypertension from the time of hospital discharge through the first six weeks after delivery.

"The monitoring platform is integrated with the electronic health record for both ordering and results," Hauspurg noted. "Our program uses a comprehensive and coordinated approach of clinical operations, EHR integration, mobile technology, best-practices algorithms and population health monitoring to address this key contributor to maternal morbidity and mortality."

Briefly, patients are enrolled in the program by their primary obstetric care provider while on the postpartum unit, after a readmission postpartum, or after identification of increased blood pressures through follow-up care in the office setting or emergency department. 

After identification and verification of eligibility, the healthcare provider places an order in the EHR with the patient's phone number, which automatically generates a text message to enroll the patient.

The computerized physician order entry triggers a message to an enterprise master patient index, which then sends an automated message to telehealth and remote patient monitoring vendor Vivify Health's system to enroll the patient. Vivify then adds a service level for the postpartum hypertension program in the patient medical record.

"The patient is enrolled into one of two groups based on whether or not they were taking oral antihypertensive medications at the time of discharge," Hauspurg explained.

"The platform involves a 'Bring Your Own Blood Pressure Device (BYOD),' either through insurance coverage, patient purchase or hospital provision. Our institution has committed to providing blood pressure cuffs for patients enrolled in the program."

The patient is trained on use of the blood pressure device by a nurse before discharge from the hospital. The nurse records blood pressure on both the home monitoring device and the hospital device to confirm accuracy. Both groups of the program are managed through a nursing-staffed UPMC call center with documentation of calls and blood pressures directly into the EHR.

RESULTS

"We have demonstrated feasibility and high compliance with our remote monitoring program," Hauspurg reported. "Further, we have shown improved control of hypertension and a reduction in hospital readmission associated with the program. Finally, enrollment in the program is associated with higher rates of engagement in postpartum care as evidenced by improved attendance at postpartum visits and patient satisfaction with the program."

Since the program's inception in January 2018, UPMC has enrolled more than 3,000 women with hypertensive disorders of pregnancy into the postpartum remote hypertension monitoring program who have contributed more than 40,000 blood pressure measurements in the first six weeks postpartum.

Women report a mean of 20.3 (SD 7.1) blood pressure values through the program. Compliance with the program is high, with >90% of women reporting at least one blood pressure in the first ten days postpartum (the highest-risk time period for maternal morbidity), >80% of women continuing beyond three weeks and 74% of women continuing beyond four weeks postpartum. At least one blood pressure measure was available beyond four weeks postpartum on 94% of women enrolled in the program.

"As a result of the program, we have been able to more accurately understand postpartum blood pressure trajectories following a hypertensive disorder and identify factors that impact postpartum blood pressure, which allows for improved interventions to reduce racial disparities in postpartum hypertension care," Hauspurg reported.

"Compared to white women, Black women have similar blood pressures at the initiation of prenatal care and in the twenty-four hours prior to hospital discharge postpartum," she added.

However, in the remote monitoring program, Black women are noted to have higher peak systolic and diastolic blood pressures compared to white women (systolic blood pressure 150±14 versus 145±13 mmHg; p<0.001 and diastolic blood pressure 98±12 versus 94±9 mmHg; p<0.001). 

Both systolic and diastolic blood pressure decline more slowly in the first six weeks postpartum among Black women compared with white women (p<0.001 for both systolic and diastolic).

As a result, at the conclusion of the program, mean blood pressure is higher among Black women compared to white women (systolic blood pressure 131±14 versus 122±11 mmHg; p< 0.001 and diastolic blood pressure 84±12 versus 79±9 mmHg; p< 0.001). Similarly, Black women were significantly more likely to meet criteria for Stage 1 or Stage 2 hypertension at the conclusion of the program (68.1% versus 51.4%; p<0.001).

ADVICE FOR OTHERS

"Our program is a well-established, scalable remote monitoring program connected in HIPAA-compliant fashion to the electronic health record, which allows for documentation, communication, and the ability to prescribe and adjust medications through a nursing call center protocol," Hauspurg said.

"For remote monitoring in the postpartum period to be implemented in a broader fashion in accordance with recommendations for care in the postpartum period, key criteria must be met."

The system must be scalable. It needs to be incorporated into the electronic health record system, and it must have the ability to be implemented at the hospital level, she added.

"The blood pressure monitors do not require device integration, and patients can use their own text-messaging-enabled smartphone, which both facilitate broad scaling," she concluded.

"Our program allows for a multi-level system, with inpatient and outpatient operational EHR integration. We have further demonstrated success with expansion and replication at two additional hospitals within the UPMC system."

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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