Exploring Implementation of m-Health Monitoring in Postpartum Women with Hypertension

Postpartum Ambulatory Blood Pressure Patterns Following New-Onset Hypertensive Disorders of Pregnancy

Importance

After a hypertensive disorder of pregnancy, hypertension can worsen in the postpartum period following hospital discharge. Risk factors for ongoing hypertension and associated outcomes have not been well characterized.

Objective

To identify risk factors and characterize outcomes for individuals with ongoing hypertension and severe hypertension following hospital discharge post partum through a hospital system's remote blood pressure (BP) management program.

Design, Setting, and Participants

This cohort study involved a population-based sample of individuals with a new-onset hypertensive disorder of pregnancy (preeclampsia or gestational hypertension) and no prepregnancy hypertension who delivered between September 2019 and June 2021. Participants were enrolled in a remote BP monitoring and management program at a postpartum unit at a referral hospital. Data analysis was performed from August 2021 to January 2023.

Exposure

Inpatient postpartum BP categories.

Main Outcomes and Measures

The primary outcomes were readmission and emergency department visits within the first 6 weeks post partum. Logistic regression was used to model adjusted odds ratios (aORs) and 95% CIs.

Results

Of 2705 individuals in the cohort (mean [SD] age, 29.8 [5.7] years), 2214 (81.8%) had persistent hypertension post partum after hospital discharge, 382 (14.1%) developed severe hypertension after discharge, and 610 (22.6%) had antihypertensive medication initiated after discharge. Individuals with severe hypertension had increased odds of postpartum emergency department visits (aOR, 1.85; 95% CI, 1.17-2.92) and hospital readmissions (aOR, 6.75; 95% CI, 3.43-13.29) compared with individuals with BP normalization. When inpatient postpartum BP categories were compared with outpatient home BP trajectories to inform optimal thresholds for inpatient antihypertensive medication initiation, there was significant overlap between postdischarge BP trajectories among those with inpatient systolic BP greater than or equal to 140 to 149 mm Hg and/or diastolic BP greater than or equal to 90 to 99 mm Hg and those with systolic BP greater than or equal to 150 mm Hg and/or diastolic BP greater than or equal to 100 mm Hg.

Conclusions and Relevance

This cohort study found that more than 80% of individuals with hypertensive disorders of pregnancy had ongoing hypertension after hospital discharge, with approximately 14% developing severe hypertension. These data support the critical role of remote BP monitoring programs and highlight the need for improved tools for risk stratification and consideration of liberalization of thresholds for medication initiation post partum.

Cellular-Enabled Remote Patient Monitoring for Pregnancies Complicated by Hypertension

Introduction

Unmanaged hypertension in pregnancy is the second most common cause of direct maternal death and disproportionately affects women in rural areas. While telehealth technologies have worked to reduce barriers to healthcare, lack of internet access has created new challenges. Cellular-enabled remote patient monitoring devices provide an alternative option for those without access to internet.

Objective

This study aimed to assess maternal and neonatal clinical outcomes and patient acceptability of an integrated model of cellular-enabled remote patient monitoring devices for blood pressure supported by a 24/7 nurse call center.

Methods

In a mixed-methods study, 20 women with hypertension during pregnancy were given a cellular-enabled BodyTrace blood pressure cuff. Participants' blood pressures were continuously monitored by a nurse call center. Participants completed a baseline survey, post-survey, and semi-structured interview after 8 weeks of device use.

Results

Participants reported a significant decrease in perceived stress after device use (P = .0004), high satisfaction with device usability (mean = 78.38, SD = 13.68), and high intention to continue device use (mean = 9.05, SD = 1.96). Relatively low hospitalization and emergency department rates was observed (mean = 0.35, SD = 0.59; mean = 0.75, SD = 0.91). Participant-perceived benefits of device use included convenience, perceived better care owing to increased monitoring, and patient empowerment. Perceived disadvantages included higher blood pressure readings compared to clinical readings and excessive calls from call center.

Conclusion

Remote patient monitoring for women whose pregnancies are complicated by hypertension can reduce barriers and improve health outcomes for women living in rural and low-health-resource areas.

Evaluating the WISE (Women in the South-East) Telehealth Network: A Model of Healthcare and Health Promotion at Rural Libraries

PURPOSE

The purpose of this study was to evaluate the effectiveness of the WISE (Women in the South-East) Telehealth Network.

DESIGN

A follow-up survey design was used to determine the impact of the program on access to healthcare.

SETTING

WISE provided preventive care to women and gender expansive people at local libraries and the Mobile Library in the rural South Carolina Lowcountry.

SUBJECTS

In 1 year (February 2021-2022), WISE reached 523 individuals with 151 agreeing to participate in the study. Most participants identified as white (66%) or Black (22%).

INTERVENTION

A Community Health Worker provided health education, connection to telehealth services, referrals, and connected individuals with community and social services.

MEASURES

The Telehealth Usability Questionnaire (TUQ), changes in knowledge, satisfaction with WISE, Acceptability of Intervention measure (AIM), and sociodemographic characteristics.

RESULTS

Participants with a high telehealth usability score were significantly more likely to be under the age of 35 (OR 4.60 [95% CI 1.21-17.52]), married (OR 10.00 [95% CI 2.19-45.64]), or white (OR 4.00 [95% CI 1.06-15.08]). The intervention earned a high acceptability score 4.46 (± .61)/5.0 by helping participants obtain necessary medical care and resources, as well as meeting their educational needs.

CONCLUSION

This study offers practical suggestions to expand the use of telehealth initiatives to improve health outcomes by engaging libraries in rural communities.

New advances in prediction and surveillance of preeclampsia: role of machine learning approaches and remote monitoring

Preeclampsia, a multisystem disorder in pregnancy, is still one of the main causes of maternal morbidity and mortality. Due to a lack of a causative therapy, an accurate prediction of women at risk for the disease and its associated adverse outcomes is of utmost importance to tailor care. In the past two decades, there have been successful improvements in screening as well as in the prediction of the disease in high-risk women. This is due to, among other things, the introduction of biomarkers such as the sFlt-1/PlGF ratio. Recently, the traditional definition of preeclampsia has been expanded based on new insights into the pathophysiology and conclusive evidence on the ability of angiogenic biomarkers to improve detection of preeclampsia-associated maternal and fetal adverse events.However, with the widespread availability of digital solutions, such as decision support algorithms and remote monitoring devices, a chance for a further improvement of care arises. Two lines of research and application are promising: First, on the patient side, home monitoring has the potential to transform the traditional care pathway. The importance of the ability to input and access data remotely is a key learning from the COVID-19 pandemic. Second, on the physician side, machine-learning-based decision support algorithms have been shown to improve precision in clinical decision-making. The integration of signals from patient-side remote monitoring devices into predictive algorithms that power physician-side decision support tools offers a chance to further improve care.The purpose of this review is to summarize the recent advances in prediction, diagnosis and monitoring of preeclampsia and its associated adverse outcomes. We will review the potential impact of the ability to access to clinical data via remote monitoring. In the combination of advanced, machine learning-based risk calculation and remote monitoring lies an unused potential that allows for a truly patient-centered care.

Risk factors associated with attendance at postpartum blood pressure follow-up visit in discharged patients with hypertensive disorders of pregnancy

BACKGROUND

This study aims to investigate the risk factors for not returning to postpartum blood pressure (BP) follow-up visit at different time points in postpartum discharged hypertensive disorders of pregnancy (HDP) patients. Likewise, females with HDP in China should have a BP evaluation continuously for at least 42 days postpartum and have BP, urine routine, and lipid and glucose screening for 3 months postpartum.

METHODS

This study is a prospective cohort study of postpartum discharged HDP patients. Telephone follow-up was conducted at 6 weeks and 12 weeks postpartum, the maternal demographic characteristics, details of labor and delivery, laboratory test results of patients at admission, and adherence to BP follow-up visits postpartum were collected. While logistic regression analysis was used to analyze the factors associated with not returning to postpartum BP follow-up visit at 6 weeks and 12 weeks after delivery, the receiver operating characteristic (ROC) curve was drawn to evaluate the model's predictive value for predicting not returning to postpartum BP visit at each follow-up time point.

RESULTS

In this study, 272 females met the inclusion criteria. 66 (24.26%) and 137 (50.37%) patients did not return for postpartum BP visit at 6 and 12 weeks after delivery. A multivariate logistic regression analysis identified education level of high school or below (OR = 3.71; 95% CI = 2.01-6.85; p = 0.000), maximum diastolic BP during pregnancy (OR = 0.97; 95% CI = 0.94-0.99; p = 0.0230)and delivery gestational age (OR = 1.12; 95% CI = 1.005-1.244; p = 0.040)as independent risk factors in predicting not returning to postpartum BP follow-up visit at 6 weeks postpartum, and education level of high school or below (OR = 3.20; 95% CI = 1.805-5.67; p = 0.000), maximum diastolic BP during pregnancy (OR = 0.95; 95% CI = 0.92-0.97; p = 0.000), delivery gestational age (OR = 1.13; 95% CI = 1.04-1.24; p = 0.006) and parity (OR = 1.63; 95% CI = 1.06-2.51; p = 0.026) as risk factors for not returning to postpartum BP follow-up visit at 12 weeks postpartum. The ROC curve analysis indicated that the logistic regression models had a significant predictive value for identify not returning to BP follow-up visit at 6 and 12 weeks postpartum with the area under the curve (AUC) 0.746 and 0.761, respectively.

CONCLUSION

Attendance at postpartum BP follow-up visit declined with time for postpartum HDP patients after discharge. Education at or below high school, maximum diastolic BP during pregnancy and gestational age at delivery were the common risk factors for not returning for BP follow-up visit at 6 and 12 weeks postpartum in postpartum HDP patients.

Postpartum Home Blood Pressure Monitoring: A Systematic Review

OBJECTIVE

To assess the effectiveness of postpartum home blood pressure (BP) monitoring compared with clinic-based follow-up and the comparative effectiveness of alternative home BP-monitoring regimens.

DATA SOURCES

Search of Medline, Cochrane, EMBASE, CINAHL, and ClinicalTrials.gov from inception to December 1, 2022, searching for home BP monitoring in postpartum individuals.

METHODS OF STUDY SELECTION

We included randomized controlled trials (RCTs), nonrandomized comparative studies, and single-arm studies that evaluated the effects of postpartum home BP monitoring (up to 1 year), with or without telemonitoring, on postpartum maternal and infant outcomes, health care utilization, and harm outcomes. After double screening, we extracted demographics and outcomes to SRDR+.

TABULATION, INTEGRATION, AND RESULTS

Thirteen studies (three RCTs, two nonrandomized comparative studies, and eight single-arm studies) met eligibility criteria. All comparative studies enrolled participants with a diagnosis of hypertensive disorders of pregnancy. One RCT compared home BP monitoring with bidirectional text messaging with scheduled clinic-based BP visits, finding an increased likelihood that at least one BP measurement was ascertained during the first 10 days postpartum for participants in the home BP-monitoring arm (relative risk 2.11, 95% CI 1.68-2.65). One nonrandomized comparative study reported a similar effect (adjusted relative risk [aRR] 1.59, 95% CI 1.36-1.77). Home BP monitoring was not associated with the rate of BP treatment initiation (aRR 1.03, 95% CI 0.74-1.44) but was associated with reduced unplanned hypertension-related hospital admissions (aRR 0.12, 95% CI 0.01-0.96). Most patients (83.3-87.0%) were satisfied with management related to home BP monitoring. Home BP monitoring, compared with office-based follow-up, was associated with reduced racial disparities in BP ascertainment by approximately 50%.

CONCLUSION

Home BP monitoring likely improves ascertainment of BP, which is necessary for early recognition of hypertension in postpartum individuals, and may compensate for racial disparities in office-based follow-up. There is insufficient evidence to conclude that home BP monitoring reduces severe maternal morbidity or mortality or reduces racial disparities in clinical outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022313075.

Patient engagement practice within perinatal eHealth: A scoping review

BACKGROUND

There is a gap in knowledge about how perinatal eHealth programs function to support autonomy for new and expectant parents from pursuing wellness goals.

OBJECTIVES

To examine patient engagement (access, personalization, commitment and therapeutic alliance) within the practice of perinatal eHealth.

DESIGN

Scoping review.

METHODS

Five databases were searched in January 2020 and updated in April 2022. Reports were vetted by three researchers and included if they documented maternity/neonatal programs and utilized World Health Organization (WHO) person-centred digital health intervention (DHI) categories. Data were charted using a deductive matrix containing WHO DHI categories and patient engagement attributes. A narrative synthesis was conducted utilizing qualitative content analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses 'extension for scoping reviews' guidelines were followed for reporting.

RESULTS

Twelve eHealth modalities were found across 80 included articles. The analysis yielded two conceptual insights: (1) The nature of perinatal eHealth programs: (1) emergence of a complex structure of practice and (2) practising patient engagement within perinatal eHealth.

CONCLUSION

Results will be used to operationalize a model of patient engagement within perinatal eHealth.

Factors associated with postpartum initiation of anti-hypertensive medication after hospital discharge among individuals with hypertensive disorders of pregnancy in a remote monitoring program

Importance

Following a hypertensive disorder of pregnancy, hypertension can worsen in the postpartum period following hospital discharge. Risk factors for hypertension exacerbation and associated outcomes have not been well characterized.

Objective

We sought to identify risk factors and characterize outcomes for individuals requiring initiation of anti-hypertensive medication following hospital discharge postpartum through our hospital system's remote blood pressure management program.

Design

We performed a cohort study of individuals delivered between 9/2019-6/2021 and enrolled in our remote blood pressure monitoring program, which utilizes standardized protocols for anti-hypertensive medication initiation postpartum.

Setting

Postpartum unit at a referral hospital.

Participants

Population-based sample of individuals with a hypertensive disorder of pregnancy (HDP, preeclampsia or gestational hypertension) and no pre-pregnancy hypertension.

Exposure

Anti-hypertensive medication initiation timing: no anti-hypertensive medications, initiation prior to hospital discharge postpartum, and initiation after hospital discharge postpartum.

Main outcomes

Postpartum readmission and emergency room visits.

Results

Of 2,705 individuals in our cohort, 1,458 (54%) required no anti-hypertensive medications postpartum, 637 individuals (24%) were discharged on anti-hypertensive medications, and 610 (23%) required initiation of anti-hypertensive agents after discharge. Utilizing an inpatient threshold of ≥ 150/100 mmHg in line with current obstetric guidelines for medication initiation postpartum fails to identify 385 (63%) of individuals who required medication initiation after discharge. These individuals had higher home blood pressures, increased odds of Emergency Room visits [aOR 2.22 (95%CI 1.65-2.98)] and hospital readmissions postpartum [aOR 5.73 (95%CI 3.72-8.82)] compared with individuals discharged on no medications.

Conclusions and Relevance

Over 20% of individuals with hypertensive disorders of pregnancy required initiation of anti-hypertensive medications after hospital discharge. Current blood pressure guidelines for medication initiation fail to identify the majority of these individuals during delivery hospitalization. These data support the critical role of remote blood pressure monitoring programs and highlight the need for improved tools for risk strati cation and liberalization of thresholds for medication initiation postpartum.

Development of a Mobile Health Application Based on a Mixed Prenatal Care in the Context of COVID-19 Pandemic

OBJECTIVE

 We describe the development and structure of a novel mobile application in a mixed model of prenatal care, in the context of the COVID-19 pandemic. Furthermore, we assess the acceptability of this mobile app in a cohort of patients.

METHODS

 First, we introduced a mixed model of prenatal care; second, we developed a comprehensive, computer-based clinical record to support our system. Lastly, we built a novel mobile app as a tool for prenatal care. We used Flutter Software version 2.2 to build the app for Android and iOS smartphones. A cross-sectional study was carried out to assess the acceptability of the app.

RESULTS

 A mobile app was also built with the main attribute of being connected in real-time with the computer-based clinical records. The app screens detail information about activities programmed and developed in the prenatal care according to gestational age. A downloadable maternity book is available and some screens show warning signs and symptoms of pregnancy. The acceptability assessment was mostly rated positively regarding the characteristics of the mobile app, by 50 patients.

CONCLUSION

 This novel mobile app was developed as a tool among pregnant patients to increase the information available about their pregnancies in the provision of a mixed model of prenatal care in the context of the COVID-19 pandemic. It was fully customized to the needs of our users following the local protocols. The introduction of this novel mobile app was highly accepted by the patients.

Use of Cellular-Enabled Remote Patient Monitoring Device for Hypertension Management in Pregnant Women: A Feasibility Study

INTRODUCTION

Hypertension affects 5-10% of pregnancies in the United States. Chronic hypertension during pregnancy can have a significant impact on maternal and neonatal outcomes, especially in rural populations. Pregnancies complicated by hypertension are currently managed through frequent clinic visits or extended hospital stays. Cellular-enabled remote patient monitoring devices provide an alternative treatment method for women in rural areas.

RESEARCH AIM

This study aimed to measure the feasibility of and patient satisfaction with using an integrated model of cellular-enabled remote patient monitoring devices for blood pressure supported by a 24/7 nurse call center.

METHODS

In a mixed methods pilot study, twelve women with chronic hypertension during pregnancy were given cellular-enabled BodyTrace^™ blood pressure cuffs and weight scales. Participants' blood pressures were continuously monitored by a nurse call center. Participants completed a survey and a brief semi-structured interview after two weeks.

RESULTS

Participants scored low on stress and anxiety with mean scores of 5.45 (SD = 3.56) and 8.09 (SD 3.62), respectively. Participants scored high on behavioral intention, system usability, and perceived benefits with mean scores of 8.73 (SD = 2.53), 75.91 (SD = 23.70), and 19.64 (SD = 5.92), respectively. Participants perceived benefits to using the device, including increased monitoring by health professionals, increased self-awareness, decreased number of clinic visits, and convenience of use. Perceived disadvantages included higher readings when compared to clinical readings.

DISCUSSION

Cellular-enabled remote patient monitoring devices for blood pressure are a valuable tool for managing treatment of pregnancies complicated by hypertension.

Improving Postpartum and Long-Term Health After an Adverse Pregnancy Outcome: Examining Interventions From a Health Equity Perspective

Gestational diabetes mellitus and hypertensive disorders in pregnancy are adverse pregnancy outcomes (APOs) that affect 15% of pregnancies in the United States. These APOs have long-term health implications, with greater risks of future cardiovascular and chronic disease later in life. In this manuscript, we review the importance of timely postpartum follow-up and transition to primary care after APOs for future disease prevention. We also discuss interventions to improve postpartum follow-up and long-term health after an APO. In recognizing racial and ethnic disparities in APOs and chronic disease, we review important considerations of these interventions through a health equity lens.

Postpartum Care in the Time of COVID-19: The Use of Telemedicine for Postpartum Care

Background: Telemedicine was implemented at our institution in response to the COVID-19 pandemic. Data do not currently exist about the use of telemedicine in providing comprehensive postpartum care. Objective: This project aimed to evaluate the impact of telemedicine on postpartum care at an urban Federally Qualified Health Center (FQHC). Study Design: This was a retrospective cohort study of patients who delivered at an urban hospital in New York between September and November 2019 (pre-COVID), February through April 2020 (peak-COVID) and June through August 2020 (ongoing-COVID). The primary outcome was postpartum visit attendance. Secondary outcomes included contraception use, breastfeeding, depression screening, hospital readmission, and emergency department visit rates. Log-binomial regression models were used to estimate relative risk. Results: Telemedicine accounted for 1% of postpartum visits in the pre-COVID cohort, 60% in the peak-COVID cohort, and 48% in the ongoing-COVID cohort. Postpartum visit attendance rates were 52% in the pre-COVID cohort, 43% in the peak-COVID cohort, and 56% in the ongoing-COVID cohort (p > 0.05). There was a nonsignificant increase in postpartum visit show rate for telemedicine visits compared to in-person visits in the peak-COVID cohort (76% vs. 65%; relative risk [RR] 1.17 [0.87-1.57]) and ongoing-COVID cohort (85% vs. 74%; RR 1.16 [0.90-1.50]). Patients were significantly less likely to have a Patient Health Questionnaire-2 Depression screen in the peak-COVID and ongoing-COVID cohorts (22% and 33%) than in the pre-COVID cohort (74%) (p < 0.01). There were no significant differences in hospital readmissions, contraceptive use or breastfeeding rates across cohorts (p > 0.05). Conclusions: At our urban FQHC, telemedicine was comparable to in-person postpartum care in terms of attendance rates during the COVID-19 pandemic, without an increase in rates of hospital visits or readmissions. However, postpartum depression screening needs to be better integrated into the telemedicine visit type.

Policy measures to expand home visiting programs in the postpartum period

The postpartum period is characterized by a myriad of changes-emotional, physical, and spiritual; whilst the psychosocial health of new parents is also at risk. More alarmingly, the majority of pregnancy-related deaths in the U.S. occur during this critical period. The higher maternal mortality rate is further stratified by dramatic racial and ethnic variations: Black, brown, and American Indian/Alaska Native indigenous people have 3-4x higher rates of pregnancy-related deaths and severe morbidity than their White, non-Hispanic, and Asian/Pacific Islander counterparts. This policy brief explores how expanding evidence based home visiting programs (HVPs) and strengthening reimbursement policies that invest in such programs can be pivoted to optimize the scope of care in the postpartum period.

The effect of the Ebe Evimde application on the self-efficacy and anxiety levels of mothers: Randomized controlled trial

Objective

Family health can be improved by making home visits with mobile applications. This study was carried out to evaluate the effect of a mobile application and web-based software called Ebe Evimde (My Home Midwife), which was designed by the researchers for use in the postpartum period, on mothers' self-efficacy and anxiety levels.

Methods

Home visits to 60 mothers in the intervention group, who are over 18 years of age, who have given birth at term, who have no complications in mother and baby, and who are in the second to fifth postpartum days, were made with the online home visits mobile support application Midwifery Home software and their self-efficacy and anxiety levels were evaluated. Mothers were divided into two groups as intervention (60) and control group (60) using a random number table.

Results

While there was a significant difference between the pretest and posttest self-efficacy levels of the intervention group, there was no difference between the pretest and posttest self-efficacy levels of the control group. When the groups obtained from the Postpartum Specific Anxiety Scale were examined, it was seen that there was a negative and very strong significant relationship between the pretest and posttest scores of the mothers in the intervention group, while when the relationship between the pretest and posttest scores of the mothers in the control group was examined; no significant relationship was observed.

Conclusion

The practice of Ebe Evimde (My Home Midwife) had a positive effect on mothers' self-efficacy and postpartum anxiety levels.

Virtual clinic in pregnancy and postpartum healthcare: A systematic review

Background and Aims

To monitor the health status of pregnant women moment by moment, new technologies in the field of telemedicine can be used, such as virtual visits and virtual clinics. During the COVID-19 pandemic, by using these technologies, useful and satisfactory services have been provided to pregnant mothers. The aim of this study is to specify the applications, features, and infrastructure of a comprehensive virtual clinic in the field of gynecological and pregnancy care.

Methods

A systematic review search was conducted through the scientific databases from February 2013 to February 2022 using Scopus, Web of Science, and PubMed. Furthermore, manual searches in Google Scholar and the reference lists of included studies were carried out.

Results

In this systematic review we included 16 articles that reported experiences in virtual clinics in pregnancy and postpartum healthcare. The involved studies were experimental, cohort, and cross-sectional studies. The target group users were pregnant or women who gave birth and families of neonatal. The application of virtual clinics was for the visit, consultation, monitoring, follow-up, and home care virtually. Highly satisfaction scores of caregivers after virtual visits and consultation were reported. There were some challenges during virtual visits and consultation; the most important challenge was a poor internet connection.

Conclusion

The reviewed studies show promising outcomes according to patient and provider satisfaction. We predict that telehealth will become a growingly significant part of gynecological care in the future.

Needs and preferences of women with prior severe preeclampsia regarding app-based cardiovascular health promotion

BACKGROUND

Women with prior severe preeclampsia are at an increased risk for cardiovascular diseases later in life compared to women who had a normotensive pregnancy. The objective of this study was to assess their needs and preferences regarding app-based cardiovascular health promotion.

METHODS

Patients (n = 35) of the Follow-Up PreEClampsia Outpatient Clinic (FUPEC), Erasmus MC, the Netherlands, participated in an anonymous online survey. The main outcomes under study were women's needs for health behavior promotion, and their preferences with respect to intervention delivery. Descriptive statistics were used to evaluate needs, and thematic analysis was used to analyze preferences.

RESULTS

Women's primary need for health behavior promotion pertained to their fat and sugar intake and physical activity; for some, to their mental health (practices), fruit and vegetable intake, salt intake, and water intake; and for a few, to their alcohol and tobacco use. Most women preferred an app-based intervention to include, in descending order: the tracking of health-related metrics, an interactive platform, the use of behavior change strategies, the provision of information, and personalization.

CONCLUSION

Cardiovascular health promotion targeting women with prior severe preeclampsia should feel relevant to its audience. App-based interventions are likely to be well received if they target fat and sugar intake and physical activity. These interventions should preferably track health-related metrics, be interactive, contain behavior change strategies, provide information, and be personalized. Adopting these findings during intervention design could potentially increase uptake, behavior change, and behavior change maintenance in this population.

Emergency Visits and Hospitalization After Chat Message, Voice Call, or Video Call for Telehealth in Obstetrics and Gynecology Using Telehealth Service User Data in Japan: Cross-sectional Study

Background

In obstetric and gynecologic practices, synchronous telehealth services via chat message, voice calls, and video calls have been increasingly equipped to improve patients’ health care accessibility and clinical outcomes. Nevertheless, differences in clinical outcomes between communication tools remain unknown, especially in terms of safety.

Objective

This study compared the occurrence of emergency visits and hospitalization after telehealth services through different communication tools, including chat messages, voice calls, and video calls.

Methods

We collected data on obstetric and gynecologic concerns of women who consulted specialized doctors and midwives through a telehealth consulting service in Japan (Sanfujin-ka Online) between January 1, 2019, and December 31, 2020. The outcomes were emergency visits or hospitalizations at night after the consultation. Chi-square test and multivariate logistic regression analysis were performed to compare the clinical outcomes between the groups who received telehealth services via chat message, voice calls, and video calls.

Results

This study included 3635 participants. The mean age of the participants was 31.4 (SD 5.7) years, and the largest age group (n=2154, 59.3%) was 30-39 years. The numbers (or proportions) of those who received telehealth services via chat message, voice calls, and video calls were 1584 (43.5%), 1947 (53.6%), and 104 (2.9%), respectively. The overall incidence of the outcome was 0.7% (26/3635), including 10 (0.3%) cases of chat message, 16 (0.5%) cases of voice calls, and no video calls. There were no emergency visits that happened due to inappropriate advice. No significant difference in the proportions of the outcomes was observed between the communication tools (P=.55). The multivariate logistic regression analysis showed no significant differences in the outcome between those who used chat message and those who used voice calls (odds ratio 1.63, 95% CI 0.73-3.65).

Conclusions

The communication tools of telehealth services in obstetrics and gynecology did not show a significant difference in terms of emergency visits or hospitalizations after using the service.

Implementing a self-monitoring application during pregnancy and postpartum for rural and underserved women: A qualitative needs assessment study

Background

Georgia has one of the highest maternal mortality rates within the US. This study describes the qualitative needs assessment undertaken to understand the needs of rural and underserved women and their perspectives on implementing a self monitoring application during pregnancy and postpartum.

Methods

Qualitative methodology was used to conduct the needs assessment of 12 health care providers (nurses, nurse-midwives, patient care coordinators, and physicians) and 25 women from rural and underserved populations in Georgia was conducted to ascertain common themes on three topics: pregnancy care experiences, comfort with technology, and initial perspectives on the proposed VidaRPM application. Transcription, coding, and consensus were conducted using content analysis and a Cohen’s Kappa coefficient was calculated to identify level of overall agreement between raters for the representative quotes identified for each theme.

Results

The overall agreement for the representative quotes that were chosen for each theme was in strong agreement (κ = 0.832). The major provider feedback included the following regarding the VidaRPM app: inclusion of questions to monitor physical well-being, embedded valid and reliable educational resources, and multiple modalities. The overall feedback from the mothers regarding the VidaRPM application was the virtual aspect helped overcome the barriers to accessing care, comfort with both WiFi and technology, and sustainable utility.

Discussion

The needs of rural and underserved pregnant women and their providers were assessed to develop and refine the VidaRPM app. This qualitative study on the VidaRPM app is the first step towards closing the gap between providers and patients during prenatal and postpartum periods by empowering and educating women into the first-year postpartum living in rural and underserved areas.

Barriers and Supports in eHealth Implementation among People with Chronic Cardiovascular Ailments: Integrative Review

eHealth interventions use information technology to provide attention to patients with chronic cardiovascular conditions, thereby supporting their self-management abilities.

OBJECTIVE

Identify barriers and aids to the implementation of eHealth interventions in people with chronic cardiovascular conditions from the perspectives of users, health professionals and institutions.

METHOD

An integrative database review of WoS, Scopus, PubMed and Scielo of publications between 2016 and 2020 reporting eHealth interventions in people with chronic cardiovascular diseases. Keywords used were eHealth and chronic disease. Following inclusion and exclusion criteria application, 14 articles were identified.

RESULTS

Barriers and aids were identified from the viewpoints of users, health professionals and health institutions. Some notable barriers include users' age and low technological literacy, perceived depersonalization in attention, limitations in technology access and usability, and associated costs. Aids included digital education and support from significant others.

CONCLUSIONS

eHealth interventions are an alternative with wide potentiality for chronic disease management; however, their implementation must be actively managed.

A Utility Framework for COVID-19 Online Forward Triage Tools: A Swiss Telehealth Case Study

The SARS-CoV-2 pandemic caused a surge in online tools commonly known as symptom checkers. The purpose of these symptom checkers was mostly to reduce the health system burden by providing worried people with testing criteria, where to test and how to self-care. Technical, usability and organizational challenges with regard to online forward triage tools have also been reported. Very few of these online forward triage tools have been evaluated. Evidence for decision frameworks may be of particular value in a pandemic setting where time frames are restricted, uncertainties are ubiquitous and the evidence base is changing rapidly. The objective was to develop a framework to evaluate the utility of COVID-19 online forward triage tools. The development of the online forward triage tool utility framework was conducted in three phases. The process was guided by the socio-ecological framework for adherence that states that patient (individual), societal and broader structural factors affect adherence to the tool. In a further step, pragmatic incorporation of themes on the utility of online forward triage tools that emerged from our study as well as from the literature was performed. Seven criteria emerged; tool accessibility, reliability as an information source, medical decision-making aid, allaying fear and anxiety, health system burden reduction, onward forward transmission reduction and systems thinking (usefulness in capacity building, planning and resource allocation, e.g., tests and personal protective equipment). This framework is intended to be a starting point and a generic tool that can be adapted to other online forward triage tools beyond COVID-19. A COVID-19 online forward triage tool meeting all seven criteria can be regarded as fit for purpose. How useful an OFTT is depends on its context and purpose.

Users' Perceptions Toward mHealth Technologies for Health and Well-being Monitoring in Pregnancy Care: Qualitative Interview Study

Background

Mobile health (mHealth) technologies, such as wearable sensors, smart health devices, and mobile apps, that are capable of supporting pregnancy care are emerging. Although mHealth could be used to facilitate the tracking of health changes during pregnancy, challenges remain in data collection compliance and technology engagement among pregnant women. Understanding the interests, preferences, and requirements of pregnant women and those of clinicians is needed when designing and introducing mHealth solutions for supporting pregnant women’s monitoring of health and risk factors throughout their pregnancy journey.

Objective

This study aims to understand clinicians’ and pregnant women’s perceptions on the potential use of mHealth, including factors that may influence their engagement with mHealth technologies and the implications for technology design and implementation.

Methods

A qualitative study using semistructured interviews was conducted with 4 pregnant women, 4 postnatal women, and 13 clinicians working in perinatal care.

Results

Clinicians perceived the potential benefit of mHealth in supporting different levels of health and well-being monitoring, risk assessment, and care provision in pregnancy care. Most pregnant and postnatal female participants were open to the use of wearables and health monitoring devices and were more likely to use these technologies if they knew that clinicians were monitoring their data. Although it was acknowledged that some pregnancy-related medical conditions are suitable for an mHealth model of remote monitoring, the clinical and technical challenges in the introduction of mHealth for pregnancy care were also identified. Incorporating appropriate health and well-being measures, intelligently detecting any abnormalities, and providing tailored information for pregnant women were the critical aspects, whereas usability and data privacy were among the main concerns of the participants. Moreover, this study highlighted the challenges of engaging pregnant women in longitudinal mHealth monitoring, the additional work required for clinicians to monitor the data, and the need for an evidence-based technical solution.

Conclusions

Clinical, technical, and practical factors associated with the use of mHealth to monitor health and well-being in pregnant women need to be considered during the design and feasibility evaluation stages. Technical solutions and appropriate strategies for motivating pregnant women are critical to supporting their long-term data collection compliance and engagement with mHealth technology during pregnancy.

The MEG3 lncRNA promotes trophoblastic cell growth and invasiveness in preeclampsia by acting as a sponge for miR-21, which regulates BMPR2 levels

Preeclampsia (PE) is one of the leading causes of maternal morbidity and mortality in pregnant women. This study aimed to investigate the potential impact and regulatory mechanisms of bone morphogenetic protein receptor 2 (BMPR2) on the progression of PE. We obtained placental tissues from pregnant women with PE and normal pregnant women, and the results showed that BMPR2 was expressed at low levels in the tissue from PE women. Genetic knockdown of BMPR2 increased the proliferation and invasion of cultured trophoblast cells, whereas its overexpression reduced these characteristics. Bioinformatics analysis and luciferase reporter gene assays confirmed that BMPR2 is a direct target of miR-21. Overexpression of a miR-21 inhibitor promoted the growth and invasiveness of trophoblast cells, whereas the opposite results were observed for the miR-21 mimic. Furthermore, miR-21 was sponged by the lncRNA MEG3, and shRNA inhibition of MEG3 reduced trophoblast cell growth and invasiveness. miR-21 was upregulated in the tissues from PE women, whereas MEG3 was downregulated, and the two were negatively correlated. Collectively, this study demonstrates that the lncRNA MEG3 acts as a sponge for miR-21, which regulates BMPR2 expression and promotes trophoblast cell proliferation and invasiveness, thereby preventing the development of PE. These findings provide novel insight into a targeted therapy that could be used to treat or prevent the development of PE.

The development of the postpartum mobile support application and the effect of the application on mothers' anxiety and depression symptoms

OBJECTIVE

The study aimed to develop the postpartum mobile support application to support postpartum mothers and to examine the effects of the use of mobile app on mothers' anxiety level and depression symptoms.

RESEARCH DESIGN/SETTING

It is a parallel group pretest-posttest randomized controlled study carried out between July 2017 and February 2020. The mothers (62 in the experiment and 62 in the control group) who gave birth in full-term at a university hospital in Konya province in Turkey and who had healthy newborns constituted the study group. Data were collected using the Information Form, the STAI State and Continuity Anxiety Scale, and the Edinburgh Postpartum Depression Scale. Mixed pattern variance analysis (mixed anova), t test in dependent groups, t test and chi square analysis in independent groups were used to analyze the data.

FINDINGS

Most of the mothers who used the application fed their baby only with breast milk and felt more sufficient about breastfeeding. The depression symptoms of mothers using the postpartum mobile support application was lower than that of the mothers in the control group; however, it was found that the application was not adequate alone to decrease anxiety levels and depression symptoms (p > 0.05).

CONCLUSIONS

The postpartum mobile support application is an important and useful source in accessing reliable information; however, it was found to be insufficient to lower anxiety levels and prevent depression symptoms at the end of the six-week postpartum period.

Cost-effectiveness of telehealth with remote patient monitoring for postpartum hypertension

OBJECTIVE

Evaluate cost-effectiveness of telehealth with remote monitoring for postpartum hypertensive disorders from the hospital's perspective.

METHODS

A decision tree was developed using results from a non-randomized controlled trial comparing telehealth to standard outpatient blood pressure monitoring. At discharge, postpartum women with a hypertensive disorder received a Bluetooth tablet, blood pressure monitor, and scale to submit vitals daily for 6 weeks. Women were managed and treated with a standard protocol. We performed a cost-effectiveness analysis using data from the hospital, device manufacturer supplied charges, and utilities. A cost-effectiveness threshold was set at $100,000/quality-adjusted life years. One-way and two-way sensitivity analyses were performed to evaluate the robustness of our results compared to baseline assumptions.

RESULTS

Telehealth monitoring significantly reduced postpartum readmissions, 3.7% (8/214) versus 0.5% (1/214), and resulted in higher quality-adjusted life years. Telehealth monitoring was cost-effective and cost-saving. Average cost of telehealth per patient was $309, and was cost-effective to a cost of $420 per patient. Telehealth monitoring remained cost-effective down to an admission cost of $10,999 compared to our baseline-estimate for the average admission cost of $14,401. Telehealth monitoring also remained cost-effective when the postpartum readmission rate was 3.0% or higher with standard monitoring. With a cost saving of $93 per patient and an estimated 333,253 pregnant women with hypertension in the US a year, telehealth could reduce health care costs in the US by approximately $31 million a year.

CONCLUSIONS

This study demonstrates telehealth with remote blood pressure monitoring may be a cost-effective and cost-saving solution for management of postpartum hypertension.

Feasibility of Using Blood Pressure Self-Monitoring and the Epic MyChart Blood Pressure Flowsheet to Monitor Blood Pressure After Preeclampsia

Preeclampsia is associated with significant morbidity and mortality. Women who experienced preeclampsia require close blood pressure surveillance postpartum. Remote monitoring of blood pressure using a mobile health application may be a viable method of surveillance in this population. The purpose of this project was to assess the feasibility of using the MyWellSpan mobile application to engage postpartum women who experienced preeclampsia in blood pressure self-monitoring. Women who chose to participate were provided an automatic blood pressure cuff and educational materials and were enrolled in MyWellSpan. A survey created by the authors asked participants to rate by Likert scale their satisfaction with the program and ease of use of the blood pressure cuff and self-monitoring. The electronic health record was reviewed retrospectively to assess utilization of the MyWellSpan mobile application to document blood pressure. The majority of women who participated reported that operating the blood pressure cuff was very easy and felt that it would be very easy to monitor their blood pressure twice daily. Sixty-nine percent of those women in the program electronically submitted at least 1 blood pressure measurement, thus confirming the feasibility of self-monitoring and reporting using a mobile application.

Patient perceptions, opinions and satisfaction of telehealth with remote blood pressure monitoring postpartum

Background

Our aim was to conduct a post participation survey of respondent experiences with in-home remote patient monitoring via telehealth for blood pressure monitoring of women with postpartum hypertension. We hypothesized that the in-home remote patient monitoring application will be implemented with strong fidelity and have positive patient acceptability.

Methods

This analysis was a planned secondary analysis of a non-randomized controlled trial of telehealth with remote blood pressure patient monitoring for postpartum hypertension compared to standard outpatient monitoring in women with a hypertension-related diagnosis during pregnancy. In collaboration with survey experts, we developed a 41-item web-based survey to assess 1) perception of quality of care received, 2) ease of use/ease to learn the telehealth program, 3) effective orientation of equipment, 4) level of perceived security/privacy utilizing telehealth and 5) problems encountered. The survey included multiple question formats including Likert scale responses, dichotomous Yes/No responses, and free text. We performed a descriptive analysis on all responses and then performed regression analysis on a subset of questions most relevant to the domains of interest. The qualitative data collected through open ended responses was analyzed to determine relevant categories. Intervention participants who completed the study received the survey at the 6-week study endpoint.

Results

Sixty six percent of respondents completed the survey. The majority of women found the technology fit easily into their lifestyle. Privacy concerns were minimal and factors that influenced this included age, BMI, marital status, and readmissions. 95% of women preferred remote care for postpartum follow-up, in which hypertensive type, medication use and ethnicity were found to be significant factors in influencing location of follow-up. Most women were satisfied with the devices, but rates varied by hypertensive type, infant discharge rates and BMI.

Conclusions

Postpartum women perceived the telehealth remote intervention was a safe, easy to use method that represented an acceptable burden of care and an overall satisfying method for postpartum blood pressure monitoring.

Trial registration

ClinicalTrials.gov identification number: NCT03111095 Date of registration: April 12, 2017.

Consumer acceptability and validity of m-Health for the detection of adverse events following immunization - The Stimulated Telephone Assisted Rapid Safety Surveillance (STARSS) randomised control trial

INTRODUCTION

Monitoring for adverse events following immunisation (AEFI) is critical for vaccine pharmacovigilance. Given the global and expanding availability of mobile phones their utility for consumer-based vaccine safety surveillance is of interest but little is known about consumer acceptability. This study nested within the Stimulated Telephone Assisted Rapid Safety Surveillance (STARSS) randomised control trial sought to evaluate the acceptability of SMS for AEFI surveillance.

METHODS

The primary STARSS study was a multi-centre RCT evaluating the efficacy of repeated SMS prompts for AEFI surveillance with participants being adult vaccinees or parents of children receiving any vaccine. This nested study enrolled primary RCT participants who completed a detailed computer assisted telephone interview to determine their attitudes towards SMS-based surveillance and ascertain their knowledge and attitudes toward vaccine safety, efficacy, data privacy and use of electronic health records. Attitudes to surveillance and related behaviour were used as measures of acceptability.

RESULTS

20% (1200/6555) of the participants were enrolled and 1139 completed the full-length questionnaire. 96% indicated that SMS-based surveillance after immunisation to check the safety of the vaccine "should be done" but 62% of all respondents said it should be done but consent should be sought first. Neither vaccine safety attitudes nor attitudes toward privacy were associated with opposition to SMS-based surveillance. In terms of SMS related behaviour demographic rather than attitudinal factors were associated with non-compliance.

CONCLUSION

Overall, the attitude towards SMS-based surveillance was very favourable. Experiencing the SMS surveillance has the effect of reducing opposition to an SMS surveillance system, and at the same time increasing the likelihood of a preference for prior consent. Detection of a vaccine safety signal could be impeded in particular demographic groups who are non-compliant and we should undertake further research to understand why these groups are non-compliant and how this can be improved.

Telemedicine in Obstetrics

Telemedicine is an important modality of care delivery in the twenty-first century and has many applications for the obstetric population. Existing research has shown the clinical efficacy and improved patient satisfaction of many telemedicine platforms in obstetrics. Telemedicine has the potential to reduce racial and geographic disparities in pregnancy care, but more research is necessary to inform best practices. Developing cost-effective telemedicine programs and establishing health care policy that standardizes insurance reimbursement are some of the most important steps toward scaling up telemedicine offerings for obstetric patients in the United States.

Hypertensive Disorders of Pregnancy, Cesarean Delivery, and Severe Maternal Morbidity in an Urban Safety-Net Population

Hypertensive disorders of pregnancy (HDP) are a leading cause of severe maternal morbidity (SMM), yet mediation by cesarean delivery is largely unexplored. We investigated the association between HDP and SMM in a cohort of deliveries at a safety-net institution in Atlanta, Georgia, during 2016-2018. Using multivariable generalized linear models, we estimated adjusted risk differences, adjusted risk ratios, and 95% confidence intervals for the association between HDP and SMM. We examined interactions with cesarean delivery and used mediation analysis with 4-way decomposition to estimate excess relative risks. Among 3,723 deliveries, the SMM rate for women with and without HDP was 124.4 per 1,000 and 52.0 per 1,000, respectively. The adjusted risk ratio for the total effect of HDP on SMM was 2.55 (95% confidence interval (CI): 2.15, 3.39). Approximately 55.2% (95% CI: 25.7, 68.5) of excess relative risk was due to neither interaction nor mediation, 24.9% (95% CI: 15.4, 50.0) was due to interaction between HDP and cesarean delivery, 9.6% (95% CI: 3.4, 15.2) was due to mediation, and 10.3% (95% CI: 5.4, 20.3) was due to mediation and interaction. HDP are a potentially modifiable risk factor for SMM; implementing evidence-based interventions for the prevention and treatment of HDP is critical for reducing SMM risk.

Transforming Health Care through Digital Revolutions

The Internet, which has spanned several networks in a broad range of domains, is having a significant impact on every aspect of our lives. The next generation of networks will utilize a wide variety of resources with significant sensing capabilities. Such networks will extend beyond physically linked computers to include multimodal-information from biological, cognitive, semantic, and social networks. This paradigm shift will involve symbiotic networks of smart medical devices, and smart phones or mobile personal computing and communication devices. These devices—and the network—will be constantly sensing, monitoring, and interpreting the environment; this is sometimes referred to as the Internet of Things (IoT). We are also witnessing considerable interest in the “Omics” paradigm, which can be viewed as the study of a domain in a massive scale, at different levels of abstraction, in an integrative manner. The IoT revolution, combined with the Omics revolution (genomics and socio-omics or social networks) and artificial intelligence resurgence, will have significant implications for the way health care is delivered in the United States. After discussing a vision for health care in the future, we introduce the P9 health care concept, followed by a discussion of a framework for smart health care. Then, we present a case study and research directions, followed by examples of ongoing work at the National Institute of Standards and Technology (NIST).

Design of the Pregnancy REmote MOnitoring II study (PREMOM II): a multicenter, randomized controlled trial of remote monitoring for gestational hypertensive disorders

Background

Observational data from the retrospective, non-randomized Pregnancy REmote MOnitoring I (PREMOM I) study showed that remote monitoring (RM) may be beneficial for prenatal observation of women at risk for gestational hypertensive disorders (GHD) in terms of clinical outcomes, health economics, and stakeholder perceptions. PREMOM II is a prospective, randomized, multicenter follow-up study that was performed to explore these promising results.

Methods

After providing written consent, 3922 pregnant women aged ≥18 years who are at increased risk of developing GHD will be randomized (1:1:1 ratio) to (a) conventional care (control group), (b) a patient self-monitoring group, and (c) a midwife-assisted RM group. The women in each group will be further divided (1:1 ratio) to evaluate the outcomes of targeted or non-targeted (conventional) antihypertensive medication. Women will be recruited in five hospitals in Flanders, Belgium: Ziekenhuis Oost-Limburg, Universitaire Ziekenhuis Antwerpen, Universitaire Ziekenhuis Leuven, AZ Sint Jan Brugge–Oostende, and AZ Sint Lucas Brugge. The primary outcomes are: (1) numbers and types of prenatal visits; (2) maternal outcomes; (3) neonatal outcomes; (4) the applicability and performance of RM; and (5) compliance with RM and self-monitoring. The secondary outcomes are: (1) cost-effectiveness and willingness to pay; (2) patient-reported outcome measures (PROMS) questionnaires on the experiences of the participants; and (3) the maternal and perinatal outcomes according to the type of antihypertensive medication. Demographic, and maternal and neonatal outcomes are collected from the patients’ electronic records. Blood pressure and compliance rate will be obtained from an online digital coordination platform for remote data handling. Information about the healthcare-related costs will be obtained from the National Coordination Committee of Belgian Health Insurance Companies (Intermutualistisch Agentschap). PROMS will be assessed using validated questionnaires.

Discussion

To our knowledge, this is the first randomized trial comparing midwife-assisted RM and self-monitoring of prenatal blood pressure versus conventional management among women at increased risk of GHD. Positive results of this study may lead to a practical framework for caregivers, hospital management, and payers to introduce RM into the prenatal care programs of high-risk pregnancies.

Trial registration

This study was registered on clinicaltrials.gov, identification number NCT04031430. Registered 24 July 2019, https://clinicaltrials.gov/ct2/show/NCT04031430?cond=premom+ii&draw=2&rank=1.

Exploring perspectives, preferences and needs of a telemonitoring program for women at high risk for preeclampsia in a tertiary health facility of Karachi: a qualitative study protocol

Background

In Pakistan, deaths from preeclampsia/eclampsia (PE/E) represent one-third of maternal deaths reported at tertiary care hospitals. To reduce the morbidity and mortality associated with PE/E, an accessible strategy is to support pregnant women at high risk for preeclampsia (HRPE) by closely monitoring their blood pressures at home (i.e., telemonitoring) for the earliest signs of preeclampsia. This could lead to the earliest possible detection of high blood pressure, resulting in early intervention such as through medications, hospitalization, or delivery of the baby. The study aims to explore the perspectives, preferences and needs of telemonitoring (TM) for pregnant women at HRPE in Karachi, to inform future implementation strategies.

Methods

The study will employ an exploratory qualitative research design. The study will be conducted at the Jinnah Postgraduate Medical Centre (JPMC) hospital and Aga Khan University Hospital (AKUH) in Karachi, Sindh, Pakistan. Data will be collected through key-informant interviews (KIIs) and in-depth patient interviews (IDPIs). IDPIs will be conducted with the pregnant women at HRPE who are visiting the out-patient department/ antenatal clinics of JPMC hospital for antenatal check-ups and immunizations. KIIs will be conducted with the obstetricians, Maternal, neonatal and child health (MNCH) specialists and health care providers at JPMC, as well as TM experts from Karachi. Study data will be analyzed through conventional content analysis. Interviews are anticipated to begin in April 2020 and to be completed during the summer of 2020.

Discussion

This is the first study to explore the use of TM program for pregnant women at HRPE in a tertiary health facility in Karachi. The research will help explore perceived benefits associated with the use of a TM program alongside potential facilitators and barriers that may help inform the future implementation of a TM program for pregnant women at HRPE in Karachi.

Use of Tablets and Smartphones to Support Medical Decision Making in US Adults: Cross-Sectional Study

BACKGROUND

Tablet and smartphone ownership have increased among US adults over the past decade. However, the degree to which people use mobile devices to help them make medical decisions remains unclear.

OBJECTIVE

The objective of this study is to explore factors associated with self-reported use of tablets or smartphones to support medical decision making in a nationally representative sample of US adults.

METHODS

Cross-sectional data from participants in the 2018 Health Information National Trends Survey (HINTS 5, Cycle 2) were evaluated. There were 3504 responses in the full HINTS 5 Cycle 2 data set; 2321 remained after eliminating respondents who did not have complete data for all the variables of interest. The primary outcome was use of a tablet or smartphone to help make a decision about how to treat an illness or condition. Sociodemographic factors including gender, race/ethnicity, and education were evaluated. Additionally, mobile health (mHealth)- and electronic health (eHealth)-related factors were evaluated including (1) the presence of health and wellness apps on a tablet or smartphone, (2) use of electronic devices other than tablets and smartphones to monitor health (eg, Fitbit, blood glucose monitor, and blood pressure monitor), and (3) whether people shared health information from an electronic monitoring device or smartphone with a health professional within the last 12 months. Descriptive and inferential statistics were conducted using SAS version 9.4. Weighted population estimates and standard errors, univariate odds ratios, and 95% CIs were calculated, comparing respondents who used tablets or smartphones to help make medical decisions (n=944) with those who did not (n=1377), separately for each factor. Factors of interest with a P value of <.10 were included in a subsequent multivariable logistic regression model.

RESULTS

Compared with women, men had lower odds of reporting that a tablet or smartphone helped them make a medical decision. Respondents aged 75 and older also had lower odds of using a tablet or smartphone compared with younger respondents aged 18-34. By contrast, those who had health and wellness apps on tablets or smartphones, used other electronic devices to monitor health, and shared information from devices or smartphones with health care professionals had higher odds of reporting that tablets or smartphones helped them make a medical decision, compared with those who did not.

CONCLUSIONS

A limitation of this research is that information was not available regarding the specific health condition for which a tablet or smartphone helped people make a decision or the type of decision made (eg, surgery, medication changes). In US adults, mHealth and eHealth use, and also certain sociodemographic factors are associated with using tablets or smartphones to support medical decision making. Findings from this study may inform future mHealth and other digital health interventions designed to support medical decision making.

Establishing Better Evidence on Remote Monitoring for Postpartum Hypertension: A Silver Lining of the Coronavirus Pandemic

The transformation of our health care system in response to coronavirus disease 2019 (COVID-19) provides a unique opportunity to examine the use of telehealth for postpartum care. The postpartum period can pose significant risks and challenges, particularly for women with hypertensive disorders of pregnancy. Remote blood pressure monitoring has proven feasible and acceptable among women and providers but has not been widely implemented or researched. Early studies have identified improved outcomes with use of telehealth, including increased compliance with care and decreased disparity in hypertension follow-up. Preliminary data make a compelling case for remote monitoring as a promising treatment strategy to manage postpartum hypertension. Remote monitoring technology should be incorporated as a standard component for the comprehensive management of postpartum hypertension during COVID-19. As a consequence of the pandemic, we now have an opportunity to research the impact of postpartum remote blood pressure monitoring on maternal outcome and disparities within these outcomes.

Telemedicine in High-Risk Obstetrics

Telemedicine involves the use of technology to provide services to patients and share medical information. Telemedicine's use has increased as technology has advanced. It allows for medicine to be practiced from a distance to reach patients in rural or underserved areas. Telemedicine has widespread uses in high-risk obstetrics, including management of diabetes, diagnosis and management of hypertensive disorders of pregnancy, screening for fetal malformations with teleultrasound, delivering care to underserved areas, and more. The use of telemedicine to provide care to patients and information to health care providers at a distance has been well accepted by the patients and providers.

Exploring the Use of Telemonitoring for Patients at High Risk for Hypertensive Disorders of Pregnancy in the Antepartum and Postpartum Periods: Scoping Review

Background

High blood pressure complicates 2% to 8% of pregnancies, and its complications are present in the antepartum and postpartum periods. Blood pressure during and after pregnancy is routinely monitored during clinic visits. Some guidelines recommend using home blood pressure measurements for the management and treatment of hypertension, with increased frequency of monitoring for high-risk pregnancies. Blood pressure self-monitoring may have a role in identifying those in this high-risk group. Therefore, this high-risk pregnancy group may be well suited for telemonitoring interventions.

Objective

The aim of this study was to explore the use of telemonitoring in patients at high risk for hypertensive disorders of pregnancy (HDP) during the antepartum and postpartum periods. This paper aims to answer the following question: What is the current knowledge base related to the use of telemonitoring interventions for the management of patients at high risk for HDP?

Methods

A literature review following the methodological framework described by Arksey et al and Levac et al was conducted to analyze studies describing the telemonitoring of patients at high risk for HDP. A qualitative study, observational studies, and randomized controlled trials were included in this scoping review.

Results

Of the 3904 articles initially identified, 20 met the inclusion criteria. Most of the studies (13/20, 65%) were published between 2017 and 2018. In total, there were 16 unique interventions described in the 20 articles, all of which provide clinical decision support and 12 of which are also used to facilitate the self-management of HDP. Each intervention’s design and process of implementation varied. Overall, telemonitoring interventions for the management of HDP were found to be feasible and convenient, and they were used to facilitate access to health services. Two unique studies reported significant findings for the telemonitoring group, namely, spontaneous deliveries were more likely, and one study, reported in two papers, described inductions as being less likely to occur compared with the control group. However, the small study sample sizes, nonrandomized groups, and short study durations limit the findings from the included articles.

Conclusions

Although current evidence suggests that telemonitoring could provide benefits for managing patients at high risk for HDP, more research is needed to prove its safety and effectiveness. This review proposes four recommendations for future research: (1) the implementation of large prospective studies to establish the safety and effectiveness of telemonitoring interventions; (2) additional research to determine the context-specific requirements and patient suitability to enhance accessibility to healthcare services for remote regions and underserved populations; (3) the inclusion of privacy and security considerations for telemonitoring interventions to better comply with healthcare information regulations and guidelines; and (4) the implementation of studies to better understand the effective components of telemonitoring interventions.

A Postpartum Remote Hypertension Monitoring Protocol Implemented at the Hospital Level

OBJECTIVE

To evaluate the feasibility, acceptability, and compliance of a remote blood pressure monitoring protocol implemented as a quality improvement measure at the hospital level for management of hypertension in postpartum women after hospital discharge.

METHODS

This is an ongoing quality improvement project that included women admitted to the postpartum unit of a single tertiary care hospital. We designed nursing call center-driven blood pressure management and treatment algorithms, which were initiated after hospital discharge until 6 weeks postpartum. Women are eligible to participate if they have a diagnosis of chronic hypertension, superimposed preeclampsia, gestational hypertension, preeclampsia, or postpartum hypertension and have access to a text messaging-enabled smartphone device. After identification by an obstetric care provider, women are enrolled into the program, which is automatically indicated in the electronic medical record. Maternal, obstetric, and sociodemographic data were obtained from the electronic medical record.

RESULTS

Between February 2018 and January 2019, we enrolled 499 patients. Here we report on the first 409 enrolled patients. Participants include 168 (41%) with gestational hypertension, 179 (44%) with preeclampsia with no history of chronic hypertension, 49 (12%) with chronic hypertension with superimposed preeclampsia, and 13 (3%) with postpartum preeclampsia. One hundred seventy-one (42%) participants had antihypertensives initiated or titrated through the program. Three hundred forty women (83%) continued the program beyond 3 weeks postpartum, and 360 (88%) attended an in-person 6-week postpartum visit. Two hundred thirty-five out of 250 women who completed a postprogram survey (94%) reported satisfaction with the program.

CONCLUSION

In this study, we detail results from an ongoing remote blood pressure monitoring program. We demonstrate high compliance, retention, and patient satisfaction with the program. This is a feasible, scalable remote monitoring program connected to the electronic medical record.

Using mHealth in postpartum women with pre-eclampsia: Lessons learned from a qualitative study

OBJECTIVE

To explore perceptions and attitudes of postpartum women with pre-eclampsia towards remote monitoring (mHealth) and communication with the call center.

METHODS

A non-randomized cohort study was conducted in postpartum hypertensive women, recruited from a tertiary hospital between October 2015 and February 2016. Participants were categorized into users (using mHealth) and non-users (not using mHealth) to monitor vital signs at home over a 2-week period after discharge. Non-users were informed about functionality of mHealth. Both groups participated in a 30-minute phone interview at the end of the study. Directed content analysis of interview transcripts was conducted.

RESULTS

In total, 21 users and 16 non-users participated in the interview. Both groups perceived that mHealth helped manage their condition. However, non-users were concerned about the challenge of incorporating mHealth into their routine, whereas users mentioned that they liked using mHealth on a daily basis. They also stated that communication with nurses in the call center was helpful. Barriers identified by users included size of the blood pressure cuffs, size of the equipment set, wireless connection, and stress associated with mHealth monitoring. Users stated that they would have preferred using mHealth during pregnancy.

CONCLUSION

The findings provide useful insights to inform a successful remote monitoring program among perinatal and postpartum women.

Mobile Health Applications for Prenatal Assessment and Monitoring

BACKGROUND

A mobile health application is an exciting, fast-paced domain that is likely to improve prenatal care.

METHODS

In this narrative review, we summarise the use of mobile health applications in this setting with a special emphasis on both the benefits of remote monitoring devices and the potential pitfalls of their use, highlighting the need for robust regulations and guidelines before their widespread introduction into prenatal care.

RESULTS

Remote monitoring devices for four areas of prenatal care are reported: (1) cardio-tocography; (2) blood glucose levels; (3) blood pressure; and (4) prenatal ultrasound. The majority of publications are pilot projects on remote consultation, education, coaching, screening, monitoring and selective booking, mostly reporting potential medical and/or economic benefits by mobile health applications over conventional care for very specific situations, indications and locations, but not always generalizable.

CONCLUSIONS

Despite the potential advantages of these devices, some caution must be taken when implementing this technology into routine daily practice. To date, the majority of published research on mobile health in the prenatal setting consists of observational studies and there is a need for high-quality randomized controlled trials to confirm the reported clinical and economic benefits as well as the safety of this technology. There is also a need for guidance and governance on the development and validation of new apps and devices and for the implementation of mobile health technology into healthcare systems in both high and low-income settings. Finally, digital communication technologies offer perspectives towards exploration and development of the very new domain of tele-pharmacology.

Relationship Between Adherence to Remote Monitoring and Patient Characteristics: Observational Study in Women With Pregnancy-Induced Hypertension

Background

Pregnancy-induced hypertension (PIH) is associated with high levels of morbidity and mortality in mothers, fetuses, and newborns. New technologies, such as remote monitoring (RM), were introduced in 2015 into the care of patients at risk of PIH in Ziekenhuis Oost-Limburg (Genk, Belgium) to improve both maternal and neonatal outcomes. In developing new strategies for obstetric care in pregnant women, including RM, it is important to understand the psychosocial characteristics associated with adherence to RM to optimize care.

Objective

The aim of this study was to explore the role of patients’ psychosocial characteristics (severity of depression or anxiety, cognitive factors, attachment styles, and personality traits) in their adherence to RM.

Methods

Questionnaires were sent by email to 108 mothers the day after they entered an RM program for pregnant women at risk of PIH. The Generalized Anxiety Disorder Assessment-7 and Patient Health Questionnaire-9 (PHQ-9) were used to assess anxiety and the severity of depression, respectively; an adaptation of the Pain Catastrophizing Scale was used to assess cognitive factors; and attachment and personality were measured with the Experiences in Close Relationships-Revised Scale (ECR-R), the Depressive Experiences Questionnaire, and the Multidimensional Perfectionism Scale, respectively.

Results

The moderate adherence group showed significantly higher levels of anxiety and depression, negative cognitions, and insecure attachment styles, especially compared with the over adherence group. The low adherence group scored significantly higher than the other groups on other-oriented perfectionism. There were no significant differences between the good and over adherence groups. Single linear regression showed that the answers on the PHQ-9 and ECR-R questionnaires were significantly related to the adherence rate.

Conclusions

This study demonstrates the relationships between adherence to RM and patient characteristics in women at risk of PIH. Alertness toward the group of women who show less than optimal adherence is essential. These findings call for further research on the management of PIH and the importance of individual tailoring of RM in this patient group.

Trial Registration

ClinicalTrials.gov NCT03509272; https://clinicaltrials.gov/ct2/show/NCT03509272

Telemonitoring for hypertensive disease in pregnancy

Introduction: Telemonitoring of hypertension in pregnancy is becoming increasingly common. Several small studies have described the potential benefits of patient-led remote monitoring, including fewer hospital visits, better blood pressure control, and cost savings. Areas covered: This review summarises the principles of prenatal remote monitoring of hypertension as well as the types of devices and applications currently in use. We summarise current evidence regarding the potential benefits and pitfalls with respect to outcomes for mothers, neonates and wider population health. Core topics for ongoing and future research are discussed, with special emphasis on feasibility and validation of technologies, methodological standardization, patient safety, privacy and acceptability, and health economics and governance. Expert opinion: Telemonitoring of hypertension in pregnancy is likely to become commonplace in the next five to ten years and research now must be directed to ensure it is used in the safest way before its general introduction into daily clinical practice can be recommended. Raising women's awareness of their health condition could improve both pregnancy and long-term health outcomes.

Pregnancy outcomes following home blood pressure monitoring in gestational hypertension

OBJECTIVES

To assess the safety and efficacy of home blood pressure monitoring (HBPM) and office (traditional) blood pressure measurements in a cohort of pregnant women with gestational hypertension (GH).

STUDY DESIGN

This was a cohort study at St. George's Hospital, University of London conducted between December 2013 and August 2018. The inclusion criteria was pregnant women with a diagnosis of GH. Eligible patients were counseled and trained by a specialist midwife and were provided with an automated Microlife® "WatchBP Home" BP machine. Each patient followed an individualised schedule of hospital visits and BP measurements based on the HBPM pathway or standard hospital protocol which was based on the National Institute of Health and Care Excellence (NICE) guideline.

MAIN OUTCOME MEASURES

Adverse fetal, neonatal and maternal outcomes as well as number of antenatal hospital visits were recorded and compared between HBPM and office (traditional) pathways.

RESULTS

143 women with GH were included in the study (80 HBPM vs 63 standard care). There were no significant difference between the two groups in maternal high-dependency unit admission (P = 0.999), birth weight centile (P = 0.803), fetal growth restriction (p = 0.999), neonatal intensive care unit admissions (p = 0.507) and composite neonatal (p = 0.654), maternal (p = 0.999) or fetal adverse outcomes (p = 0.999). The number of Day Assessment Unit (DAU) visits was significantly lower in the HBPM group than the traditional pathway (median 4.0 vs. 5.0, P = 0.009). The difference was greater when the number of visits were adjusted for the duration of monitoring in weeks (median: 1.0 vs 1.5, P < 0.001). There were no significant difference between the two groups in the total number of outpatient (P = 0.357) and triage visits (p = 0.237). However, the total number of antenatal visits adjusted for the duration of monitoring was significantly lower for the HBPM group compared to the traditional pathway (median 1.4 vs 1.8, P = 0.020).

CONCLUSIONS

HBPM in women with GH results in significantly less antenatal visits compared to women on a standard pathway of care. The two groups had comparable fetal, neonatal and maternal adverse outcomes. Large multicentre studies are needed to ascertain the safety of rare adverse pregnancy outcomes.

The Support for New Mums Project: A protocol for a pilot randomized controlled trial designed to test a postnatal psychoeducation smartphone application

AIM

To report a pilot trial protocol for testing the effectiveness of the Support for New Mums smartphone application in a cohort of first-time mothers.

DESIGN

A pilot/feasibility randomized controlled trial using a two-group pre-test and repeated post-test design.

METHOD

This protocol follows the Standard Protocol Items: Recommendations for Intervention Trials (SPIRIT) guidelines. The Intervention group will receive access to the smartphone application for 6 weeks post birth. Both Intervention and control groups will receive standardized institutional postnatal care services. Trial funding was gained from respective grant sponsors in May and November 2016.

DISCUSSION

The Support for New Mums smartphone application could be a novel method for addressing the gap in provision of postpartum care services providing psychoeducation and improving maternal parental self-efficacy for Australian childbearing women.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12618001580268.

Telehealth with remote blood pressure monitoring for postpartum hypertension: A prospective single-cohort feasibility study

OBJECTIVE

Investigate feasibility of telehealth with remote blood pressure monitoring for management of hypertension in postpartum women at risk of severe hypertension after hospital discharge.

METHODS

In a single-center, prospective single-cohort feasibility study, women with hypertension in pregnancy participated in a postpartum telehealth intervention for blood pressure management after discharge. The primary feasibility outcome measures were recruitment and retention through 6 weeks postpartum. Secondary outcomes included the incidence of severe postpartum hypertension and/or need for blood pressure treatment after discharge, participant satisfaction, and 6-week hospital readmission. Participants received a tablet and equipment to transmit vital signs to a central monitoring site daily. Participants participated in telehealth or telephone visits with a nurse at 48 h and as needed.

RESULTS

Among 1413 deliveries 263 (19%) women had hypertension in pregnancy and 55/124 (47%) of women approached were consented. The retention rate was 95%. Among study participants, the incidence of severe hypertension after discharge was 9 (16%). 29 (53%) of participants required treatment due to exacerbations in blood pressure after discharge, in which 9(16%) were severe. There were no hospital readmissions. Overall 39 (86%) participants were satisfied with the remote monitoring.

CONCLUSIONS

Feasibility and participant satisfaction were demonstrated. The incidence of severe hypertension and need for blood pressure treatment after discharge and during 6 weeks postpartum was 16% and 53%. Our results indicate telehealth is a promising strategy for postpartum hypertension management to decrease maternal morbidity and hospital readmission.

A Prenatal Remote Monitoring Program in Pregnancies Complicated with Gestational Hypertensive Disorders: What Are the Contributors to the Cost Savings?

Background: In 2015, we performed a cost analysis of a prenatal remote monitoring (RM) program compared with conventional care (CC) for women diagnosed with gestational hypertensive disorders (GHD). Introduction: We investigated where the cost savings were distributed by dividing our patient population into three subgroups, according to the gestational age (GA) at the time of delivery: (1) <34 weeks; (2) 34-37 weeks; and (3) >37 weeks of GA. Materials and Methods: Health care costs were calculated from patient-specific hospital bills at Ziekenhuis Oost Limburg (Genk, Belgium) in 2015-2016. Cost comparisons were made from the perspectives of the Belgium national health care system (HCS), the National Institution for Insurance of Disease and Disability (RIZIV), and the costs to individual patients. Results: A total of 256 pregnant women were included, 80 (31.25%) of whom received RM and 176 (68.75%) of whom received CC. The greatest difference in costs between RM and CC was in the group that delivered before 34 weeks of GA, followed by the group who delivered after 37 weeks of GA, and then the group of women who delivered at 34-37 weeks of GA. Most of the cost savings were in neonatal care, for both the three separate study subgroups and the total study group. Discussion and Conclusion: Our data showed that RM is more cost-effective than CC for pregnant women with GHD. Further investigation of the effects of RM on the long-term economic and social costs is recommended, together with an analysis of the price that should be asked for RM services.