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

Exploring the impact of integrating telehealth in obstetric care: A scoping review

BACKGROUND

The use of telemedicine has spread to all areas of medicine, including obstetrics, over the last few decades.

OBJECTIVE

To identify and map the diversity and applicability of telemedicine in the obstetric literature, in the antenatal, intrapartum or postnatal period. To assess patient satisfaction and possible areas for future development.

METHODS

This scoping review was conducted following the Joanna Briggs Institute (JBI) methodological guidelines for scoping reviews and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and its extension for scoping reviews (PRISMA-ScR). We searched the databases PubMed (Medline), CINAHL, CENTRAL (Cochrane Library), EMBASE Ovid and Scopus. We also searched Google Scholar, clinicaltrial.gov, the WHO International Clinical Trials Registry Platform (ICTRP-WHO) and the reference lists of the included studies. We included any primary study design that focused on a population of women in the antenatal, intrapartum or postnatal period. Studies selection and data extraction were performed blindly and independently by two authors. We summarised the results narratively and used graphs and tables to present key concepts thematically.

RESULTS

We included 66 studies. We categorised the studies according to population, type of intervention, outcomes and user satisfaction. Most of the studies involved pathological (36%) and physiological (30%) pregnancy management, the type of intervention was mainly divided into televisits or video calls with professionals (43%) and the use of specific apps or devices (40%). The maternal outcomes studied were mainly quantitative, i.e., improvement in blood chemistry tests or vital parameters (65%) and treatment adherence (frequency of follow-up visits or keeping appointments, 27%). Patient satisfaction was positive in the majority of cases.

CONCLUSIONS

There is still little international agreement on the concept and possible applications of telemedicine in obstetrics, although it is increasingly being used in clinical practice. Studies have shown positive results in terms of improved care, particularly in terms of treatment adherence and as an alternative strategy in the management of pregnancy, postpartum and abortion care. Both patients and health professionals were satisfied with it, especially when offered as a complement or alternative to the traditional method of face-to-face visits. Future developments seem to be the time and cost-saving potential of telemedicine and its application to couples' infertility.

Establishing an Evaluation Indicator System for User Satisfaction With Hypertension Management Apps: Combining User-Generated Content and Analytic Hierarchy Process

BACKGROUND

Hypertension management apps (HMAs) can be effective in controlling blood pressure, but their actual impact is often suboptimal. Establishing a user satisfaction evaluation indicator system for HMAs can assist app developers in enhancing app design and functionality, while also helping users identify apps that best meet their needs. This approach aims to improve the overall effectiveness of app usage.

OBJECTIVE

This study aims to systematically collect data on HMAs and their user reviews in the United States and China. It analyzes app usage patterns and functional characteristics, identifies factors influencing user satisfaction from existing research, and develops a satisfaction evaluation indicator system to provide more accurate recommendations for improving user satisfaction.

METHODS

We conducted a descriptive statistical analysis to assess the development status of HMAs in both countries and applied the task-technology fit model to evaluate whether the app functionalities align with business needs. We separately summarized the factors influencing user satisfaction in both countries from previous research, utilized the analytic hierarchy process to develop an evaluation indicator system for HMA user satisfaction, and calculated satisfaction levels. Based on these findings, we propose improvements to enhance app functionality and user satisfaction.

RESULTS

In terms of current development status, there were fewer HMAs and user reviews in China compared with the United States. Regarding app functional availability, fewer than 5% (4/91) of the apps achieved a demand fulfillment rate exceeding 80% (8/10). Overall, user satisfaction in both countries was low.

CONCLUSIONS

In the United States, user satisfaction was lowest for advertising distribution, data synchronization, and reliability. By contrast, Chinese apps need improvements in cost efficiency and compatibility.

Patient perceptions of remote patient monitoring program for hypertensive disorders of pregnancy

PURPOSE

The utilization of remote patient monitoring (RPM) with home blood pressure monitoring has shown improvement in blood pressure control and adherence with follow-up visits. Patient perceptions regarding its use in the obstetric population have not been widely studied. The aim of this study was to assess patients' knowledge about hypertensive disorders of pregnancy and perceptions and satisfaction of the RPM program.

METHODS

Descriptive analysis of survey responses of patients with PPHTN enrolled into the RPM program for 6 weeks after delivery between October 2021 and April 2022. Surveys were automatically administered at 1-, 3-, and 6-week postpartum. Responses were further compared between Black and non-Black patient-reported race.

RESULTS

545 patients received the RPM program. Of these, 306 patients consented to data collection. At 1 week, 88% of patients that responded reported appropriately that a blood pressure greater than 160/110 is abnormal. At 3 weeks, 87.4% of patients responded reported they were "very" or "somewhat" likely to attend their postpartum follow-up visits because of RPM. At 6 weeks, 85.5% of the patients that responded were "very" or "somewhat" satisfied with the RPM program. Responses were not statistically different between races.

CONCLUSIONS

Majority of postpartum patients enrolled in the RPM program had correct knowledge about hypertension. In addition, patients were highly satisfied with the RPM program and likely to attend postpartum follow-up based on responses. Further research is warranted to validate these findings and to address any barriers for patients who did not utilize the program.

Addressing Racial Disparities in the Hypertensive Disorders in Pregnancy: A Plan for Action from the Preeclampsia Foundation's Racial Disparities Task Force

Hypertensive disorders of pregnancy (HDP) are among the leading causes of maternal mortality in the United States, with Black women and birthing people disproportionately having higher HDP-related deaths and morbidity. In 2020, the Preeclampsia Foundation formed a national Racial Disparities Task Force (RDTF) to identify key recommendations to address issues of racial disparities related to HDP. Recommendations are centered around the Foundation's three pillars: Community, Healthcare Practice, and Research. Healthcare practices include adequate treatment of chronic hypertension in Black women and birthing people, re-branding low-dose aspirin to prenatal aspirin to facilitate uptake, and innovative models of care that especially focus on postpartum follow-up. A research agenda that examines the influence of social and structural determinants of health (ssDOH) on HDP care, access, and outcomes is essential to addressing disparities. One specific area that requires attention is the development of metrics to evaluate the quality of obstetrical care as it relates to racial disparities in Black women and birthing people with HDP. The recommendations generated by the Preeclampsia Foundation's RDTF highlight the strategic priorities and are a call to action that requires listening to the voices and experiences of Black women and birthing people, engaging their communities, and multi-sectoral collaboration to improve healthcare practices and drive needed research.

Birthing Parent Experiences of Postpartum at-Home Blood Pressure Monitoring Versus Office-Based Follow up After Diagnosis of Hypertensive Disorders of Pregnancy

Hypertensive disorders of pregnancy are a leading cause of pregnancy-related morbidity and mortality. The primary objective of this study was to compare the frequency of documentation of postpartum blood pressure through remote blood pressure monitoring with text-message delivered reminders versus office-based follow-up 7-10 days postpartum. The secondary objective was to examine barriers and facilitators of both care strategies from the perspectives of individuals who experienced a hypertensive disorder of pregnancy. We conducted a randomized controlled trial at a tertiary care academic medical center in the southeastern US with 100 postpartum individuals (50 per arm) from 2018 to 2019. Among 100 trial participants, blood pressure follow-up within 7-10 days postpartum was higher albeit not statistically significant between postpartum individuals randomized to the remote assessment intervention versus office-based standard care (absolute risk difference 18.0%, 95% CI -0.1 to 36.1%, p = 0.06). Patient-reported facilitators for remote blood pressure monitoring were maternal convenience, clarity of instructions, and reassurance from the health assessments. These positive aspects occurred alongside barriers, which included constraints due to newborn needs and the realities of daily postpartum life.

Implementation of a Cell-Enabled Remote Blood Pressure Monitoring Program During the Postpartum Period at a Safety-Net Hospital

BACKGROUND

Postpartum hypertension is a risk factor for severe maternal morbidity; however, barriers exist for diagnosis and treatment. Remote blood pressure (BP) monitoring programs are an effective tool for monitoring BP and may mitigate maternal health disparities. We aimed to describe and evaluate engagement in a remote BP monitoring program on BP ascertainment during the first 6-weeks postpartum among a diverse patient population.

METHODS AND RESULTS

A postpartum remote BP monitoring program, using cell-enabled technology and delivered in multiple languages, was implemented at a large safety-net hospital. Eligible patients are those with hypertensive disorders before or during pregnancy. We describe characteristics of patients enrolled from January 2021 to May 2022 and examine program engagement by patient characteristics. Linear regression models were used to calculate mean differences and 95% CIs between characteristics and engagement metrics. We describe the prevalence of patients with BP ≥140/or >90 mm Hg. Among 1033 patients, BP measures were taken an average of 15.2 days during the 6-weeks, with the last measurement around 1 month (mean: 30.9 days), and little variability across race or ethnicity. Younger maternal age (≤25 years) was associated with less frequent measures (mean difference, -4.3 days [95% CI: -6.1 to -2.4]), and grandmultiparity (≥4 births) was associated with shorter engagement (mean difference, -3.5 days [95% CI, -6.1 to -1.0]). Prevalence of patients with BP ≥140/or >90 mm Hg was 62.3%, with differences by race or ethnicity (Black: 72.9%; Hispanic: 52.4%; White: 56.0%).

CONCLUSIONS

A cell-enabled postpartum remote BP monitoring program was successful in uniformly monitoring BP and capturing hypertension among a diverse, safety-net hospital population.

Postpartum Remote Blood Pressure Monitoring Using a Mobile App in Women with a Hypertensive Disorder of Pregnancy

BACKGROUND

Hypertensive disorders of pregnancy affect approximately 15% of pregnancies in the United States and are a leading cause of postpartum readmissions. Morbidity due to hypertension may be higher in the first several weeks postpartum. The ability to monitor blood pressure and intervene in the postpartum period is critical to reducing morbidity and mortality.

LOCAL PROBLEM

At WellSpan Health, hypertensive disorders were increasing and a leading cause of severe maternal morbidity and readmission.

INTERVENTIONS

A remote blood pressure monitoring app called BabyScripts™ myBloodPressure was implemented in September 2020. Prior to discharge postpartum, all patients with a diagnosis of a hypertensive disorder of pregnancy were given an automatic blood pressure cuff and instructions on how to monitor and track their blood pressure daily in the app.

RESULTS

A total of 1,260 patients were enrolled in the BabyScripts™ myBloodPressure module between September 2020 and July 2022 across five maternity hospitals. Of those enrolled 74% ( n = 938) entered seven or more blood pressures, and of those who entered at least one blood pressure 9% ( n = 107) entered at least one critical range blood pressure ( ≥ 150 mmHg systolic and or ≥ 100 mmHg diastolic).

CONCLUSION

Most women enrolled in the app were highly engaged and entered seven or more readings. Patients with critical blood pressures were identified; thus, the program has the potential to identify those at risk of severe complications. Barriers should be removed, and remote patient monitoring considered as a solution to improve postpartum assessment in patients with hypertensive disorders of pregnancy.

Redesigning Care for the Management of Postpartum Hypertension: How Can Ob-Gyns and Primary Care Physicians Partner in Caring for Patients after a Hypertensive Pregnancy?

The standard care model in the postpartum period is ripe for disruption and attention. Hypertensive disorders of pregnancy (HDPs) can continue to be a challenge for the postpartum person in the immediate postpartum period and is a harbinger of future health risks. The current care approach is inadequate to address the needs of these women. We propose a model for a multidisciplinary clinic and collaboration between internal medicine specialists and obstetric specialists to shepherd patients through this high-risk time and provide a bridge for lifelong care to mitigate the risks of a HDP. KEY POINTS: · HDPs are increasing in prevalence.. · The postpartum period can be more complex for women with HDPs.. · A multidisciplinary clinic could fill the postpartum care gap for women with HDP..

Improving obstetric and perinatal outcomes with a remote patient monitoring program for hypertension in a large integrated care system

OBJECTIVE

To determine the effect of a remote patient monitoring program for hypertension (RPM HTN) in patients diagnosed with hypertensive disorders of pregnancy.

STUDY DESIGN

We used a matched retrospective cohort design to evaluate differences in obstetric and perinatal outcomes using data from electronic medical records. Patients enrolled in RPM HTN between November 1, 2019, and October 31, 2021, who delivered a pregnancy at ≥20 weeks gestation were compared to a cohort of patients matched by age, race, HTN and diabetes status, who delivered in the 48-month period before implementation of RPM HTN.

RESULTS

1030 patients were enrolled in RPM HTN and 937 were matched to historical controls. Five hundred and seventeen (50.2 %) were enrolled in the antepartum period and 513 (49.8 %) were enrolled postpartum. Patients in the RPM HTN cohort were more likely to have a post-hospital discharge blood pressure (BP) measured within the first 20 days after delivery (RR 1.56, 95 % CI: 1.47-1.65: p < 0.01) and were more likely to have that BP be normal (RR 1.43, 95 % CI: 1.31-1.55: p = 0.05). They were also more likely to be taking antihypertensives postpartum (RR 1.27, 95 % CI: 1.15-1.40; p < 0.01) and to be evaluated by an obstetric clinician within 20 days of delivery (RR 1.50, 95 % CI 1.42-1.58; p < 0.01).

CONCLUSIONS

A remote HTN monitoring program for 937 obstetric patients was associated with improved BP monitoring, better postpartum BP control, and improved linkages to clinician care after delivery, when compared to historical controls.

Digital health in perinatal care: Exploring usage, attitudes, and needs among Swiss women in urban and rural settings

Background

Switzerland's healthcare system is known for its quality but faces challenges such as slow digitalization and fragmentation, especially in perinatal care. This study investigates Swiss women's use, needs, and attitudes in respect of digital health tools during pregnancy and postpartum, focusing on any differences between rural and urban populations.

Methods

A web-based cross-sectional survey targeted pregnant women and those who had given birth in the last 12 months. Participants were recruited through social media, and the data were analyzed using principal component analysis and multivariable regressions to explore factors affecting the use of digital tools and attitudes toward eHealth.

Results

A total of 1160 participants completed the survey. Healthcare professionals (92%) and private networks (77%) were the primary sources of information. Women expressed a strong preference for app features such as data access (73%), prescription management (73%), and scheduling appointments with healthcare professionals (71%). However, they also raised concerns about the impersonal nature of digital healthcare interactions (71%). Overall, rural women had more negative attitudes toward online health information seeking, which can be attributed to differences in education levels.

Conclusion

The findings indicate that while Swiss women in the perinatal period do utilize digital tools, they focus more on nonmedical topics such as tracking physiological development. The study underscores the importance of adapting digital health solutions to the specific needs of women in the perinatal period. Emphasis should be placed on developing applications that are not only informative but also empower women on their healthcare journey while ensuring data privacy and supporting personal interactions with healthcare providers.

Evaluation of a telehealth program for high-risk pregnancy in a health service provider institution

INTRODUCTION

eHealth offers a solution to current challenges in maternal health. Telemonitoring can rethink antenatal care, achieving more personalized medicine, especially in high-obstetric risk conditions. A home care model mediated by the development of a mobile and web application that seeks support in clinical decision-making was created in our institution. The software architecture consists of an information system (HCIS, Health Care Information System), a database, an authentication server, and an interoperability bus.

METHODS

The usability of the software by patients was assessed using the Information Systems Usability Questionnaire (CSUQ) version 3, as well as the satisfaction of the care model designed through a survey in a prospective observational study in 62 patients with a high-risk pregnancy. Participants were monitored in real-time through blood glucose, blood pressure, and weight measurements, and attended telemedicine appointments with an obstetrician from admission to six weeks postpartum.

RESULTS

The CSUQ results show a good acceptance of the use of the application by patients both in the global score and the different domains, Global, System utility (SYSUSE), Information Quality (INFOQUAL), and Interface quality (INTERQUAL). The satisfaction survey also shows good results in general and by domains.

CONCLUSION

The findings of this study provide some suggestions for the implementation of a technological development and a care model from the patient's perspective.

Impact of the COVID-19 Pandemic on Prenatal Care Utilization at a Public Hospital

OBJECTIVE

The aim of the study is to compare rates of prenatal care utilization before and after implementation of a telehealth-supplemented prenatal care model due to the coronavirus disease 2019 (COVID-19) pandemic.

STUDY DESIGN

Using electronic medical record data, we identified two cohorts of pregnant persons that initiated prenatal care prior to and during the COVID-19 pandemic following the implementation of telehealth (from March 1, 2019 through August 31, 2019, and from March 1, 2020, through August 31, 2020, respectively) at Grady Memorial Hospital. We used Pearson's Chi-square and two-tailed t-tests to compare rates of prenatal care utilization, antenatal screening and immunizations, emergency department and obstetric triage visits, and pregnancy complications for the prepandemic versus pandemic-exposed cohorts.

RESULTS

We identified 1,758 pregnant patients; 965 entered prenatal care prior to the COVID-19 pandemic and 793 entered during the pandemic. Patients in the pandemic-exposed cohort were more likely to initiate prenatal care in the first trimester (46.1 vs. 39.0%, p = 0.01), be screened for gestational diabetes (74.4 vs. 67.0%, p <0.001), and receive dating and anatomy ultrasounds (17.8 vs. 13.0%, p = 0.006 and 56.9 vs. 47.3%, p <0.001, respectively) compared with patients in the prepandemic cohort. There was no difference in mean number of prenatal care visits between the two groups (6.9 vs. 7.1, p = 0.18). Approximately 41% of patients in the pandemic-exposed cohort had one or more telehealth visits. The proportion of patients with one or more emergency department visits was higher in the pandemic-exposed cohort than the prepandemic cohort (32.8 vs. 12.3%, p < 0.001). Increases in rates of labor induction were also observed among the pandemic-exposed cohort (47.1 vs. 38.2%, p <0.001).

CONCLUSION

Rates of prenatal care utilization were similar before and during the COVID-19 pandemic. However, pregnant persons receiving prenatal care during the pandemic entered care earlier and had higher utilization of certain antenatal screening services than those receiving prenatal care prior to the pandemic.

KEY POINTS

· Patients initiated prenatal care earlier during the COVID-19 pandemic.. · Uptake of telehealth services was low.. · Rates of diabetes screening and ultrasound use increased during the pandemic..

Increasing Access: Telehealth and Rural Obstetric Care

Parturients in rural areas face many barriers in access to care, including distance to maternity care sites and lack of maternity providers. Expanding telehealth modalities is recommended to help expand access to care. Although there is increasing evidence in support of telehealth in rural America, the success of telehealth lies in infrastructure (broadband network availability), regional support, and funding.

Postpartum remote home blood pressure monitoring: the new frontier

There has been an alarming and substantial increase in hypertensive disorders of pregnancy, which are a significant driver of maternal morbidity and mortality. The postpartum period is an especially high-risk time, with >50% of pregnancy-related deaths and significant morbidity occurring during this period. The American College of Obstetricians and Gynecologists suggests inpatient or equivalent monitoring of blood pressures in patients with hypertensive disorders of pregnancy for the immediate 72 hours postpartum and again within 7 to 10 days postpartum. Hypertensive disorders of pregnancy significantly contribute to healthcare costs through increasing admission lengths, rates of readmissions, the number of medications given, and laboratory studies ordered, and through the immeasurable impact on the patient and society. Telemedicine is an essential option for patients with barriers to accessing care, particularly those in remote areas with difficulty accessing subspecialty care, transportation, childcare, or job security. The implementation of these programs also has potential to mitigate racial inequities given that patients of color are disproportionately affected by the morbidity and mortality of hypertensive disorders of pregnancy. Remote blood pressure monitoring programs are generally acceptable, with high levels of satisfaction in the obstetrical population without posing an undue burden of care. Studies have reported different, but encouraging, measures of feasibility, including rates of recruitment, consent, engagement, adherence, and retention in their programs. Considering these factors, the widespread adoption of postpartum blood pressure monitoring programs holds promise to improve the identification and care of this at-risk population. These immediate clinical effects are significant and can reduce short-term hypertension-related morbidity and even mortality, with the potential for long-term benefit with culturally competent, well-reimbursed, and widespread use of these programs. This clinical opinion aims to show that remote monitoring of postpartum hypertensive disorders of pregnancy is a reliable and effective alternative to current follow-up care models that achieves improved blood pressure control and diminishes racial disparities in care while simultaneously being acceptable to providers and patients and cost-saving to hospital systems.

Masked pregnancy-associated hypertension as a predictor of adverse outcomes

BACKGROUND

Masked hypertension has been described in nonpregnant populations as elevated blood pressure in the home setting that is not reproduced on clinical assessment. Patients with masked hypertension have a greater risk of cardiovascular morbidity than patients who have blood pressures within normal range or those with white coat hypertension.

OBJECTIVE

This study aimed to determine whether masked pregnancy-associated hypertension detected on Connected Maternity Online Monitoring, a remote home blood pressure monitoring system, is associated with higher rates of hypertensive disorders of pregnancy during delivery admission and maternal and neonatal morbidities.

STUDY DESIGN

This was a retrospective cohort study of all patients on Connected Maternity Online Monitoring who delivered at 6 hospitals in a single healthcare system between October 2016 and December 2020. Patients were classified as having either normal blood pressure or masked pregnancy-associated hypertension. Masked pregnancy-associated hypertension was defined as remotely detected systolic blood pressure of ≥140 mm Hg or diastolic blood pressure of ≥90 mm Hg after 20 weeks of gestation on 2 occasions before diagnosis in a clinical setting. The chi-square test and Student t test were used for demographic and outcomes comparisons. Logistic regression was used to adjust outcomes by race, insurance, and body mass index.

RESULTS

A total of 2430 deliveries were included in our analysis, including 165 deliveries that met the criteria for masked pregnancy-associated hypertension. Clinically established pregnancy-associated hypertension, defined at the time of delivery, was more common in the masked pregnancy-associated hypertension group than in the normotensive group (66% vs 10%; adjusted odds ratio, 17.2; 95% confidence interval, 11.91-24.81). Patients with masked pregnancy-associated hypertension had higher rates of preeclampsia with severe features on delivery admission than normotensive patients (28% vs 2%; adjusted odds ratio, 23.35; 95% confidence interval, 14.25-38.26). Preterm delivery (16% vs 7%; adjusted odds ratio, 2.47; 95% confidence interval, 1.55-3.94), cesarean delivery(38% vs 26%; adjusted odds ratio, 1.58; 95% confidence interval, 1.13-2.23), small for gestational age (11% vs 5%; adjusted odds ratio, 2.27; 95% confidence interval, 1.31-3.94), and neonatal intensive care unit admission (8% vs 4%; adjusted odds ratio, 2.20; 95% confidence interval, 1.18-4.09) were more common among patients with masked pregnancy-associated hypertension than among normotensive patients.

CONCLUSION

With more outcomes research, remote blood pressure monitoring may prove to be an important tool in identifying pregnancies at risk of complications related to masked hypertension.

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.

Validation of a Remote Monitoring Blood Pressure Device in Pregnancy

BACKGROUND

The Ideal Life Blood Pressure Manager measures blood pressure (BP) and automatically transmits results to the patient's medical record independent of internet access, but has not been validated. Our objective was to conduct a validation study of the Ideal Life BP Manager in pregnant women using a validation protocol.

METHODS

Pregnant participants were enrolled into three subgroups per the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization protocol: normotensive (systolic blood pressure (SBP) < 140 and diastolic blood pressure (DBP) < 90), hypertensive without proteinuria (SBP ≥ 140 or DBP ≥ 90), and preeclampsia (SBP ≥ 140 or DBP ≥ 90 with proteinuria). Two trained research staff used a mercury sphygmomanometer to validate the device, alternating sphygmomanometer, and device readings for a total of 9 measurements.

RESULTS

Among 51 participants, the mean SBP and DBP differences and standard deviations between the device and the mean staff measurements for all participants were 1.7 ± 7.1 and 1.5 ± 7.0 mm Hg, respectively. The standard deviations of the individual participant's paired device and mean staff SBP and DBP measurements were 6.0 and 6.4 mm Hg, respectively. The device was more likely to overestimate rather than underestimate BP (SBP: mean difference = 1.67, 95% CI [-12.15 to 15.49]; DBP: mean difference = 1.51, 95% CI [-12.26 to 15.28]). Most paired readings had a difference of less than 10 mm Hg across averaged paired readings.

CONCLUSION

The Ideal Life BP Manager met internationally recognized validity criteria in this sample of pregnant women.

Postpartum Home Blood Pressure Monitoring Program: Improving Care for Hypertension During Postpartum after a Hospital Birth

BACKGROUND AND SIGNIFICANCE

Hypertensive disorders of pregnancy complicate about 10% of pregnancies and are a leading cause of maternal morbidity and mortality.

PURPOSE

The purpose of this quality improvement project was to evaluate a program to provide a home blood pressure monitor to all postpartum patients who had a hypertensive diagnosis and elevated blood pressure.

METHODS

The program includes a blood pressure monitor, instructions for its use, education about hypertension, and a guidance grid with standardized blood pressure parameters reviewed prior to discharge from the hospital. Patients are taught about potential adverse outcomes during postpartum. Patients are instructed to follow-up with their care provider based on the parameters. A retrospective medical record review was used to evaluate clinical outcomes.

RESULTS

Medical records of 185 patients indicated that 20% ( n = 36) who received the home BP monitor reported one or more mild-to-severe range blood pressure(s) during postpartum. Twenty-eight percent ( n = 52) had outpatient medication adjustments, including decreasing, increasing, starting, and discontinuing medications. Nine percent ( n = 17) of patients returned to the obstetric triage for evaluation. There was patient overlap between those experiencing elevated blood pressures, medication adjustments, and those who returned to hospital for evaluation.

CLINICAL IMPLICATIONS

Ongoing monitoring may improve identification and management of postpartum hypertension and potentially prevent progression to hypertensive-related adverse events.

Improving Access to Home Blood Pressure Monitors at a Federally Qualified Health Center

Background: Self-monitoring of blood pressure (BP) clinically decreases BP. However, cost can limit access, especially in underserved populations. Objective: This mixed-methods pilot study aims to determine the impact of providing home BP monitors free of charge to patients at a federally qualified health center (FQHC) by quantifying the effect on BP and surveying patients to measure satisfaction and engagement. Methods: One hundred eighty patients with clinically diagnosed hypertension received BP monitors. Patient charts were reviewed to collect demographics and office BP readings 3 months before and after receiving a monitor. A 13-question phone survey was conducted to a sample of patients addressing satisfaction and engagement. Answers were based on a Likert scale and dichotomous yes/no. Results were analyzed with descriptive statistics and paired t tests. Results: The chart review demonstrated a significant mean decrease in systolic BP by 5.44 mm Hg ( P < 0.001, −8.03 to −2.84) and a mean decrease in diastolic BP by 2.70 mm Hg ( P < 0.001, −4.08 to −1.32) after the intervention. For those included who responded to the survey (13%), there was a significant mean increase in the frequency of checking BP per week by 1.5 Likert points ( P < 0.00001, −1.0 to −1.9), and a majority (57.8%) felt slightly or much more active in their health care in addition to other benefits. Conclusion: Providing BP monitors to FQHC patients free of charge may have contributed to a significantly decreased office BP, improved engagement, and satisfaction. This program removed cost barriers and allowed patients to be more active in their health care.

Society for Maternal-Fetal Medicine Special Statement: Telemedicine in obstetrics-quality and safety considerations

The frequency of telemedicine encounters has increased dramatically in recent years. This review summarizes the literature regarding the safety and quality of telemedicine for pregnancy-related services, including prenatal care, postpartum care, diabetes mellitus management, medication abortion, lactation support, hypertension management, genetic counseling, ultrasound examination, contraception, and mental health services. For many of these, telemedicine has several potential or proven benefits, including expanded patient access, improved patient satisfaction, decreased disparities in care delivery, and health outcomes at least comparable to those of traditional in-person encounters. Considering these benefits, it is suggested that payers should reimburse providers at least as much for telemedicine as for in-person services. Areas for future research are considered.

Peripartum and Long-Term Maternal Cardiovascular Health After Preeclampsia

There is widespread acceptance of the increased prevalence of cardiovascular diseases occurring within 1 to 2 decades in women following a preeclamptic pregnancy. More recent evidence suggests that the deranged biochemical and echocardiographic findings in women do not resolve in the majority of preeclamptic women following giving birth. Many women continue to be hypertensive in the immediate postnatal period with some exhibiting occult signs of cardiac dysfunction. There is now promising evidence that with close monitoring and effective control of blood pressure control in the immediate postnatal period, women may have persistently lower blood pressures many years after stopping their medication. This review highlights the evidence that delivering effective medical care in the fourth trimester of pregnancy can improve the long-term cardiovascular health after a preeclamptic birth.

Privacy and Security Risk Factors Related to Telehealth Services - A Systematic Review

The objective of the study is to identify challenges and associated factors for privacy and security related to telehealth visits during the COVID-19 pandemic. The systematic search strategy used the databases of PubMed, ScienceDirect, ProQuest, Embase, CINAHL, and COCHRANE, with the search terms of telehealth/telemedicine, privacy, security, and confidentiality. Reviews included peer-reviewed empirical studies conducted from January 2020 to February 2022. Studies conducted outside of the US, non-empirical, and non-telehealth related were excluded. Eighteen studies were included in the final analysis. Three risk factors associated with privacy and security in telehealth practice included: environmental factors (lack of private space for vulnerable populations, difficulty sharing sensitive health information remotely), technology factors (data security issues, limited access to the internet, and technology), and operational factors (reimbursement, payer denials, technology accessibility, training, and education). Findings from this study can assist governments, policymakers, and healthcare organizations in developing best practices in telehealth privacy and security strategies.

Trust and Uncertainty in the Implementation of a Pilot Remote Blood Pressure Monitoring Program in Primary Care: Qualitative Study of Patient and Health Care Professional Views

BACKGROUND

Trust is of fundamental importance to the adoption of technologies in health care. The increasing use of telemedicine worldwide makes it important to consider user views and experiences. In particular, we ask how the mediation of a technological platform alters the trust relationship between patient and health care provider.

OBJECTIVE

To date, few qualitative studies have focused on trust in the use of remote health care technologies. This study examined the perspectives of patients and clinical staff who participated in a remote blood pressure monitoring program, focusing on their experiences of trust and uncertainty in the use of technology and how this telehealth intervention may have affected the patient-provider relationship.

METHODS

A secondary qualitative analysis using inductive thematic analysis was conducted on interview data from 13 patients and 8 staff members who participated in a remote blood pressure monitoring program to elicit themes related to trust.

RESULTS

In total, 4 themes were elicited that showed increased trust (patients felt reassured, patients trusted the telehealth program, staff felt that the data were trustworthy, and a better patient-provider partnership based on the mutually trusted data), and 4 themes were elicited that reflected decreased trust (patients' distrust of technology, clinicians' concerns about the limitations of technologically mediated interactions, experiences of uncertainty, and institutional risk).

CONCLUSIONS

Managing trust relationships plays an important role in the successful implementation of telemedicine. Ensuring that trust building is incorporated in the design of telehealth interventions can contribute to improved effectiveness and quality of care.

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.

Hypertensive disorders of pregnancy: definition, management, and out-of-office blood pressure measurement

Hypertensive disorders of pregnancy increase the risk of adverse maternal and fetal outcomes. In 2018, the Japanese classification of hypertensive disorders of pregnancy was standardized with those of other countries, and a hypertensive disorder of pregnancy was considered to be present if hypertension existed during pregnancy and up to 12 weeks after delivery. Strategies for the prevention of hypertensive disorders of pregnancy have become much clearer, but further research is needed on appropriate subjects and methods of administration, and these have not been clarified in Japan. Although guidelines for the use of antihypertensive drugs are also being studied and standardized with those of other countries, the use of calcium antagonists before 20 weeks of gestation is still contraindicated in Japan because of the safety concerns that were raised regarding possible fetal anomalies associated with their use at the time of their market launch. Chronic hypertension is now included in the definition of hypertensive disorders of pregnancy, and blood pressure measurement is a fundamental component of the diagnosis of hypertensive disorders of pregnancy. Out-of-office blood pressure measurements, including ambulatory and home blood pressure measurements, are important for pregnant and nonpregnant women. Although conditions such as white-coat hypertension and masked hypertension have been reported, determining their occurrence in pregnancy is complicated by the gestational week. This narrative review focused on recent reports on hypertensive disorders of pregnancy, including those related to blood pressure measurement and classification.

Sociotechnical Factors Affecting Patients' Adoption of Mobile Health Tools: Systematic Literature Review and Narrative Synthesis

BACKGROUND

Mobile health (mHealth) tools have emerged as a promising health care technology that may contribute to cost savings, better access to care, and enhanced clinical outcomes; however, it is important to ensure their acceptance and adoption to harness this potential. Patient adoption has been recognized as a key challenge that requires further exploration.

OBJECTIVE

The aim of this review was to systematically investigate the literature to understand the factors affecting patients' adoption of mHealth tools by considering sociotechnical factors (from technical, social, and health perspectives).

METHODS

A structured search was completed following the participants, intervention, comparators, and outcomes framework. We searched the MEDLINE, PubMed, Cochrane Library, and SAGE databases for studies published between January 2011 and July 2021 in the English language, yielding 5873 results, of which 147 studies met the inclusion criteria. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and the Cochrane Handbook were followed to ensure a systematic process. Extracted data were analyzed using NVivo (QSR International), with thematic analysis and narrative synthesis of emergent themes.

RESULTS

The technical factors affecting patients' adoption of mHealth tools were categorized into six key themes, which in turn were divided into 20 subthemes: usefulness, ease of use, data-related, monetary factors, technical issues, and user experience. Health-related factors were categorized into six key themes: the disease or health condition, the care team's role, health consciousness and literacy, health behavior, relation to other therapies, integration into patient journey, and the patients' insurance status. Social and personal factors were divided into three key clusters: demographic factors, personal characteristics, and social and cultural aspects; these were divided into 19 subthemes, highlighting the importance of considering these factors when addressing potential barriers to mHealth adoption and how to overcome them.

CONCLUSIONS

This review builds on the growing body of research that investigates patients' adoption of mHealth services and highlights the complexity of the factors affecting adoption, including personal, social, technical, organizational, and health care aspects. We recommend a more patient-centered approach by ensuring the tools' fit into the overall patient journey and treatment plan, emphasizing inclusive design, and warranting comprehensive patient education and support. Moreover, empowering and mobilizing clinicians and care teams, addressing ethical data management issues, and focusing on health care policies may facilitate adoption.

Learning from COVID-19 related trial adaptations to inform efficient trial design-a sequential mixed methods study

BACKGROUND

Many clinical trial procedures were often undertaken in-person prior to the COVID-19 pandemic, which has resulted in adaptations to these procedures to enable trials to continue. The aim of this study was to understand whether the adaptations made to clinical trials by UK Clinical Trials Units (CTUs) during the pandemic have the potential to improve the efficiency of trials post-pandemic.

METHODS

This was a mixed methods study, initially involving an online survey administered to all registered UK CTUs to identify studies that had made adaptations due to the pandemic. Representatives from selected studies were qualitatively interviewed to explore the adaptations made and their potential to improve the efficiency of future trials. A literature review was undertaken to locate published evidence concerning the investigated adaptations. The findings from the interviews were reviewed by a group of CTU and patient representatives within a workshop, where discussions focused on the potential of the adaptations to improve the efficiency of future trials.

RESULTS

Forty studies were identified by the survey. Fourteen studies were selected and fifteen CTU staff were interviewed about the adaptations. The workshop included 15 CTU and 3 patient representatives. Adaptations were not seen as leading to direct efficiency savings for CTUs. However, three adaptations may have the potential to directly improve efficiencies for trial sites and participants beyond the pandemic: a split remote-first eligibility assessment, recruitment outside the NHS via a charity, and remote consent. There was a lack of published evidence to support the former two adaptations, however, remote consent is widely supported in the literature. Other identified adaptations may benefit by improving flexibility for the participant. Barriers to using these adaptations include the impact on scientific validity, limitations in the role of the CTU, and participant's access to technology.

CONCLUSIONS

Three adaptations (a split remote-first eligibility assessment, recruitment outside the NHS via a charity, and remote consent) have the potential to improve clinical trials but only one (remote consent) is supported by evidence. These adaptations could be tested in future co-ordinated 'studies within a trial' (SWAT).

Malaria and Helminthic Co-Infection during Pregnancy in Sub-Saharan Africa: A Systematic Review and Meta-Analysis

Malaria and helminthic co-infection during pregnancy causes fetomaternal haemorrhage and foetal growth retardation. This study determined the pooled burden of pregnancy malaria and helminthic co-infection in sub-Saharan Africa. CINAHL, EMBASE, Google Scholar, Scopus, PubMed, and Web of Science databases were used to retrieve data from the literature, without restricting language and publication year. The Joanna Briggs Institute's critical appraisal tool for prevalence studies was used for quality assessment. STATA Version 14.0 was used to conduct the meta-analysis. The I2 statistics and Egger's test were used to test heterogeneity and publication bias. The random-effects model was used to estimate the pooled prevalence at a 95% confidence interval (CI). The review protocol has been registered in PROSPERO, with the number CRD42019144812. In total, 24 studies (n = 14,087 participants) were identified in this study. The pooled analysis revealed that 20% of pregnant women were co-infected by malaria and helminths in sub-Saharan Africa. The pooled prevalence of malaria and helminths were 33% and 35%, respectively. The most prevalent helminths were Hookworm (48%), Ascaris lumbricoides (37%), and Trichuris trichiura (15%). Significantly higher malaria and helminthic co-infection during pregnancy were observed. Health systems in sub-Saharan Africa must implement home-grown innovative solutions to underpin context-specific policies for the early initiation of effective intermittent preventive therapy.