Intervention planning and modification of the BUMP intervention: a digital intervention for the early detection of raised blood pressure in pregnancy

Comparison of clinic and home blood pressure readings in higher risk pregnancies - Secondary analysis of the BUMP 1 trial

OBJECTIVE

To compare clinic and home blood pressure readings in higher risk pregnancies in the antenatal period from 20 weeks gestation, and to evaluate differences between the two modalities.

STUDY DESIGN

A cohort study comprising a secondary analysis of a large randomised controlled trial (BUMP 1).

POPULATION

Normotensive women at higher risk of pregnancy hypertension randomised to self-monitoring of blood pressure.

MAIN OUTCOME MEASURES

The primary outcome was the overall mean difference between clinic and home readings for systolic blood pressure (sBP) and diastolic blood pressure (dBP). Blood pressure readings were averaged across each gestational week for each participant and compared within the same gestational week. Calculations of the overall differences were based on the average difference for each week for each participant.

RESULTS

The cohort comprised 925 participants. In total, 92 (10 %) developed a hypertensive disorder during the pregnancy. A significant difference in the overall mean sBP (clinic - home) of 1.1 mmHg (0.5-1.6 95 %CI) was noted, whereas no significant difference for the overall mean dBP was found (0.0 mmHg (-0.4-0.4 95 %CI)). No tendency of proportional bias was noted based on Bland-Altman plots. Increasing body mass index in general increased the difference (clinic - home) for both sBP and dBP in a multivariate analysis.

CONCLUSIONS

No clinically significant difference was found between clinic and home blood pressure readings in normotensive higher risk pregnancies from gestational week 20+0 until 40+0. Clinic and home blood pressure readings might be considered equal during pregnancy in women who are normotensive at baseline.

Detection and Control of Pregnancy Hypertension Using Self-Monitoring of Blood Pressure With Automated Telemonitoring: Cost Analyses of the BUMP Randomized Trials

BACKGROUND

Pregnancy hypertension continues to cause maternal and perinatal morbidity. Two linked UK randomized trials showed adding self-monitoring of blood pressure (SMBP) with automated telemonitoring to usual antenatal care did not result in earlier detection or better control of pregnancy hypertension. This article reports the trials' integrated cost analyses.

METHODS

Two cost analyses. SMBP with usual care was compared with usual care alone in pregnant individuals at risk of hypertension (BUMP 1 trial [Blood Pressure Monitoring in High Risk Pregnancy to Improve the Detection and Monitoring of Hypertension], n=2441) and with hypertension (BUMP 2 trial, n=850). Clinical notes review identified participant-level antenatal, intrapartum, and postnatal care and these were costed. Comparisons between trial arms used means and 95% CIs. Within BUMP 2, chronic and gestational hypertension cohorts were analyzed separately. Telemonitoring system costs were reported separately.

RESULTS

In BUMP 1, mean (SE) total costs with SMBP and with usual care were £7200 (£323) and £7063 (£245), respectively, mean difference (95% CI), £151 (-£633 to £936). For the BUMP 2 chronic hypertension cohort, corresponding figures were £13 384 (£1230), £12 614 (£1081), mean difference £323 (-£2904 to £3549) and for the gestational hypertension cohort were £11 456 (£901), £11 145 (£959), mean difference £41 (-£2486 to £2567). The per-person cost of telemonitoring was £6 in BUMP 1 and £29 in BUMP 2.

CONCLUSIONS

SMBP was not associated with changes in the cost of health care contacts for individuals at risk of, or with, pregnancy hypertension. This is reassuring as SMBP in pregnancy is widely prevalent, particularly because of the COVID-19 pandemic.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03334149.

Planning and developing a web-based intervention for active surveillance in prostate cancer: an integrated self-care programme for managing psychological distress

Objectives

To outline the planning, development and optimisation of a psycho-educational behavioural intervention for patients on active surveillance for prostate cancer. The intervention aimed to support men manage active surveillance-related psychological distress.

Methods

The person-based approach (PBA) was used as the overarching guiding methodological framework for intervention development. Evidence-based methods were incorporated to improve robustness. The process commenced with data gathering activities comprising the following four components:

• A systematic review and meta-analysis of depression and anxiety in prostate cancer

• A cross-sectional survey on depression and anxiety in active surveillance

• A review of existing interventions in the field

• A qualitative study with the target audience

The purpose of this paper is to bring these components together and describe how they facilitated the establishment of key guiding principles and a logic model, which underpinned the first draft of the intervention.

Results

The prototype intervention, named PROACTIVE, consists of six Internet-based sessions run concurrently with three group support sessions. The sessions cover the following topics: lifestyle (diet and exercise), relaxation and resilience techniques, talking to friends and family, thoughts and feelings, daily life (money and work) and information about prostate cancer and active surveillance. The resulting intervention has been trialled in a feasibility study, the results of which are published elsewhere.

Conclusions

The planning and development process is key to successful delivery of an appropriate, accessible and acceptable intervention. The PBA strengthened the intervention by drawing on target-user experiences to maximise acceptability and user engagement. This meticulous description in a clinical setting using this rigorous but flexible method is a useful demonstration for others developing similar interventions.

Trial registration and Ethical Approval

ISRCTN registered: ISRCTN38893965. NRES Committee South Central – Oxford A. REC reference: 11/SC/0355

Effect of Self-monitoring of Blood Pressure on Blood Pressure Control in Pregnant Individuals With Chronic or Gestational Hypertension: The BUMP 2 Randomized Clinical Trial

Importance

Inadequate management of elevated blood pressure is a significant contributing factor to maternal deaths. The role of blood pressure self-monitoring in pregnancy in improving clinical outcomes for the pregnant individual and infant is unclear.

Objective

To evaluate the effect of blood pressure self-monitoring, compared with usual care alone, on blood pressure control and other related maternal and infant outcomes, in individuals with pregnancy hypertension.

Design, Setting, and Participants

Unblinded, randomized clinical trial that recruited between November 2018 and September 2019 in 15 hospital maternity units in England. Individuals with chronic hypertension (enrolled up to 37 weeks' gestation) or with gestational hypertension (enrolled between 20 and 37 weeks' gestation). Final follow-up was in May 2020.

Interventions

Participants were randomized to either blood pressure self-monitoring using a validated monitor and a secure telemonitoring system in addition to usual care (n = 430) or to usual care alone (n = 420). Usual care comprised blood pressure measured by health care professionals at regular antenatal clinics.

Main Outcomes and Measures

The primary maternal outcome was the difference in mean systolic blood pressure recorded by health care professionals between randomization and birth.

Results

Among 454 participants with chronic hypertension (mean age, 36 years; mean gestation at entry, 20 weeks) and 396 with gestational hypertension (mean age, 34 years; mean gestation at entry, 33 weeks) who were randomized, primary outcome data were available from 444 (97.8%) and 377 (95.2%), respectively. In the chronic hypertension cohort, there was no statistically significant difference in mean systolic blood pressure for the self-monitoring groups vs the usual care group (133.8 mm Hg vs 133.6 mm Hg, respectively; adjusted mean difference, 0.03 mm Hg [95% CI, -1.73 to 1.79]). In the gestational hypertension cohort, there was also no significant difference in mean systolic blood pressure (137.6 mm Hg compared with 137.2 mm Hg; adjusted mean difference, -0.03 mm Hg [95% CI, -2.29 to 2.24]). There were 8 serious adverse events in the self-monitoring group (4 in each cohort) and 3 in the usual care group (2 in the chronic hypertension cohort and 1 in the gestational hypertension cohort).

Conclusions and Relevance

Among pregnant individuals with chronic or gestational hypertension, blood pressure self-monitoring with telemonitoring, compared with usual care, did not lead to significantly improved clinic-based blood pressure control.

Trial Registration

ClinicalTrials.gov Identifier: NCT03334149.

Effect of Self-monitoring of Blood Pressure on Diagnosis of Hypertension During Higher-Risk Pregnancy: The BUMP 1 Randomized Clinical Trial

IMPORTANCE

Inadequate management of elevated blood pressure (BP) is a significant contributing factor to maternal deaths. Self-monitoring of BP in the general population has been shown to improve the diagnosis and management of hypertension; however, little is known about its use in pregnancy.

OBJECTIVE

To determine whether self-monitoring of BP in higher-risk pregnancies leads to earlier detection of pregnancy hypertension.

DESIGN, SETTING, AND PARTICIPANTS

Unblinded, randomized clinical trial that included 2441 pregnant individuals at higher risk of preeclampsia and recruited at a mean of 20 weeks' gestation from 15 hospital maternity units in England between November 2018 and October 2019. Final follow-up was completed in April 2020.

INTERVENTIONS

Participating individuals were randomized to either BP self-monitoring with telemonitoring (n = 1223) plus usual care or usual antenatal care alone (n = 1218) without access to telemonitored BP.

MAIN OUTCOMES AND MEASURES

The primary outcome was time to first recorded hypertension measured by a health care professional.

RESULTS

Among 2441 participants who were randomized (mean [SD] age, 33 [5.6] years; mean gestation, 20 [1.6] weeks), 2346 (96%) completed the trial. The time from randomization to clinic recording of hypertension was not significantly different between individuals in the self-monitoring group (mean [SD], 104.3 [32.6] days) vs in the usual care group (mean [SD], 106.2 [32.0] days) (mean difference, -1.6 days [95% CI, -8.1 to 4.9]; P = .64). Eighteen serious adverse events were reported during the trial with none judged as related to the intervention (12 [1%] in the self-monitoring group vs 6 [0.5%] in the usual care group).

CONCLUSIONS AND RELEVANCE

Among pregnant individuals at higher risk of preeclampsia, blood pressure self-monitoring with telemonitoring, compared with usual care, did not lead to significantly earlier clinic-based detection of hypertension.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03334149.

Patients' and Providers' Perspectives on and Needs of Telemonitoring to Support Clinical Management and Self-care of People at High Risk for Preeclampsia: Qualitative Study

Background

Preeclampsia is one of the leading causes of maternal mortality worldwide, with a global prevalence at 2%-8% of pregnancies. Patients at high risk for preeclampsia (PHRPE) have an increased risk of complications, such as fetal growth restriction, preterm delivery, abnormal clotting, and liver and kidney disease. Telemonitoring for PHRPE may allow for timelier diagnosis and enhanced management, which may improve maternal and perinatal outcomes.

Objective

The objective of this study is to determine the perceptions and needs of PHRPE and their health care providers with respect to telemonitoring through semistructured interviews with both groups. This study explored (1) what the needs and challenges of monitoring PHRPE are during pregnancy and in the postpartum period and (2) what features are required in a telemonitoring program to support self-care and clinical management of PHRPE.

Methods

This study used a qualitative descriptive approach, and thematic analysis was conducted. PHRPE and health care providers from a high-risk obstetrical clinic in a large academic hospital in Toronto, Canada, were asked to participate in individual semistructured interviews. Two researchers jointly developed a coding framework and separately coded each interview to ensure that the interviews were double-coded. The software program NVivo version 12 was used to help organize the codes.

Results

In total, 7 PHRPE and 5 health care providers, which included a nurse practitioner and physicians, participated in the semistructured interviews. Using thematic analysis, perceptions on the benefits, barriers, and desired features were determined. Perceived benefits of telemonitoring for PHRPE included close monitoring of home blood pressure (BP) measurements and appropriate interventions for abnormal BP readings; the development of a tailored telemonitoring system for pregnant patients; and facilitation of self-management. Perceived barriers to telemonitoring for PHRPE included financial and personal barriers, as well as the potential for increased clinician workload. Desired features of a secure platform for PHRPE included the facilitation of self-management for patients and decision making for clinicians, as well as the inclusion of evidence-based action prompts.

Conclusions

The perceptions of patients and providers on the use of telemonitoring for PHRPE support the need for a telemonitoring program for the management of PHRPE. Recommendations from this study include the specific features of a telemonitoring program for PHRPE, as well as the use of frameworks and design processes in the design and implementation of a telemonitoring program for PHRPE.

Effects of slow and deep breathing on reducing obstetric intervention in women with pregnancy-induced hypertension: a feasibility study protocol

Objective: To evaluate whether a slow and deep breathing (SDB) intervention is acceptable to pregnant women. Methods: The trial aims to recruit 67 pregnant women who have developed pregnancy-induced hypertension (clinicaltrials.gov: NCT04059822). SDB will be undertaken daily for 10 min using a video aid and women will self-monitor blood pressure (BP) daily. At 36-weeks gestation women will complete an online questionnaire. Adherence, recruitment rates, and acceptance of the intervention will be evaluated. Conclusion: The findings from this trial will evaluate if women accept SDB as a treatment method. Initial analysis will evaluate if BP and/or obstetric interventions reduce following SDB intervention.

Exploring the potential for introducing home monitoring of blood pressure during pregnancy into maternity care: current views and experiences of staff-a qualitative study

OBJECTIVE

One in 20 women are affected by pre-eclampsia, a major cause of maternal and perinatal morbidity, death and premature birth worldwide. Diagnosis is made from monitoring blood pressure (BP) and urine and symptoms at antenatal visits after 20 weeks of pregnancy. There are no randomised data from contemporary trials to guide the efficacy of self-monitoring of BP (SMBP) in pregnancy. We explored the perspectives of maternity staff to understand the context and health system challenges to introducing and implementing SMBP in maternity care, ahead of undertaking a trial.

DESIGN

Exploratory study using a qualitative approach.

SETTING

Eight hospitals, English National Health Service.

PARTICIPANTS

Obstetricians, community and hospital midwives, pharmacists, trainee doctors (n=147).

METHODS

Semi-structured interviews with site research team members and clinicians, interviews and focus group discussions. Rapid content and thematic analysis undertaken.

RESULTS

The main themes to emerge around SMBP include (1) different BP changes in pregnancy, (2) reliability and accuracy of BP monitoring, (3) anticipated impact of SMBP on women, (4) anticipated impact of SMBP on the antenatal care system, (5) caution, uncertainty and evidence, (6) concerns over action/inaction and patient safety.

CONCLUSIONS

The potential impact of SMBP on maternity services is profound although nuanced. While introducing SMBP does not reduce the responsibility clinicians have for women's health, it may enhance the responsibilities and agency of pregnant women, and introduces a new set of relationships into maternity care. This is a new space for reconfiguration of roles, mutual expectations and the relationships between and responsibilities of healthcare providers and women.

TRIAL REGISTRATION NUMBER

NCT03334149.

Blood pressure monitoring in high-risk pregnancy to improve the detection and monitoring of hypertension (the BUMP 1 and 2 trials): protocol for two linked randomised controlled trials

INTRODUCTION

Self-monitoring of blood pressure (BP) in pregnancy could improve the detection and management of pregnancy hypertension, while also empowering and engaging women in their own care. Two linked trials aim to evaluate whether BP self-monitoring in pregnancy improves the detection of raised BP during higher risk pregnancies (BUMP 1) and whether self-monitoring reduces systolic BP during hypertensive pregnancy (BUMP 2).

METHODS AND ANALYSES

Both are multicentre, non-masked, parallel group, randomised controlled trials. Participants will be randomised to self-monitoring with telemonitoring or usual care. BUMP 1 will recruit a minimum of 2262 pregnant women at higher risk of pregnancy hypertension and BUMP 2 will recruit a minimum of 512 pregnant women with either gestational or chronic hypertension. The BUMP 1 primary outcome is the time to the first recording of raised BP by a healthcare professional. The BUMP 2 primary outcome is mean systolic BP between baseline and delivery recorded by healthcare professionals. Other outcomes will include maternal and perinatal outcomes, quality of life and adverse events. An economic evaluation of BP self-monitoring in addition to usual care compared with usual care alone will be assessed across both study populations within trial and with modelling to estimate long-term cost-effectiveness. A linked process evaluation will combine quantitative and qualitative data to examine how BP self-monitoring in pregnancy is implemented and accepted in both daily life and routine clinical practice.

ETHICS AND DISSEMINATION

The trials have been approved by a Research Ethics Committee (17/WM/0241) and relevant research authorities. They will be published in peer-reviewed journals and presented at national and international conferences. If shown to be effective, BP self-monitoring would be applicable to a large population of pregnant women.

TRIAL REGISTRATION NUMBER

NCT03334149.