Reports From the Field

Rapid-Cycle Innovation Testing of Text-Based Monitoring for Management of Postpartum Hypertension


 

References

From the Maternal and Child Health Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Dr. Hirshberg, Dr. Srinivas); Hospital of the University of Pennsylvania, Department of Nursing, Department of Obstetrics and Gynecology, Philadelphia, PA (Ms. Bittle); Penn Medicine Center for Health Care Innovation, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Mr. Vandertuyn, Ms. Mahraj, Dr. Asch, Mr. Rosin); and the Department of Family Medicine, University of Washington, Seattle, WA (Dr. Bennett).

Abstract

  • Objective: To investigate engagement with a bidirectional text messaging system as an alternative to in-person follow-up for postpartum women with hypertensive disorders.
  • Methods: We utilized rapid-cycle innovation processes to implement postpartum SMS text messaging follow-up in women with hypertensive disorders who delivered between September–December 2014. Patients were given electronic blood pressure cuffs and education before discharge. Standard texts reminded patients to send blood pressures daily on each of the 7 days post discharge. The study obstetrician sent text message responses based on a pre-specified management algorithm. Ability to meet ACOG guidelines was defined as receiving at least 1 reading on post-discharge days 1 or 2 and days 5, 6, or 7.
  • Results: We enrolled 32 patients. Six (19%) returned for usual care office blood pressure checks. We received at least 1 blood pressure from 27 (84%) participants. Nearly 20 (65%) texted readings on 5 of the 7 days. 27 (84%) texted at least one reading on day 1 or 2, and 21 (66%) texted at least one pressure on day 5, 6, or 7 (P = 0.001 vs. usual care). Two patients required medications and none were readmitted for hypertension. Patients reported preference for home testing and text messaging over return visits.
  • Conclusion: Remote blood pressure monitoring via text messaging is a patient-centered method for postpartum hypertension surveillance. Further testing is needed prior to widespread adoption within the broader obstetric community.

Key words: postpartum hypertension, remote monitoring, text-based intervention.

Hypertensive disease is a leading cause of maternal morbidity and mortality [1,2] and the leading cause of obstetric readmissions, accounting for 27% of obstetric readmissions in the United States in 2009 [3]. The majority of patients readmitted with hypertension have a diagnosis of hypertensive disorder of pregnancy on initial admission for delivery, indicating that these readmissions are the result of disease persistence or progression in contrast to new-onset disease. Peak blood pressure in these patients usually occurs 3 to 6 days postpartum [4–6] and is typically unaccompanied by warning symptoms. For these reasons, identifying patients who are at risk for persistent disease and being proactive in their postpartum care may decrease postpartum stroke and seizure. The recent Hypertension in Pregnancy guidelines provided by the American College of Obstetricians and Gynecologists (ACOG) recommend monitoring blood pressure for at least 72 hours postpartum (inpatient or outpatient) and again 7 to 10 days after delivery in women in whom a hypertensive disease of pregnancy is diagnosed [6].

Although there is a clear need for effective and reliable blood pressure surveillance for high-risk women soon after delivery, significant obstacles exist. Our own high-risk blood pressure transition clinic, which occurred every other week and was staffed by maternal-fetal medicine specialists, had an average attendance of only 30% over a 2-year period. Moreover, all of the hypertension-related readmissions occurred in the first 7 days post discharge, which was before the scheduled clinic visit for approximately 50% of patients. Phone call reminders were also found to be an ineffective strategy, as the women did not answer or return voice messages left by the practice. In fact, a postpartum unit quality improvement project validated that follow-up phone calls after discharge from the postpartum unit were less effective than text messaging when reminding women of their blood pressure follow-up appointment at the clinic [7].

As an alternative to in-person visits or traditional voice telephonic communication, mobile phone “Short Message Service” (SMS) text messaging has been used successfully in health care for appointment reminders, result reporting, support of medication and treatment adherence, and dosage adjustment [8–13]. As of 2014, 90% of American adults own a cell phone and over 79% of those send and receive text messages [14]. Among a young population, which is at high risk for hypertensive disorders of pregnancy, data further reveals a preference for text messaging over live calls [15]. Among low-income women under age 30, the rates of cell phone use and text communication are very high [14,15], making text-based surveillance a promising and more patient-centered strategy for a broad population.

We report the results of rapid-cycle innovation and implementation of active, remote surveillance of hypertension with new text message communication strategies in the first 7 days post-discharge. We chose a Plan-Do-Study-Act cycle approach, in which small tests are performed and studied and changes made to accelerate improvement, in order to enhance our ability to acquire blood pressure data [16,17]. The goals of the work were to (1) assess patient engagement using a remote method of blood pressure monitoring, (2) increase ascertainment of postpartum blood pressure data and obtain at least once daily blood pressure readings on all patients on post discharge days 1–2 and 5–7, which is in accordance with the recommended guidelines [6] for blood pressure surveillance, and (3) address all “at risk” severe range blood pressure readings within a short time interval and prior to the need for readmission. We describe a program of remote blood pressure monitoring and communication via text message designed to increase patient engagement and participation, thereby having the potential to result in earlier interventions, reduce readmissions, and decrease overall morbidity.

Methods

We performed a series of 6 rapid-cycle innovation devel-opment and implementation interventions with a cohort of women with chronic hypertension (CHTN), gestational hypertension (GHTN), or preeclampsia (with and without severe features and superimposed) who delivered at our institution between 20 September 2014 and 14 December 2014. All patients were > 18 years old, able to speak and read English, had a hypertension diag-nosis listed above, and had access to a cell phone with unlimited text messaging capabilities. Patients received standard postpartum care and were continued or started on antihypertensive medications based on a standardized postpartum hypertension protocol previously developed at our institution (available on request). This project was undertaken as a quality improvement initiative and as such was exempt from formal review by our institutional review board. However, all patients signed a waiver acknowledging that SMS texting is not a secure communications technology. A single research telephone was used for physician-patient communication to further ensure privacy.

Patients who qualified for the intervention study were recruited on the postpartum unit following delivery. Those who agreed to participate were provided with electronic blood pressure monitors (CVS Pharmacy automatic blood pressure monitor and Omron 3 Series upper arm blood pressure monitor) prior to discharge and instructed on their use. Patients were told to expect their first text message reminder to send in their blood pressure the day after discharge; an example of a text reminder is “Good morning. Please send us a blood pressure reading by 12 pm.” Patients were enrolled for 7 days post discharge and were interviewed regarding their experience at the end of their 7-day enrollment. As this was primarily a feasibility and quality improvement study, patients were also instructed to continue to follow up with the standard of care at the hypertension clinic visit.

For each of the 7 days following discharge from the hospital, patients received a standard text message in the morning and afternoon reminding them to text their blood pressure to the research telephone by a specific time. Reported blood pressures were reviewed and a standard response was sent by the study obstetrician based on an algorithm consistent with the institution’s postpartum hypertension protocol. Patients were sent reminders at all time points whether or not they had texted any BPs.

The ACOG Hypertension in Pregnancy guidelines recommend monitoring blood pressure at 72 hours postpartum (inpatient or outpatient) and again 7 to 10 days postpartum in women diagnosed with a hypertensive disorder of pregnancy [6]. We measured our ability to meet these guidelines by identifying how many patients texted blood pressures on post-discharge days 1 or 2 and post-discharge days 5, 6, or 7, as most patients were discharged home on postpartum day 2 or 3.

Sequential interventions were performed following principles of rapid-cycle validation using a Plan-Do-Study-Act cycle [16,17], each testing new ways to enhance our ability to acquire blood pressure data, but using small samples large enough only to test feasibility and initial responses (Table 1).

Strategies to enhance patient engagement were modified based on patient interviews and results from the immediately preceding cycle (for example, Cycle 1 interview information and results were used to make changes in Cycle 2), as well as studies on telemonitoring adherence in other populations [18]. The program ended after 6 cycles, as the study team felt there was sufficient promise to design an expanded platform suitable for a larger study.

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