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

Results

Overall

At the patient level, we received at least 1 blood pressure during the requested time frame from 27 of the 32 patients enrolled (84%). Nearly 65% of patients (20/32) texted at least 1 blood pressure reading on at least 5 out of the 7 days enrolled. 

By Cycle

Cycle 1 - Basic

Cycle 1 tested our basic hypothesis that patients would take their blood pressure at home and transmit the results by text message: 5 of 7 patients responded to our reminders, each transmitting blood pressures on at least 5 of the 7 days requested.

Four severe-range blood pressures, defined as systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure ≥ 110 [6], were sent to the physician responder, two times each in 2 patients. All four “at risk” severe blood pressures were addressed within 24 hours of the text message. No medications were initiated, as elevated blood pressures were not persistent and patients were asymptomatic.

Cycle 2 - Education

Patients in Cycle 1 reported during their follow-up interview that they became more aware of the possible morbidity associated with persistent postpartum hypertension as the cycle progressed. Therefore, Cycle 2 tested our hypothesis that focused education would improve patient engagement.

All five patients in this cohort sent in at least one blood pressure during the cycle period. All transmitted at least one blood pressure text on post-discharge day 1 or 2. Four of the five patients (80%) also sent in at least one blood pressure on day 5, 6, or 7.

There were no significantly elevated blood pressures sent to the physician responder.

Cycle 3 - Personalization

Patients in Cycle 2 reported during their interview that they felt the text message responses from the provider were too automated. Cycle 3 tested our hypothesis that added personalization, with patient and infant names included in the messages, would improve engagement.

Three of five patients in this cohort sent at least one blood pressure text on post-discharge day 1 or 2 (60%). Only one patient (20%) also sent in at least one blood pressure on day 5, 6, or 7.

One significantly elevated blood pressure was sent to the physician responder. This blood pressure was addressed within 24 hours of the text message. No medications were initiated, as elevated blood pressures were not persistent and patients were asymptomatic.

Cycle 4 - Response Timing

Patients in Cycle 3 had lower response rates than previous cycles and noted that they wanted more flexibility in the time to respond, as their schedules were unpredictable with a newborn at home. Although they enjoyed the personalized aspect, they did not feel it influenced their responses, which is evidenced by the low response rate on days 5, 6, or 7. Therefore, Cycle 4 tested our hypothesis that allowing patients to commit to a time of their choice for receiving the reminder texts would improve their response rate.

All five patients enrolled in this cohort sent in at least one blood pressure. We received at least one blood pressure text on post-discharge day 1 or 2 from all five patients in this cycle (100%). Three of the five patients (60%) also sent in at least one blood pressure on day 5, 6, or 7.

Five severely elevated blood pressures were sent to the physician responder, all from a single patient. This patient had been discharged home on hydrochlorothiazide 12.5 mg for persistently elevated blood pressures while in the hospital after being diagnosed with severe preeclampsia. All five “at risk” blood pressures were addressed within 24 hours of the text message. On her fifth day of remote surveillance, 5 mg of amlodipine was added to her daily regimen for blood pressures ranging from 150–170/90–110 mm Hg. Her blood pressure at her 6-week postpartum visit was 120/60 mm Hg and she had seen her primary care doctor in the interim for further hypertension management.

Cycle 5 - Snooze and Countdown

Although most of the patients enrolled in Cycle 4 stated that they were very busy in the immediate postpartum period and not always able to respond in a timely fashion, allowing patients to receive the reminder text at their own designated convenient time did not increase engagement. Patients reported that while they always carried their cell phones, they did not always carry their blood pressure cuff, limiting their ability to send in a reading at the time of the reminder. Additionally, patients reported feeling less motivated to continue texting blood pressures towards the end of the cycle. Cycle 5 tested our hypothesis that patient engagement would improve if reminder text messages were sent closer to the morning or evening deadline. Patients were provided with the opportunity to request “snooze” response if they did have their cuff accessible. Additionally, standard responses were accompanied by a countdown message. For example, “Your blood pressure looks good. Four more days of checking your blood pressure to go.”

All five enrolled in this cohort sent in at least one blood pressure, and all (100%) transmitted at least one blood pressure text on post-discharge day 1 or 2 and on day 5, 6, or 7. Only two “snooze” requests were made over the course of the arm by a single patient, who responded both times after the additional reminder.

Four severely elevated blood pressures were sent to the physician responder, all from a single patient. This patient was diagnosed with preeclampsia with severe features on delivery admission, and her blood pressures normalized prior to discharge. All four “at risk” blood pressures were addressed within 24 hours of the text message. Due to persistently elevated diastolic blood pressures ranging from 110–120 mm Hg, she was started on hydrochlorothiazide 12.5 mg on day 6 of the cycle and monitored for additional days following cycle completion with improved blood pressures.