Telehealth with Remote Blood Pressure Monitoring Compared to Standard Care for Postpartum Hypertension

OBJECTIVE

Hypertensive disorders of pregnancy (HDP) affect 10% of pregnancies in the United States and are the most common diagnoses associated with postpartum readmissions [1–2]. The American College of Obstetrics and Gynecology suggests blood pressure (BP) follow-up seven to ten-days postpartum for women with HDP, but 50– 70% do not follow-up [1] [3]. The objective of this study was to evaluate whether postpartum home telehealth with remote BP monitoring versus standard outpatient care reduces readmission rates within six-weeks postpartum in women with HDP.

STUDY DESIGN

We performed a non-randomized controlled trial comparing hospital readmission rates for participants with HDP allocated to telehealth with remote BP monitoring (intervention) versus standard outpatient care (control). In a 1:1 fashion we allocated a participant after consent to the intervention and the next eligible woman with a similar HDP who agreed to be approached but declined or was not approached due to lack of equipment/staff availability to the control group (Figure). Participants in the intervention group received a tablet and Bluetooth BP monitor for daily transmission of vitals to a central database for six weeks [4]. Trained nurses utilized our previously published algorithm to guide antihypertensive initiation/titration [4]. Controls were advised to follow standard care, which included a clinic visit seven to ten-days and six-weeks postpartum [1]. The primary outcome was hypertension related readmission through six-weeks postpartum. Our secondary outcomes included hypertension related postpartum emergency room (ER)/triage visit, acquisition of BP within ten days of delivery, and use of antihypertensives six-weeks postpartum. Among the intervention participants, we investigated the rates of severe hypertension and increasing BPs requiring treatment after discharge. All analyses were based on the intention-to-treat principle. We used a chi-square test for dichotomous variables and a Wilcoxon rank sum test for continuous variables. All reported P-values and 95% confidence intervals (CI) are two-sided. To account for potential confounding and effect modification a multivariable binary regression model was used to account for baseline differences in study groups for all outcomes. IRB #017–003, approved 03/21/2017.

Figure.

Flow diagram for study enrollment

RESULTS

From April 2017-June 2018, 428 women were enrolled (214 to intervention; 214 to control). The intervention group had fewer hypertension-related readmissions compared to the controls (1 [0.5%] vs. 8 [3.7%], aRR 0.12; 95% CI: 0.01–0.96). Significantly more women in the intervention group than the control group had at least one BP measured within ten-days postpartum (202 [94.4%] vs. 129 [60.3%], aRR 1.59, 95% CI: 1.36–1.77). There were no differences in ER/triage visits or use of antihypertensives six-weeks postpartum between groups (Table 1). In the intervention arm, severe hypertension occurred in 56 (26.2%) women and 116 (54.2%) had increased BPs requiring treatment after discharge [1]. The median (IQR) days to the first severe hypertension reading was 6.0 (4.8–9.0) and to the first BP requiring treatment was 6.0 (5.0–9.0).

Table 1.

Outpatient Outcomes among Home Telehealth with Remote Blood Pressure Monitoring versus Standard Outpatient Care for Postpartum Women with Hypertensive Disorders of Pregnancy.

	Telehealth (N=214)		Standard Outpatient Care (N=214)		P-value	RR (95% CI)	Adjusted P-value	Adjusted RR (95% CI)
Health care utilization through 6-weeks
Hospital readmission-hypertension related*, n (%)	1	(0.5)	8	(3.7)	0.037	0.13 (0.02–0.99)	0.045	0.12 (0.01–0.96)
Emergency/triage room visit hypertension related*, n (%)	11	(4.6)	13	(6.0)	0.831	0.76 (0.38–1.85)	0.808	0.81 (0.36–1.80)
Had a blood pressure reviewed within 10 days of delivery*, n (%)	202	(94.4)	129	(60.3)	<0.001	1.56 (1.39–1.76)	<0.001	1.59 (1.36–1.77)
6-week study endpoint
Total participants on antihypertensive treatment regimen*, n (%)	57	(26.6)	37	(17.3)	0.027	1.54 (1.06–2.23)	0.866	1.03 (0.74–1.44)

Data are expressed as mean ± SD, median (interquartile range), or n (%).

^*Adjusted for delivery mode, insurance status, antihypertension medication use at hospital discharge and total postpartum admission days.

Statistical tests including Wilcoxon rank sum, Chi-square, or Fisher exact test were used where appropriate\

CONCLUSION

Telehealth with remote BP monitoring and standardized management of postpartum hypertension was associated with reduced readmissions compared to standard care. Telehealth with remote BP monitoring offers a promising strategy for achieving higher acquisition of BP’s, early identification and treatment of uncontrolled hypertension, and ultimate reduction in hospital readmissions.