Quality of Blood Pressure Monitoring During Telehealth Visits for Pregnant Patients at Risk of Preeclampsia

Introduction

Hypertensive disorders of pregnancy (HDP) are one of the leading causes of maternal morbidity and mortality in the United States, accounting for 6% of pregnancy-related deaths. ¹ The prevalence of HDP is also increasing, as 15.9% of delivery hospitalizations in the United States in 2019 had the diagnosis of HDP, compared with 13.4% in 2017. ² Preeclampsia, a type of HDP, is characterized by new-onset high blood pressure after 20 weeks of gestation and is commonly associated with excess protein in the urine, often involving other laboratory abnormalities and/or symptoms suggestive of end-organ damage. ³ Preeclampsia is associated with an increased risk of severe maternal outcomes, such as placental abruption, stroke, renal failure, and death. ⁴ Fetuses of patients with preeclampsia are at risk of intrauterine fetal demise, fetal growth restriction, and premature birth complications. ⁵

Other types of HDP include chronic hypertension, which is defined as hypertension before 20 weeks of gestation, and gestational hypertension, which is defined as having a systolic blood pressure (SBP) of 140 or above or diastolic blood pressure (DBP) of 90 or above on two different occasions at least 4 h apart in a patient with normal blood pressures prior. Both these types of HDP increase the risk of a patient developing preeclampsia. ⁶ Eclampsia is a severe form of HDP characterized by maternal seizures. ³

Blood pressure measurement is key to the screening, diagnosis, and management of preeclampsia and other forms of HDP. ^3,7 The COVID-19 pandemic was a pivotal time for the use of telehealth in obstetric care, as well as the incorporation of self-measured blood pressure (SMBP) into routine obstetric care. However, even before the pandemic, telehealth played a role in obstetrics. A systematic review published in February 2020 found that telehealth reduced the need for in-person high-risk obstetric monitoring office visits without compromising health outcomes. ⁸ With the onset of the COVID-19 pandemic and new social distancing guidelines, the use of telehealth for antepartum and postpartum visits became significantly more prevalent, and many patients were encouraged to obtain SMBP during telehealth obstetric visits. ⁹

An elevated blood pressure measurement (SBP of 140 or higher or DBP of 90 or higher) during a telehealth visit could trigger various follow-up recommendations depending on the clinical context and severity, including the recommendation for an immediate or appropriately prompt clinician-measured blood pressure for verification and subsequent management. ^9,10

Furthermore, many insurance companies broadened the insurance coverage of telehealth and blood pressure cuffs during the COVID-19 pandemic. ¹¹ Medicaid, which covers 42% of all births in the United States and two-thirds of births among Black women, ^12,13 who have been found to die from preeclampsia and eclampsia at five times the rate of White women, ¹⁴ also underwent significant changes in response to the increasing use of telehealth during the pandemic. Antepartum telehealth visits were 165% higher during the pandemic compared with prior for patients insured by Medicaid. ¹⁵ Similarly for privately insured patients, a study on trends in telehealth utilization during the antepartum period found that in January 2020, antepartum telehealth use was at 1.1%, increasing dramatically to 17.3% in November 2020, and to 9.9% in October 2021. ¹⁵ Telehealth continues to have an important role in obstetric care even after the COVID-19 pandemic. ^16,17

The continued importance of telehealth and HDP has informed current recommendations for obstetric visits and HDP screening. The United States Preventative Services Task Force (USPSTF) recommends that blood pressure measurements be obtained at every obstetric visit and called for more research on telehealth and its role in screening for HDP. ⁷ To advance this call for research, there is a need to evaluate how well blood pressure measurements have been integrated into obstetric telehealth visits. The goal of this study was to assess how often SMBP was documented during obstetric telehealth visits for patients with risk factors for preeclampsia using data obtained by chart review. In this study, we define telehealth as live, real-time (synchronous) visits performed virtually via video or audio alone between patients and their clinicians during prenatal and postpartum appointments. ¹⁶

Methods

We performed a retrospective chart review of patients with one or more preeclampsia risk factors who delivered at a tertiary hospital from January to March 2021, 9 months to a year after the onset of the COVID-19 pandemic. Eligible patients had one or more risk factors for preeclampsia, as defined by the American College of Obstetricians and Gynecologists, ¹⁸ including advanced maternal age (≥35), black race, body mass index ≥30, nulliparity, multiple gestation, Medicaid insurance, type 1 or type 2 diabetes, renal disease, autoimmune illness, chronic hypertension, and a prior diagnosis of preeclampsia or eclampsia.

For patients with at least one risk factor, chart review was conducted, and demographic information, including age at delivery, insurance status, race, and ethnicity, was recorded, in addition to information about their pregnancy, such as type of antepartum clinic visited (maternal fetal medicine [MFM], private, or federally qualified health center [FQHC]), number of ante- and postpartum visits, number of telehealth visits, blood pressure cuff access, diagnosis of prior and new hypertensive disorders, and chart documentation of SMBP readings. All clinics were affiliated to the tertiary hospital.

In the state in which this study was carried out, synchronous telehealth video and audio only visits were reimbursed by insurance companies. The telehealth visits were clearly designated as such by clinicians for billing purposes. We excluded telephone documentations where the designation of telehealth was not present. Of note, this study does not include remote blood pressure monitoring, which generally refers to the collection of blood pressure by patients and the subsequent electronic transmission to clinicians. ¹⁶ Visits were conducted by obstetric providers alone (obstetricians, certified nurse midwives, and advanced practice registered nurses) and patients received usual obstetric or postpartum care during these visits.

Differences in demographic and clinical characteristics between (1) patients with 0, 1, and ≥2 telehealth visits and (2) patients with and without ≥1 SMBP documented during their telehealth visits were calculated using chi-squared tests or Fisher's exact tests, if the expected count in any given category was <5. If significant differences were detected, post hoc pairwise comparison tests were conducted using Bonferroni corrections for multiple comparisons. All analyses were conducted in RStudio version 2022.12.0 + 353 (R Foundation for Statistical Computing) with the threshold for statistical significance set at p < 0.05. This study was granted exemption status by the Institutional Review Boards (IRB Protocol ID: 2000032863).

Results

Discussion

With HDP serving as a major cause of morbidity and mortality in the United States and abroad, telehealth and home-based blood pressure monitoring have been major tools of interest to reduce time to diagnosis, inform interventions, and improve outcomes. Although telehealth has played a role in obstetric care for many years, its use significantly increased during and after the onset of the COVID-19 pandemic. Blood pressure monitoring is an important part of in-person visits, and, similarly, should be an integral part of telehealth visits to maintain standard of care as outlined by the USPSTF guidelines. ⁷ The data, however, are limited with respect to the integration of blood pressure monitoring and documentation during obstetric telehealth visits.

This study focused on telehealth visits of patients 9 months to 1 year after the onset of the COVID-19 pandemic, during a time when many obstetric clinics continued telehealth visits while also reintegrating in-person health care. Despite the return to traditional health care, the majority of participants in our study had at least one telehealth visit. Of note, 106 (43.4%) patients with 2 or more telehealth visits had at least one SMBP documented. This highlights opportunities for quality improvement since all patients regardless of their risk factors for preeclampsia are supposed to have a blood pressure measurement taken at every obstetric visit. ⁷ Potential reasons for poor documentation of blood pressure during telehealth visits include patients' lack of access to blood pressure cuffs, inadequate instruction on their use during the visit, and incomplete documentation in chart notes.

Although telehealth and telehealth-supporting tools in obstetrics, such as blood pressure cuffs, have the potential to reduce the barriers that prevent patients from accessing in-person health care, variations in blood pressure cuff coverage could perpetuate inequities in care. Of note, our study was conducted in a state where Medicaid broadened coverage of blood pressure cuffs in pregnancy during the COVID-19 pandemic and continues to broaden that coverage to all pregnant patients even after the pandemic. ¹⁹

A February 2020 national analysis report on blood pressure cuff coverage in the United States found that most private insurers do not cover home blood pressure monitors. ²⁰ Of commercially insured adults who received ambulatory blood pressure cuffs between 2012 and 2018, 4-in-10 incurred a direct expense as a result. ²¹ Private insurance coverage for blood pressure cuffs in pregnancy even after the COVID-19 pandemic remains variable with some private insurance companies not covering blood pressure cuff devices for SMBP in pregnant patients who do not have a current diagnosis of hypertension in pregnancy, regardless of whether they have risk factors for developing preeclampsia later in pregnancy or in the postpartum period.

Hence, we advocate for private insurance companies to cover blood pressure cuffs for all pregnant patients, especially for those with risk factors for preeclampsia. Furthermore, there is room for continued advocacy to expand Medicaid coverage for blood pressure cuffs for self-measurement across the United States, given that according to the American Medical Association, based on data available as of March 15, 2023, Medicaid currently covers automated blood pressure devices in only 38 states. ²²

With regard to instructing patients to take blood pressure measurements during telehealth visits and documenting, our finding that patients who attended FQHCs were more likely to have blood pressure documentation during telehealth visits compared with patients who attended private and MFM clinics may be due to differences in telehealth protocols. While conducting chart review, it was noted that the format of notes documenting telehealth visits differed significantly among providers, practices, and clinic types. While some notes followed premade templates with blood pressures clearly documented, other telehealth chart notes were less standardized. Protocols that standardize notes for telehealth visits with clear places to input patients' blood pressure measured during the visit can help improve quality standards for telehealth.

While beyond the scope of this study, accuracy of blood pressure measurements is an important consideration when providing supporting tools for SMBP during telehealth. A study validating blood pressure cuffs owned by nonpregnant patients who had a diagnosis of hypertension found that blood pressure cuffs that were validated were more likely to be accurate than those that were not validated. ²³ In addition, the aforementioned study showed that blood pressure cuffs owned for 4 years or less were more likely to give accurate blood pressure measurements compared with those owned for longer periods of time. ²³

Using proper techniques while obtaining SMBP, such as having the appropriately sized cuff, being seated upright with both feet on the ground, and resting for at least 5 min before obtaining a blood pressure measurement, is equally important to avoid erroneous values. ²⁴ Hence, it is important to have protocols that inform and educate patients about these important considerations for obtaining accurate SMBP during telehealth visits and to facilitate access to appropriate blood pressure cuffs for patients. ^25,26

There are many opportunities for future research on blood pressure monitoring during telehealth visits. Qualitative and quantitative mixed-methods studies that focus on the patient experience with the use of telehealth and SMBP could highlight additional supports and barriers that could inform improved workflows for telehealth visits. Further research is needed to determine how blood pressure documentation might differ during telehealth visits in states lacking Medicaid coverage of blood pressure cuffs. Lastly, while beyond the scope of this research, more studies are needed on the role of telemonitoring, or remote blood pressure monitoring, in the screening and management of HDP.

Conclusions

With the rise of telehealth during the COVID-19 pandemic as well as the continued use of telehealth in the years postpandemic onset, it is important to study and understand the process of the integration of SMBP into obstetric care provided via telehealth. The findings of this study support the need for protocols that standardize the recording and documenting of SMBP during obstetric telehealth visits, especially for patients with risk factors for preeclampsia. Educating patients on proper techniques to obtain SMBP, improving the quality of blood pressure measurement and documentation during telehealth visits, and increasing access to blood pressure cuffs can help ensure that patients have the tools they need for comprehensive telehealth visits and enhance surveillance for patients with HDP.