Four of five patients in this cohort sent at least one blood pressure text on post-discharge day 1 or 2 (80%). Three patients (60%) 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 and no medications were initiated.
Post-Cycle Interviews
Overall, patients reported satisfaction with the text messaging system in their post-cycle interviews. The convenience of the intervention was acknowledged by many, including one patient who commented that “this was a lot better than having to pay for the bus and waiting for hours in some waiting room.” One patient also reported that the increased awareness was important, stating that “when [she] got home and realized that [her blood pressure] was still high, [she] did her own research and learned more about hypertension and preeclampsia.” Others reported that they still checked their blood pressure after the cycle, and “would have went longer than a week if they had asked me to.”
Discussions
Our results suggest that remote blood pressure monitoring via text message communication engages patients and shows promise as a convenient and effective means of hypertension surveillance in the immediate postpartum period, in accordance to ACOG guidelines. Additionally, we were able to test this monitoring system using inexpensive, rapid-cycle validation techniques. Although these techniques are insufficiently controlled and of inadequate statistical power for definitive results, they were able to provide quick evidence toward a pragmatic and workable solution to an important clinical problem within the specific clinical context of our practice, though the results are likely to generalize to other settings. We found varied compliance based on the different engagement strategies, and although no single cycle proved superior, overall patient participation was good and provides a basis for different texting options in future work. Developing a method that both engages patients and is streamlined for providers is critical to our ability to translate this recommendation into practice. Although we did not specifically test how the system works from a provider’s point of view, the study obstetricians believe that this would help and can be fit within the existing workflows of the practices at most institutions.
This rapid-cycle intervention study provides several additional lessons, as we were able to rapidly implement this on our unit and test several hypotheses related to patient engagement. Most patients found the text messaging system to be a convenient way to communicate with their obstetrician. Even when patients had prenatal care at other institutions and delivered at our hospital without a prior patient/physician relationship (n = 5), we were able to engage them in text messaging. However, there was some evidence of patient drop out over the course of the week, as patients were more likely to text in blood pressure in the first few days of the cycle than the last few days (Figure 2).
Other telemedicine interventions have been studied in maternity care and have had inconsistent results. The Cochrane review on telephone support for women during pregnancy and up to 6 weeks after birth found that interventions were mainly aimed at smoking cessation, breastfeeding continuation, preterm birth, and postpartum depression [19]. To date, none of the randomized trials in pregnancy or the postpartum period have focused on postpartum hypertension. The results of our interventions are encouraging and support the use of text messaging in obstetrical care, particularly in the postpartum period. While text messaging cannot provide all the information that can be obtained in a doctor’s visit, such as physical exam, urine dipsticks, and review of symptoms, it can identify the minority of patients that may need to be seen in the office based on the severity of their blood pressures.