Rhode Island - Statewide Postpartum Hypertension Remote Surveillance

Uncontrolled hypertensive disorders of pregnancy (HDP) are a major source of maternal mortality. National guidelines recommend blood pressure (BP) measurement 3-10 days after discharge and ≥1 preventive care visit within one year of delivery. Yet, barriers such as childcare or transportation issues reduce adherence to in-person BP checks, particularly among racial or ethnic minority patients. Programs in which patients self-measure BP (SMBP) at home show promising results regardless of patient race. However, a recent meta-analysis concluded current SMBP programs do not reduce maternal mortality or racial disparities in clinical outcomes, potentially due to their specific limitations: they end within six weeks of birth (though HDP can persist for months) and have decreased engagement with non-White people or those living in disadvantaged areas, though these populations are at the highest risk of persistent HTN and its adverse long-term effects. Thus, there is an urgent need to optimize SMBP programs to target short- and long-term HDP-related morbidity and to broadly implement these programs to eliminate disparities in HDP-related outcomes. One such program is Rhode Island (RI)-Statewide Postpartum HypErtension REmote Surveillance (RI-SPHERES), a technology-based SMBP program that aims to reduce short- and long-term HDP-associated morbidity in RI using the collaborative care model, a health services intervention that improves health outcomes and reduces racial disparities on a population level for people with chronic conditions. The proposed research aims to determine the effectiveness of RI-SPHERES in reducing short- and long-term morbidity associated with HDP throughout RI. This builds upon our pilot RCT (NCT05595629), in which a standard SMBP program was compared to a SMBP program that used a Bluetooth-enabled BP cuff that syncs to a smartphone application (app) to send automated reminders and provide adaptive messaging tailored to distinct BP values and symptoms. RI-SPHERES will expand this SMBP program to provide app-based patient-informed educational content on HDP-specific preventive care and bidirectional communication with RI-SPHERES staff for one year postpartum. Incorporating adaptive and automatic messaging increases RI-SPHERES' scalability by reducing clinical staff burden. However, formal analysis of factors that may hinder widespread implementation of RI-SPHERES is needed. Thus, we will conduct a Hybrid Type I Non-Inferiority Implementation-Effectiveness Trial among 1536 patients with HDP that compares a standard SMBP program to RI-SPHERES in terms of persistent HTN at six weeks postpartum and receipt of preventive care within one year of delivery (Specific Aim 1). We will examine the effect of both programs on increasing equity in terms of race, ethnicity, language, and geography for postpartum patients with HDP in Rhode Island (Specific Aim 2). We will also develop an implementation toolkit to facilitate the dissemination of RI-SPHERES (Specific Aim 3). The proposed project is expected to deliver a mechanism that will fill multiple research gaps for HDP identified by the US Preventive Services Task Force: 1) addressing health inequities through multilevel interventions, 2) evaluating SMBP programs; and 3) mitigating HDP's short- and long-term health consequences of HDP.

• Attendance of preventive care visit [Time frame: From six weeks postpartum until one year postpartum]
• Blood pressure ascertainment [Time frame: 1-10 days after hospital discharge]
• Total number of self-measured blood pressure assessments provided to program in immediate postpartum period [Time frame: Hospital discharge to six weeks postpartum]
• Total number of self-measured blood pressure assessments provided to program after six weeks postpartum [Time frame: Six weeks postpartum until one year postpartum]
• Severe maternal morbidity after hospital discharge [Time frame: Hospital discharge until 6 weeks postpartum]
• Persistent stage I hypertension [Time frame: Six weeks, six months, and 12 months postpartum]
• Persistent stage II hypertension [Time frame: Six and 12 months postpartum]
• Severe hypertension after hospital discharge [Time frame: Hospital discharge to 6 weeks postpartum]
• Emergency room visit for hypertension-related etiology [Time frame: Hospital discharge to 6 weeks postpartum]
• Readmission to inpatient hospital for hypertension-related etiology [Time frame: Hospital discharge until 6 weeks postpartum]
• Initiation or titration of antihypertension medication [Time frame: Hospital discharge to 6 weeks postpartum]
• Postpartum visit attendance [Time frame: Four to six weeks postpartum]