by Melissa Skirten, RN, BSN, MN and MSN Health Informatics)

University of Victoria, Departments of Nursing and Health Informatics

Citation: Skirten, M. (2023). Designing Remote Patient Monitoring to Optimize Care for Hypertensive Disorders of Pregnancy: A Rapid Review. Canadian Journal of Nursing Informatics, 18(2).  https://cjni.net/journal/?p=11566

Abstract

Background: Remote patient monitoring (RPM) may safely support the self-management of hypertensive disorders of pregnancy (HDP). Information on program design and outcomes are needed to support implementation of RPM into obstetrics practice.

Objectives: Using a rapid review approach, this study explores how RPM interventions for HDP have been designed, assesses if they are accessible, acceptable, and effective, and provides recommendations to optimize future implementations.

Method: A search of Medline, CINAHL Complete, and Goggle was conducted between October 15 and 16, 2022. The search identified 21 articles describing 14 studies and 13 interventions.

Results: While devices and systems varied, the majority utilized a smartphone (n=9).  Diverse monitoring support models were also evident. While results were mixed with regards to improving BP control, and earlier recognition and treatment for HDP, RPM interventions that used smartphones, provided BP devices, and offered device training, monitoring support, and self-management education were accessible and acceptable. When providers are engaged, RPM can support reduced health system utilization and compliance with monitoring guidelines.

Conclusions: RPM for HDP can promote patient satisfaction and improve compliance with monitoring guidelines. Future pilot studies should consider smartphone solutions and include patient and provider co-design to further assess efficacy and feasibility.

Keywords: hypertensive disorders of pregnancy, gestational hypertension, pre-eclampsia, postpartum hypertension, remote patient monitoring, telehealth, telemonitoring, mobile applications

Background

Hypertensive disorders of pregnancy (HDP) represent a broad range of conditions including chronic hypertension, gestational hypertension, preeclampsia and eclampsia, and postpartum hypertension (Butalia et al., 2018; Kumar et al., 2022). HDP affect approximately 7% of Canadian pregnancies and are associated with adverse neonatal and maternal outcomes (Butalia et al., 2018; Hodgkinson et al., 2014; Magee et al., 2014). For example, HDP can cause fetal growth restriction, low birth weight, prematurity, respiratory distress syndrome, and intrauterine death. As one of the leading causes of maternal morbidity or mortality, HDP are also linked to placental abruption, stroke, multiple organ failure, and disseminated intravascular coagulation (Salazar et al., 2019; Teng et al., 2021). While often assumed to resolve with the end of the pregnancy, HDP are not a transient health problem.

Many women will continue to be hypertensive for 6 to 12 weeks postpartum and the risk for long term maternal cardiovascular risks is well established (Butalia et al., 2018; Ditisheim et al., 2018; Hauspurg et al., 2019; Kamravamanesh et al., 2018; Melchiorre et al., 2020; Sawyer et al., 2020). Women who experience HDP are four times more likely to have or develop essential hypertension and have double the risk of developing cardiovascular disease (Ackerman-Banks et al., 2022; National Institute for Health Care and Excellence, 2019; Graves et al., 2019). Earlier diagnosis and regular monitoring could support the management of HDP to reduce the number of adverse outcomes and long-term complications (Melchiorre et al., 2020; Tucker et al., 2017).

Due to the availability of small, accurate, user-friendly, and inexpensive blood pressure devices, self-monitoring of blood pressure is becoming more prevalent to support the diagnosis of hypertension in the general population (Parati et al., 2021). However, self-monitoring requires motivation to take regular BP readings, proper BP measurement technique, manual recording of BP readings, and sharing BP readings with a health care provider (Carter et al., 2018; Kronish et al., 2017; Omboni et al., 2020; Parati et al., 2021; Rabi et al., 2020; Wood et al., 2017). In addition, self-monitoring without active management by health care providers, may not be enough to improve BP control or ensure appropriate follow-up (Lavallee et al., 2018; Lee & Park, 2016). Remote patient monitoring (RPM) may be a solution to improve self-monitoring and health knowledge, trigger earlier clinical assessment and treatment, and support shared decision making (Omboni et al., 2020; Walker et al., 2019).

RPM is a method of care delivery that uses technology to electronically gather, transfer, and share patient data, such as blood pressure or assessment data, from outside of conventional clinical settings (Government of Canada, 2022). Depending on the implementation design, patients take readings in a location of their choosing using a wireless, often Bluetooth-enabled device. Then, through various methods, the readings are electronically transmitted to a health care provider or application where an alert may be triggered and/or education provided to the patient. While RPM for the screening, diagnosis, and management of hypertension is not new, more recently this technology is being explored to improve diagnosis and facilitate monitoring and treatment for HDP (American College of Obstetricians and Gynecologists, 2018; Kumar et al., 2022; Omboni et al., 2020; Rivera-Romero et al., 2018; Salazar et al., 2019; Yeh et al., 2022).

Research Questions

The purpose of this rapid review is to explore how RPM interventions for HDP have been designed to optimize accessibility, acceptability, and effectiveness. Specifically, it addresses the following research questions:

(1) How are RPM interventions for HDP designed?

(2) Have these RPM interventions demonstrated accessibility, acceptability, and effectiveness?

(3) What can be learned to optimize RPM interventions for HDP?  

Ethics Considerations

This research project did not involve any human subjects.  As such, a request for exemption for an ethics consult was approved by the manager of Human Research Ethics at the University of Victoria’s Office of Research Services on October 14, 2022.

Methods

Rapid Review Approach

While systematic reviews are considered the gold standard of good quality research, there is a need to provide more timely and relevant research to facilitate decision. Rapid review methods have been developed to support a prompt uptake of evidence into practice (Haby et al., 2016). The Cochrane Rapid Review Methodology Group defines a rapid review as “a form of knowledge synthesis that accelerates the process of conducing a traditional systematic review through streamlining or omitting a variety of methods to produce evidence for stakeholders in a resource-efficient manner” (Tricco et al., 2022, p. 945). While methodological trade-offs can result in missed, or inadequately appraised or synthesized evidence, in health care settings dealing with funding, resource and expertise constraints, rapid reviews are a practical, feasible and efficient way to support evidence based practice.

In response to clinical inquiries, the rapid review method was chosen to quickly and efficiently gain an understanding of current RPM designs and outcomes related to the management of HDP. This rapid review used targeted research questions, limited search strategy, streamlined critical appraisal, and only one reviewer for study selection, data extraction and synthesis to ensure completion within two months (Haby et al., 2016). The results of this review may encourage further research and/or a pilot project to assess the feasibly of RPM for the management of HDP in a rural site in British Columbia. A similar review exploring these research questions has not been identified in the literature.

Search Strategy

A search strategy was developed with consultation from a University of Victoria Research Librarian (see Table 1). The literature search was constrained to Medline (Ovid) and CINAHL Complete (EBSCO) databases. MEDLINE was chosen for its coverage of research relevant to nursing practice and multidisciplinary care. Whereas CINAHL, the Cumulative Index to Nursing & Allied Health Literature, was chosen for its variety of resources and focus on nursing topics. Given the rapid pace of health technology innovation, the search was not limited to peer reviewed literature and a grey literature search was conducted on Google. To keep the results manageable, the search was limited to full text, English articles published within the last 10 years.

Table 1. Database Search Strategy

Inclusion Criteria

Studies were eligible if: (1) published in English from 2012 to present, (2) full text was available, (3) included pregnant and/or postpartum patients, (4) described a remote monitoring program for the identification or management of HDP (i.e., gestational hypertension, essential hypertension, or pre-eclampsia/eclampsia, postpartum hypertension), (4)  the remote monitoring intervention included patient self-measurement of blood pressure and the electronic transfer of clinical data, (5) discussed clinical outcomes, quality outcomes, and/or patient experiences, (6), protocols and additional articles not meeting the above criteria were eligible if they provided valuable information about the intervention design in included studies.

Exclusion Criteria

Studies were ineligible if: (1) monitoring focused on hospitalized patients, (2) outcomes were not related to accessibility and/or acceptability and/or effectiveness (e.g., economic evaluations), (3) study protocols, supplements, reviews, books, book sections, columns, commentary, editorials.

Selection Procedure

The literature search was conducted between October 15 and 16^th, 2022. The initial database and Google search resulted in 105 references for review. The selection procedure is illustrated in the PRISMA diagram in Figure 1 (Page et al., 2021). After duplicates were removed, 87 articles were available for title and abstract screening. After reviewing the titles and abstracts, 25 studies were eligibility for full text review.  In the full text review, nine articles were excluded, and five additional articles were added after a review of article references.  Five studies were merged resulting in a review of 21 articles describing 14 studies. Covidence systematic review software was utilized to support the data search and extraction processes.

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-analysis Flow Diagram

Data extraction

A data extraction form was created by the author in Covidence software to systematically collect data from each record regarding intervention design and outcome measures.  All articles were reviewed a minimum of three times to complete the applicable sections of the data extraction form. The completed data extraction forms were then compiled and exported in an MS Excel spreadsheet for data synthesis and analysis.  As themes in the data emerged, additional reviews of the articles were completed to support data synthesis and analysis. The full data extraction tables are available upon request. Table 2 summarizes the included articles.

Table 2. Summary of Included Studies (n=21)

Results

Study Characteristics

The included articles were published between 2016 to 2021 mainly from the United Kingdom and United States. 11 articles reported on antepartum RPM programs, and 10 articles reported on postpartum RPM programs. Study designs included 11 non-randomized experimental studies, four randomized control trials (RCT), three qualitative studies, one case control study, one cross sectional study, and one protocol. To avoid duplication, articles reporting on related studies were merged. Thus, 21 articles were merged into 14 studies. Of the 14 studies included, 13 unique RPM interventions were described. A protocol was added to provide further details on an RPM intervention described in two studies.

Critical Appraisal

The applicable Joanna Briggs Institute (JBI)’s critical appraisal checklists were used to guide a streamlined assessment of the rigour, relevance, and results of the articles. Most of the articles in this review were found to use multiple measures of outcomes, appropriate statistical analysis, adequately represented the voice of participants, and reported on outcomes in a reliable way. However, several risks for bias were also identified.

All of the studies were un-blinded and only four assigned participants to treatment and control groups randomly.  Given the nature of the study population and intervention, it is not always possible or ethical to randomize participants and/or blind participants or providers. However, selection bias may have affected the results if more willing and engaged participants were selected to participate. Observer bias also cannot be ruled out as participants may have acted differently knowing they are part of a study or trial.

Eight of the 14 included studies had fewer than 100 participants, and homogenous participant populations were identified within and across studies (e.g., White, English-speaking, access to a smartphone), limiting the generalizability of the findings. Most studies did not address the potential impact from previous experiences self-monitoring or interference from outside providers. Thus, confounding bias cannot be ruled out. Reporting bias is also a concern given the high proportion of studies reporting positive outcomes.  Four of the 21 articles were not peer reviewed.

How Are RPM Interventions for HDP Designed?

While a full technical evaluation is outside the scope of this review, an overview of the monitoring technology, protocols, and support will help decision makers to understand how RPM interventions are designed and provide context for the outcomes reported.

Monitoring Technology

All interventions collected maternal BP readings, and three interventions collected additional physiological measures including weight, heart rate, pulse, oxygen saturation, and activity. Two interventions also asked participants about symptoms related to HDP. The interventions used a variety of devices to collect patient data including Bluetooth-enabled, wireless BP monitors, scales, and oximeters, smart watches, and activity trackers. Four interventions provided all the devices required for participation. Eight of the interventions provided the BP monitoring device. Nine interventions mentioned using devices that were validated or approved for clinical use.

Tablets or smartphones were required in all interventions to automatically transmit, manually enter, or send text readings and/or responses into a monitoring system. Nine interventions required the use of the participants’ smartphones. Monitoring data was received and stored using a variety of systems including centralized monitoring platforms, web-based dashboard, portal, text-based platforms, mobile applications, databases, and study servers.  While most monitoring systems incorporated pre-determined or customizable BP parameters to regulate when alerts were sent to monitoring clinicians, providers, and participants, others included more sophisticated functions. Some systems displayed trends and/or sent automatic reminders and provided rule-based immediate feedback to participants (Cairns et al., 2018; Dougall et al., 2020; Ganapathy et al., 2016; Hirshberg et al., 2018; Sheehan et al., 2019; Tucker et al., 2021). For example, in one study, twice daily reminders were sent to participants to text in their BP readings (Hirshberg et al., 2018). After texting in their BP readings, they received immediate feedback based on a preprogramed automated algorithm (Hirshberg et al., 2018). Similarly, the Safe@Home platform responded to participants who submitted elevated BP readings with an in-application symptom checklist and an alert to the monitoring team (van den Heuvel et al., 2020). In the BUMP 1 and 2 trials, reminders and triggered messages were received by participants according to a rule-based algorithm developed with the clinical team (Chappell et al., 2022; Dougall et al., 2020; Tucker et al., 2021). Only three of the interventions described integration with the electronic health record.  

Monitoring Protocols

While the monitoring duration and frequency varied considerably based on clinical needs and program or study goals, more than half of the interventions in this review mentioned the development of a BP management and treatment protocol or algorithm to standardize the assessment of monitoring data and appropriate actions. For example, one intervention included the development of a nurse-driven BP management and treatment algorithm to support early identification and prompt treatment of severe hypertension and medication management (Hoppe et al., 2019; Hoppe et al., 2020). In another study, a monitoring team used flowcharts to assess BP readings and symptoms and determine treatments (van den Heuvel et al., 2020).

In other interventions, automated instructions were created within the monitoring system to guide participants to self-manage their condition. For instance, in one mobile application, participants entered their BP readings and answered questions about their symptoms (Sheehan et al., 2019). If the BP readings and/or symptoms were outside of pre-set parameters, a red message was triggered to advise the participant to contact their midwife or hospital (Sheehan et al., 2019). Similarly, in response to submitted BP readings, the display on another application would change colours to direct the participant’s next actions (i.e., green to re-check in one week, amber to repeat in 4 hours and red to proceed to the hospital; Ganapathy et al., 2016).  In another example, a telemonitoring service provided automatic instructions to support the down-titrate of medication in response to BP readings (Cairns et al., 2018). As well, BUMP 1 and 2 participants were provided with colour-coded instructions to guide actions based on BP readings (Dougall et al., 2020; Tucker et al., 2021).

Monitoring Support

In most of the interventions, clinicians or researchers were available to support the monitoring of participants. Monitoring providers included registered nurses, midwives, researchers, physicians, or a combination. Monitoring providers were responsible for a variety of tasks including enrolment and training, setting parameters, monitoring readings, communicating with other providers, and following up with participants.

Ten of the interventions described some form of education and/or training at enrollment. For instance, in one postpartum intervention, prior to discharge, participants were trained to use the remote monitoring devices and system (Rhoads et al., 2017). While device training was common, other programs included an educational component.  For example, participants enrolled in either of the BUMP trials were provided with clear instructions on the use of the monitoring system and BP device, and information on the health benefits and how to incorporate self-monitoring into daily life (Tucker et al., 2021).  The enrollment process may also include providing access to the monitoring system and setting parameters (Burgess et al., 2021).

Monitoring providers were responsible for examining participants’ data and alerts and organizing follow-up care.  For example, one intervention monitored by midwives, used pre-determined alarms to notify the midwife of abnormal readings requiring assessment (Lanssens et al., 2017).  The midwife would then consult with the obstetrician to discuss management options prior to contacting the participant. In other interventions, elevated readings triggered participants to contact their local hospital or obstetrician or family physician (Tucker et al., 2021).

Monitoring providers responded to participants in a variety of ways including phone calls, text messages, in-application messages, or emails. While follow-up visits varied, some interventions continued with the standard outpatient appointment schedule and others offered a reduced appointment schedule (Hoppe et al., 2019; Hauspurg et al., 2019; Sheehan et al., 2019).  

Are RPM Interventions for HDP Accessible, Acceptable and Effective?

In this review, accessibility is defined as the ease with which interventions are reachable in suitable settings, at a reasonable time, and in an adequate manner (i.e., ease of use and inclusion and/or exclusion criteria (BC Patient Safety & Quality Council, 2020; Chan et al., 2021).

Acceptability is achieved when an intervention respects the person’s needs, preferences, and expectations (i.e., patient retention, engagement, and satisfaction (BC Patient Safety & Quality Council, 2020; Chan et al., 2021).

Effectiveness describes whether the intervention achieved its intended outcomes (i.e., improved BP control and/or early identification of hypertension/ preeclampsia, reduced health care utilization, better compliance with hypertension monitoring guidelines, and enhanced self-care knowledge (BC Patient Safety & Quality Council, 2020; Chan et al., 2021).

Accessibility Outcomes

In 11 studies, participants were asked about ease of use. Most of the participants were comfortable or confident using the devices and found them easy to use (Burgess et al., 2021; Cairns et al., 2020; Ganapathy et al., 2016; Hauspurg et al., 2019; Rhoads et al., 2017; N. A. Thomas et al., 2021). One study using a smart watch and mobile application, reported ease of use even among undereducated participants (Ganapathy et al., 2016). Still, a few participants did find the BP cuff was hard to put on and uncomfortable (Cairns et al., 2020; Runkle et al., 2021; N. A. Thomas et al., 2021).

Participants also described the monitoring system as easy to use, learn, and navigate, and/or practical, convenient, and flexible (Cairns et al., 2018; Cairns et al., 2020; Hinton et al., 2017; Hoppe et al., 2019; Musyoka et al., 2019; Rhoads et al., 2017; Runkle et al., 2021; N. A. Thomas et al., 2021; Tucker et al., 2021; van den Heuvel et al., 2020). However, a few participants did experience some technical and/or connectivity issues or irritation with regards to the monitoring system (Cairns et al., 2020; Hinton et al., 2017; N. A. Thomas et al., 2021).  For example, some women participating in RPM for a postpartum hypertension trial, experienced frustration with an inability to customize alarm settings, skip sections of monitoring interviews, and modify submissions, and difficulties with data transmission (Hinton et al., 2017). While none of the studies reported on the impact of technical issues on the number of readings received, participants using the MyChart application reported the BP cuff was simple to use, yet 31% chose not to record their readings in the application and 29% of those participants continued monitoring their BP at home using the cuff provided (Burgess et al., 2021).

Reasons for exclusion and/or study inclusion criteria were discussed in 10 studies. While this criterion speaks to the generalizability of findings, it may also identify challenges to intervention availability. Generally speaking, the inclusion criteria were broad including individuals who are over the age of 18, English speaking, at risk for or diagnosed with a HDP, and have access to a smartphone (Burgess et al., 2021; Cairns et al., 2018; Hauspurg et al., 2019; Hirshberg et al., 2018; van den Heuvel et al., 2020). However, individuals may not be included if their arm circumference was greater than 42 cm, they were not referred to the program, equipment or staff were unavailable, and due to various medical reasons (Cairns et al., 2018; Hauspurg et al., 2019; Hirshberg et al., 2018; Hoppe et al., 2020; Lanssens et al., 2017; Rhoads et al., 2017; Runkle et al., 2021; van den Heuvel et al., 2020).

Additionally, two studies reported on reasons individuals declined to consent to participate. The most common reasons included feeling overwhelmed with the postpartum period, perceptions that participation was too time consuming, not wanting to self-monitor, and an inability to return the equipment (Cairns et al., 2018; Hoppe et al., 2019). It was also noted that the interventions that provided devices also tended to have smaller rates of enrolment which may be partially attributed to device availability (Ganapathy et al., 2016; Hoppe et al, 2020; Lanssens et al., 2017; Musyoka et al., 2019; Rhoads et al., 2017). Hence, RPM devices and systems appear to be easy to use but may not have been available to all who could have benefited.

Acceptability Outcomes

Rates of retention and/or participant engagement were reported in 11 studies. All the researchers reported high rates of program completion (Cairns et al., 2018; Chappell et al., 2022; Hoppe et al., 2019; Hoppe et al., 2020; van den Heuvel et al., 2020). As well, most interventions reported regular participant engagement as measured by compliance with study protocols including the number of readings received and the number of days of monitoring (Cairns et al., 2018; Chappell et al., 2022; Hauspurg et al., 2019; Hirshberg et al., 2018; Hoppe et al., 2019; Hoppe et al., 2020; Rhoads et al., 2017; Runkle et al., 2021; van den Heuvel et al., 2020).  For example, when standard postpartum care may result in two in-office BP readings, a text-based remote monitoring intervention received an average of 16 out of a maximum of 28 BP readings per participant (Hirshberg et al., 2018). Participants in the SAFE@HOME application were asked to submit a BP reading on weekdays (van den Heuvel et al., 2020). Of a possible 100 BP measurements, participants completed a median of 90 BP measurements in 20 weeks of monitoring, or 4.5 measurements per week (van den Heuvel et al., 2020). With standard care, it would be challenging to have patients present so frequently for in-person BP readings). Only one study reported on declining levels of patient retention over the course of the program (Hauspurg et al., 2019).

In 10 studies, a measure of participant satisfaction was also described. Overall, the participants in this review expressed satisfaction with their RPM experiences and would recommend the intervention to others (Cairns et al., 2020; Ganapathy et al., 2016; Hauspurg et al., 2019; Hoppe et al., 2019; Musyoka et al., 2019; Sheehan et al., 2019; N. A. Thomas et al., 2021; van den Heuvel et al., 2020).  Some participants even reported a preference for home monitoring over hospital, clinic, or home visits, however support from monitoring providers was valued (Cairns et al., 2020; Chappell et al., 2022; Ganapathy et al., 2016; Hauspurg et al., 2019; Hinton et al., 2017; Hoppe et al., 2019; N. A. Thomas et al., 2021; Sheehan et al., 2019). RPM was also associated with enhanced feelings of control and reduced anxiety, and positive feelings of shared responsibility with health care providers (Cairns et al., 2020; Hinton et al., 2017; N. A. Thomas et al., 2021; Sheehan et al., 2019). While most participants had positive experiences communicating with providers about self-monitoring, some participants sensed that their physicians felt uninvolved, and not trusting of their ability to self-monitor (Cairns et al., 2020; Hinton et al., 2017). 

When reported, reasons for attrition included loss to follow-up, missing data, technical issues, withdrawal, unable or unwilling to manage daily monitoring, or maternal or newborn health concerns (Cairns et al., 2018; Chappell et al., 2022; Hoppe et al., 2019; Hoppe et al., 2020; Runkle et al., 2021; van den Heuvel et al., 2020). While not regularly reported, there were several participants who did not complete follow-up as intended but instead choose to continue to self-monitor independently (Burgess et al., 2021; Chappell et al., 2022; Hinton et al., 2017; Tucker et al., 2021).

Effectiveness Outcomes

In this review, 12 studies reported on one or more measures of effectiveness. While none of the interventions reported any adverse outcomes related to RPM, no clinically significant differences in pregnancy outcomes was identified either (Chappell et al., 2022; Lanssens et al., 2018; Tucker et al., 2021; van den Heuvel et al., 2020). With regards to BP control, results are mixed. On the one hand, a RCT reported no significant improvement in BP control (Chappell et al., 2022). Whereas the results from a longitudinal RCT trial suggested that RPM interventions can successfully lower mean BP even 3-4 years after the intervention (Cairns et al., 2018; Cairns et al., 2020; Kitt et al., 2021).

Likewise, most researchers observed that RPM interventions may support more rapid recognition and timely treatment for HDP (Burgess et al., 2021; Cairns et al., 2018; Hauspurg et al., 2019; Hirshberg et al., 2018; Hoppe et al., 2019: Hoppe et al., 2020; Lanssens et al., 2017; Runkle et al., 2021; Tucker et al., 2021).  However, one RCT reported no statistically significant improvement in the detection of hypertension with RPM over standard care (Tucker et al., 2021).

Despite concerns that self-monitoring could lead to increases in inappropriate clinic or hospital visits, a number of researchers in this review reported that RPM interventions do not increase health care utilization (Hirshberg et al., 2018; Hoppe et al., 2020; Lanssens et al., 2017; Lanssens et al., 2018; Lavallee et al., 2018; van den Heuvel et al., 2020). In fact, RPM may support a decrease in health care utilization (Hirshberg et al., 2018; Hoppe et al., 2020; Lanssens et al., 2018; van den Heuvel et al., 2020). For example, when compared with standard care, participants in one antenatal RPM intervention had fewer admissions to the prenatal ward, fewer hospitalizations, and fewer prenatal visits (Lanssens et al., 2018). Regular communication of BP readings also allowed several interventions to offer patients a reduced appointment schedule while continuing to follow recommended monitoring guidelines (Hauspurg et al., 2019, Hirshberg et al., 2018; Lanssens et al., 2018; Sheehan et al., 2019). 

Some researchers in this review found that RPM interventions lead to significant improvements in meeting recommended guidelines for BP monitoring (Hauspurg et al., 2019; Hirshberg et al., 2018; Hoppe et al., 2020). In a study of rural women using a smartphone application to monitor their BP, researchers found that during the final weeks of pregnancy when 54% of clinic visits were missed, participants logged an average of 16 readings (Runkle et al., 2021). In addition, a reduced need for in-person BP checks and improved rates of attendance at the 6-week postpartum visit were reported in two postpartum RPM studies (Burgess et al., 2021; Hauspurg et al., 2019).

Given the variability in educational resources provided and monitoring support, results are limited with regards to improvements in patients’ reported understanding of the benefits of self-management for HDP (Cairns et al., 2020; Hinton et al., 2017; Hirshberg et al. 2018; Rhoads et al., 2017; Sheehan et al., 2019; Tucker et al., 2021).

Recommendations: What Can Be Learned to Optimize RPM Interventions?

Pilot Study

Based on the findings of this review, RPM for HDP demonstrates promise to improve the quality of care provided to women with HDP. However, a pilot study is needed to further assess the efficacy and feasibility of the use of RPM for HDP with the target population. The pilot study would evaluate the processes, resources, management, and safety measures required to conduct a larger study to determine if RPM for HDP is a safe and viable option for Canadian patients   (Beets et al., 2021; Thabane et al., 2010). Review findings suggest that the design of a pilot project take into consideration device models, device training, change management, physician engagement, monitoring support, and self-management education.

Device Models

The choice of technology and the decision to provide or not provide devices is important to the accessibility and acceptability of a RPM service (Chan et al., 2021; Kaihlanen et al., 2022). As Rhoads et al. reported, postpartum women with hypertension who choose not to use RPM technology may have lower facilitating conditions and may perceive lower benefits and higher barriers (2017). Based on the options presented in this review, programs appear to have the choice between a device-based RPM model that includes a BP monitor and/or other devices linked to a monitoring system accessible on a provided device or a mobile or text-based application accessible on the patient’s smartphone.  

On the one hand, utilizing a device-based RPM model, allows programs to select clinically validated, advanced solutions and/or BP devices that sync data directly into a monitoring system, thereby reducing the risk of user error, making data more useable for providers, and possibly improving ease of use for patients (Chappell et al., 2022; Hirshberg et al., 2018; Omboni et al., 2020; Wood et al., 2017).  However, issues with device management including the high cost of devices, and equipment return processes and availability can reduced the accessibility of these interventions (Ganapathy et al., 2016; Hoppe et al., 2019; Hoppe et al., 2020; Rhoads et al., 2017).

On the other hand, access to a smartphone or cellular device was not a significant barrier to participation in the interventions in this review (Burgess et al., 2021; Cairns et al., 2018; Hauspurg et al., 2019; Runkle et al., 2021; Sheehan et al., 2019). Thus, mobile or text-based RPM interventions that offer the loan of a BP monitor appear to be acceptable and may reduce barriers caused by device costs and device management issues (Canada Health Infoway, 2018; Hauspurg et al., 2019; Hirshberg et al., 2018; Rhoads et al., 2017; Runkle et al., 2021; Tucker et al., 2021; van den Heuvel et al., 2020). However, further research into the costs and infrastructure required to deploy the various RPM solutions and a more detailed comparison of the different models is recommended.

Device Training

Consistent reports of participant satisfaction and engagement indicate that RPM devices are generally accessible and acceptable. However, it is likely that accessibility and acceptance was a function of the provision of BP devices, ease of use, and participant training (Chappell et al., 2022; Hirshberg et al., 2018). BP monitors were provided in all but one intervention. Most of the programs also provided training on device(s) and/or the monitoring system. For example, in one intervention participants were educated on proper BP measurement and asked to provide a return demonstration using their cuff (Burgess et al., 2021). These participants expressed satisfaction with the education and found the BP cuff easy to use (Burgess et al., 2021). This anticipatory guidance is likely the reason more device and/or system issues were not reported.

While the choice of technology is important, it is the whole package of an intervention that makes RPM successful. Change management, physician engagement, monitoring support, and integration of education will support the development of an RPM system that is accessible, acceptable, and effective. 

 Change Management and Physician Engagement

Physicians must understand the problem and agree that RPM is an appropriate solution to facilitate co-ownership and commitment to the RPM service (Cresswell et al., 2013). If physicians are involved in the selection and design of the RPM intervention, they may have more positive attitudes about the change and perceive it as an “enhancement as opposed to a requirement” (Detwiller & Petillion, 2014, p. 269). In turn, physician engagement will support recruitment, collaboration with patients, and intervention effectiveness (Burgess et al., 2021; Hauspurg et al., 2019; Hoppe et al., 2019).

Participant recruitment may rely on physician engagement. For instance, in one intervention, participants were enrolled in the RPM program by their obstetrics provider while on the postpartum unit or after readmission postpartum (Hauspurg et al., 2019). In the SNAP-HT trial, women were approached after they were identified by their care provider (Cairns et al., 2018).

Physician engagement also supports collaborative relationships between providers and patients to enhance informed decision-making and quality of care (Burgess et al., 2021). For example, one participant felt the RPM intervention allowed her to share responsibility with her physician: “it felt like he [the GP] was kind of backing it that it’s a good thing” (Cairns et al., 2020, p. 4). Another participant suggested that specific knowledge of BP readings was helpful and gave her the confidence to discuss them with her provider (Cairns et al., 2020). When physicians are engaged, they can acknowledge their patient’s ability to self-manage their BP and encourage them to feel empowered (Sheehan et al., 2019). Conversely, if providers are not engaged, participants may perceive them as not supportive, involved, or confident in the ability of the patient to self-monitor (Cairns et al., 2020; Hinton et al., 2017).

In addition, physician engagement is key to reducing health care system utilization.  For example, one study did not find a reduction in total prenatal visits until a year after the initial implementation (Lanssens et al., 2018). However, to see a reduction in health system utilization physicians must be given time to experience RPM to understand the impact on their practice and patients (Burgess et al., 2021; Runkle et al., 2021). Thus, engaging physicians can expand accessibility, enhance acceptance, and improve effectiveness of RPM interventions for HDP (Burgess et al., 2021; Lanssens et al., 2018; E. E. Thomas et al., 2021; van den Heuvel et al., 2020).

Monitoring Support

While participants enjoyed using the devices and did not want to go to the hospital more than necessary, monitoring providers can offer reassurance to encourage self-monitoring and reduce anxiety (Hinton et al., 2017; Hoppe et al., 2020; Sheehan et al., 2019). For example, one study reported that 82% of participants felt more comfortable knowing a nurse was checking in on their readings daily (Hauspurg et al., 2019).

Monitoring staff can also provide emotional support to complement RPM interventions and support continuity of care.  For example, a postpartum participant in a telehealth and RPM intervention reported that “the nurses at the telehealth made me feel like I mattered and were very informative” (Hoppe et al., 2020, p. 5). As well, participants appreciated the extra support, reassurance, and information provided by monitoring staff (Burgess et al., 2021; Hinton et al., 2017).  While having a 24/7 centralized monitoring support service may be out of range for many programs, having dedicated monitoring staff responsible for enrolment, monitoring, and communicating with patients and the health care team can facilitate accessibility and acceptance, and may support effectiveness (Burgess et al., 2021; Rhoads et al., 2017; E. E. Thomas et al., 2021).

Self-Management Education

RPM has the potential to support earlier detection and treatment for increases in BP however, women need to understand why self-management is important if they are to comply with monitoring guidelines (N. A. Thomas et al., 2021). This review finds that if women with HDP are given the appropriate resources, they can be safely monitored remotely, comply with BP management instructions, and appreciate the opportunity RPM gives them to more fully engage in their health care (Cairns et al., 2020; Hinton et al., 2017; Sheehan et al., 2019). For example, one participant observed that her BP was especially high and as a result sought treatment (Hinton et al., 2017). She believes were it not for the technology, her preeclampsia would have gone untreated (Hinton et al., 2017). Thus, to optimize acceptability and effectiveness, RPM systems need to include self-care management tools and education that provide timely and useful information to increase self-awareness and support women to take an active role in managing their hypertension (Cairns et al., 2020; Chappell et al., 2022; Hinton et al., 2017; Musyoka et al., 2019; Sheehan et al., 2019; E. E. Thomas et al., 2021).

Discussion

Findings from other studies demonstrate that women can and will self-monitor their BP, are using mobile applications in pregnancy, and are interested in wearable technology (Jakubowski et al., 2022; Lee & Moon, 2016; Özkan ?at & Yaman Sözbir, 2021; Runkle et al., 2019; Schramm et al., 2019; Wilson et al., 2022; Yeh et al., 2022). This review further confirms that women at-risk for preeclampsia or with postpartum HDP can be safely monitored remotely, may prefer self-monitoring, and may benefit from remote monitoring. With appropriate planning and support, RPM for HDP has the potential to encourage earlier detection and treatment, support compliance with clinical monitoring recommendations, reduce health care utilization, and improve patient satisfaction. However, due to the high cost of devices and device management requirements, device-based solutions may not be widely accessible and appropriate for all clinical programs (Casale et al., 2021; Halsey, 2021).

This review suggests that RPM interventions that leverage technology that is familiar to patients, such as a smartphone, may be more available and accessible and have similar outcomes as more advanced, device-based approaches (Halsey, 2021). However, while smartphone applications and web-based portals may be feasible, application development and/or vendor and maintenance costs and privacy considerations must be explored (Chan et al., 2021; Marko et al., 2016; Potzel et al., 2021). While the use of wearable sensors to monitor vital signs and physiological measures is not widespread in routine medical practice or obstetrics due to privacy, reliability, and data management concerns, decision makers would also be wise to future-proof RPM interventions to take advantage of advances in this area (Runkle et al., 2019).The importance of co-designing RPM interventions with patients to ensure they are easy to use and provide timely, useful feedback, education, and coaching to encourage adherence and engagement was also highlighted (LeBaron, 2022; E. E. Thomas et al., 2021; Vernon & Yang, 2022).

Echoing findings from a qualitative needs assessment study, women valued the convenience of being able to manage their condition at home while a provider was checking in on them remotely (Vernon & Yang, 2022). However, patient participation in usability testing, and assessment of the impact of social determinants of health and cultural norms may improve acceptability of RPM interventions (LeBaron, 2022; Moradian et al., 2018). In addition, RPM intervention that include educational resources may improve self-management (Vernon & Yang, 2022). Working with patients to design RPM interventions that integrate behavior change methods and digital therapeutics may better support their needs, facilitate engagement, and improve effectiveness (Dang et al., 2020; Noah et al., 2018; Potzel et al., 2022; Tack, 2021; E. E. Thomas et al., 2021).

Finally, this review backs findings from other studies that stress the importance of co-designing RPM interventions with physicians and effective change management to facilitate communication, enhance shared decision-making, and improve effectiveness (Cresswell et al., 2013; Detwiller & Petillion, 2014; Halsey, 2021; LeBaron, 2022; E. E. Thomas et al., 2021; Vernon & Yang, 2022). Without buy-in and timely, responsive communication between the monitoring team, physicians, and patients, RPM interventions will not be fully accessible, acceptable, or effective (Cresswell et al., 2013; E. E. Thomas et al., 2021).

Study Limitations

This review is limited by the rapid review methodology used. The search strategy was limited to published literature that described completed and/or ongoing interventions and outcomes. This focused search strategy likely resulted in the exclusion of valuable resources.  For example, several protocols and studies were excluded because outcomes were not discussed.

The lack of additional more experienced researchers to support the search, screening, extraction, and synthesis processes limits the reliability, reproducibility, validity, and overall quality of the findings. However, the reality is that in the current resource constrained health care environment, rapid reviews are the most accessible method for health care employees interested in systematically researching topics of interests to improve clinical practise.

Future research should examine physicians’ and monitoring providers’ perceptions and experiences of RPM interventions for HDP, the development of monitoring and treatment protocols of RPM for HDP, and the use of RPM for HDP in rural and remote populations and with First Nations and other minority populations.

Conclusion

Designing a successful RPM intervention for HDP is a complex undertaking that requires a careful consideration of RPM devices, systems, and models of care. RPM devices need to be at hand or within reach and easy to use, but patient training is required to optimize accessibility. RPM systems may be most responsive to patients when they are based on smartphone technology, but self-care education and knowing a provider is monitoring the readings will optimize acceptance and effectiveness. Patient engagement in RPM supports compliance with BP monitoring guidelines, but physician engagement is required to reduce health care utilization and support continuity of care.  RPM interventions have the potential to improve the quality of care provided to women with HDP and reduce health care utilization when they are designed with patients and providers in mind. 

Acknowledgments

The author would like to acknowledge the support provided by Dr. Debra Sheets, Professor, School of Nursing at the University of Victoria and Dr. Alex Kuo, Professor, School of Health Information Science at the University of Victoria.

Author Biography

Melissa Skirten has a Masters’ of Nursing and Masters of Science in Health Informatics from the University of Victoria. She is currently working as a Nursing Informatics Specialist for Interior Health in British Columbia, Canada. In this role, she informs the development, design, and implementation of virtual care projects.

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