From the 2024 HVPA National Conference
Mark Shneyderman, Graduate (Icahn School of Medicine at Mount Sinai) Christina Lefebvre, Graduate, Camila Vicioso, Graduate, Amare Osei, Graduate, Ahana Chowdhury, Graduate, Brianna Sukhdeo, Graduate, Ceyda Oner, Postgraduate, Cynthia Abraham, Postgraduate
Background
Preeclampsia and other hypertensive disorders of pregnancy (HDP) are major contributors to maternal morbidity and mortality in the United States and are among the leading causes of readmission following delivery. HDP is the second most common indicator for readmission, following postpartum infections. In the U.S., Black women bear the highest prevalence of HDP (20.9%), and the rate of preeclampsia is 60% higher for Black women than for White women. Yet, the risk factors associated with HDP readmission are poorly characterized and are consequently poorly addressed in clinical practice.
Objective
Our aim is to identify and implement new protocols at Mount Sinai Hospital (MSH) to reduce postpartum readmission rates for preeclampsia after a retrospective review of preeclampsia readmissions in a high-risk cohort. In addition, there is a paucity of data on readmission rates for postpartum preeclampsia in patients previously diagnosed with an HDP. Our data addresses this gap in the literature and provides a foundation for subsequent initiatives focused on OB/GYN patient safety and quality improvement.
Methods
Mount Sinai OB/GYN Ambulatory Practice patients (Medicaid-insured) who delivered at MSH from June 2021 through August 2023 and who were diagnosed with an HDP during their intrapartum course were identified. Retrospective chart review included: patient demographics, obstetric history, admission and readmission lengths, blood pressure readings, delivery information, antihypertensive prescriptions, adherence to standard postpartum blood pressure monitoring protocols, and existing social determinant of health (SDOH)-related concerns, such as financial insecurity, transportation needs, etc.
Results
The total sample size was 185 patients. 22.7% (n = 42) were readmitted with a diagnosis of preeclampsia. The median number of days post-discharge that patients were readmitted was 7 days. The mean maximum intrapartum systolic blood pressure for readmitted patients versus for non-readmitted patients was 155 mmHg and 179 mmHg, respectively (p < .001), and the mean maximum diastolic blood pressures for readmitted versus for non-readmitted patients were 91 mmHg and 102 mmHg, respectively (p < .001). In addition, 44.0% (n = 81) of patients monitored blood pressures at home postpartum, and 44.9% (n = 83) of patients attended an outpatient blood pressure check within one week of discharge. 38.1% (n = 16) of readmitted patients were identified with at least one SDOH-related concern, compared to only 21.7% (n = 31) of non-readmitted patients (p = .06). Finally, Black patients were disproportionately readmitted, as 53.8% (n = 98) of the sample population was Black and accounted for 61.9% (n = 26) of readmissions.
Conclusions
Readmission rates for patients diagnosed with an HDP are significantly higher in our study than national ranges. Differences in the pharmacologic management of patients both intrapartum and postpartum may contribute to this phenomenon. Readmission rates were also higher for populations with an SDOH-related concern or were Black, suggesting a need to reach all communities with effective and inclusive care.
Clinical Implications
The Mount Sinai OB/GYN Ambulatory Practice serves a particularly vulnerable patient population. Our results highlight the need to improve workflows along the continuum of peripartum care. As a result of our findings, we have implemented a tripartite “Blood Pressure (BP) Bundle” initiative that 1) educates patients pre-discharge about the warning signs of preeclampsia, 2) facilitates patient BP tracking post-discharge, and 3) enables a telehealth visit functionality for the vital one-week outpatient blood pressure check in an effort to reduce postpartum readmissions for preeclampsia.