Hypertensive disorders complicate 10% of pregnancies, while the incidence of pre-eclampsia is 2-8%. Women with high blood pressure in pregnancy are advised to attend hospital twice weekly for BP and urine testing to monitor for pre-eclampsia, a potentially life-threatening disease for both mother and baby. However, the majority of these women will not develop pre-eclampsia. This frequent monitoring and repeated hospital visits represent a source of anxiety to women and their families and have significant cost implications for limited healthcare resources. Innovative solutions are urgently needed to reduce the demand on these women and the financial burden on the NHS.
At St George’s University Hospital, the maternal fetal medicine team (obstetricians and midwives), together with the Health Foundation (Innovation for Improvement grant £75,000), developed, evaluated and implemented a new care pathway entitled ‘home monitoring of hypertension in pregnancy’ (HaMpton). Shortlisted for a BMJ Innovation Award, this involves the use of an innovative smartphone app that allows women to monitor their blood pressure (BP) and urine at home, and alerts them if they need to attend hospital for further assessment.
Pregnant women at risk of developing pre-eclampsia input their BP and urine results into the app, then answer a set of trigger questions that help identify pre-eclampsia. The app links with a hospital computer where the data can be monitored by clinicians in real time. Pregnant women have been involved in the design and feedback of HaMpton. Costs included development of the App, online platform, BP monitors, urine dipsticks, staff salary and the economic analysis. We conducted a baseline audit of 58 pregnant women with hypertension attending the Day Assessment Unit for BP monitoring. Women with pre-existing hypertension are advised to have weekly BP checks with their GP from booking until 6 weeks after birth (a total of 36 weeks).
A GP appointment costs the NHS £35 per patient. Women who develop pregnancy-induced hypertension are referred to the hospital midwife (cost: £50, including midwifery time and investigations). Women who are commenced on antihypertensive treatment are admitted overnight (cost: £250/night). HaMpton reduced the number of appointments for hypertension monitoring by 53% and the amount of time per appointment. We surveyed patients and staff about their experience of the care pathway. Women highlighted the benefits of continuity of care and person-centred care.
We noted a significant improvement in the quality of care for women with ‘white coat’ hypertension, leading to a reduction in medical intervention. HaMpton also empowers women to be involved in their own care. Healthcare professionals said that HaMpton allowed them to use their time and resources more efficiently, reducing waiting times. Average cost saving per patient per week was £300. On average, patients required home monitoring for 6 weeks. The project has proved to be very successful. We have demonstrated that home BP monitoring is safe, clinically- and cost-effective and improves patient satisfaction. With the help of the Health Foundation and the determined efforts of our team, home BP monitoring has now become embedded in routine practice.
Key metrics are outlined in Figure 2 (supplementary material).
•Marked (52%) reduction in number of BP follow-up appointments in DAU.
•Reduction in average DAU appointment times from 114 to 66 minutes.
•100% patient satisfaction; excellent staff satisfaction (Figures 3,4).
•66% of women felt less anxious when checking their BP at home compared to in hospital and also noted significantly lower BP readings.
•Safety: no suboptimal outcomes; no patients discontinued.
•Average cost saving per patient per week: £300. On average, patients required home monitoring for 6 weeks. If scaled up across the UK, this represents a potential cost-saving of £50 Million/year
Current adoption sites: St George’s Hospital, Kingston Hospital, Croydon Hospital, Liverpool Women’s Hospital, Bolton NHS Foundation Trust. App adopted free as part of the implementation plan. The next phase is to commercialise and roll out the app/online platform nationally. Awarded £75,000 (+ additional £30,000 for dissemination of our innovation as Small Scale Spread Award) by the Health Foundation. HaMpton has the potential to expand into other areas, such as monitoring of sugar levels in women with diabetes. Winner, Excellence in Healthcare Innovation and Education Awards 2016, St George’s University of London. Recognised as an innovative service improvement in the official CQC report (2016).