Combating the Rise in Pregnan­cy-Related Hypertension

A program to support maternal health in Ohio has tallied some early but important wins in areas that are key to improving medical management of pregnancy-related hypertensive disorders.

This state-wide quality improvement project was developed by the Ohio Department of Health, administered by the Ohio Colleges of Medicine Government Resource Center, and led in part by physicians in Cleveland Clinic’s Ob/Gyn & Women’s Health Institute alongside The Ohio State University Wexner Medical Center, University Hospitals Cleveland Medical Center, and the MetroHealth system. It aims to address morbidity, mortality and health disparities associated with hypertensive disorders of pregnancy (HDP) through implementation of the Alliance for Innovation in Maternal Health (AIM) Severe Hypertension in Pregnancy Patient Safety Bundle.

HDP includes gestational hypertension, preeclampsia and eclampsia, and can occur in patients with and without a known diagnosis of chronic hypertension. They are a leading cause of severe maternal morbidity and mortality, says Justin Lappen, MD, section head of Maternal Fetal Medicine at Cleveland Clinic and a principal investigator in the state quality initiative.

“The Ohio Pregnancy-Associated Mortality Review, which reviews all cases of maternal death in the state, found that about 12% of maternal deaths over an eight-year period in Ohio were related to hypertensive disorders,” says Dr. Lappen. “Of those, approximately 70% occurred postpartum and over 85% were deemed preventable. So this is a really pertinent area for a quality initiative on a statewide level.”

The right response, anywhere and on time

Initiated in 2020 and now with more than 50 participating hospitals throughout Ohio, the project focuses on five critical domains outlined by the Alliance for Innovation and Maternal Health as critical to improving care for patients who present with HDP.

• Recognition
• Readiness
• Response
• Reporting
• Respectful care

“We have specific initiatives in each of those domains,” says Dr. Lappen. “Hospital teams are focusing on the identification and treatment of severe hypertension in pregnancy, which includes the provision of appropriate acute antihypertensive therapy within 60 minutes of diagnosis.”

In addition to the management of severe hypertension in the hospital, postpartum follow-up is critical to reducing maternal risk and achieving health equity, he adds.

“Physiologically, blood pressure increases in the days following delivery. As such, timely follow-up for patients with severe hypertension is essential to achieving optimal blood pressure control and reducing maternal risk. Through this project, we are striving to eliminate barriers to follow-up, to provide blood pressure cuffs to all patients and educate all patients on the proper technique to take their blood pressure, and to counsel patients on post-birth warning signs where prompt evaluation is recommended,” Dr. Lappen says. “We are tracking these patients within our system, and throughout the state, so that we can continue to identify missed opportunities and areas of improvement.”

The fifth domain – respectful care — underscores the importance of achieving health equity and the elimination of health disparities.

“We know that Black women are at a 2.5- to 3-fold increased risk of maternal mortality, including from hypertensive disorders of pregnancy. In this quality initiative, we have implemented implicit bias/anti-racism training for our entire department. Additionally, we are incorporating shared-decision making, providing culturally sensitive education for all patients, and working to eliminate barriers related to social determinants of health, transportation, and health literacy and numeracy,” he says.

Treatment of sustained severe hypertension within 60 minutes and number of daily COVID-19 cases during baseline and implementation periods.

Clinical change package

The core mechanism for the project is a “clinical change package,” says Dr. Lappen – a document containing best practices adopted from national evidence-based standards for implementation in Ohio.

“It was really infused by the perspective of leaders in the state, adopting evidence-based best practices to our patients, communities, and health systems in Ohio,” he says. “This funded project provides support to hospital quality initiative teams throughout the implementation of this project. As hospitals join, we provide education, dedicated QI coaching support, and mentorship. We have monthly action-period calls where we review project data, provide education on hypertension in pregnancy and quality improvement science, discuss best practices, and share experiences from around the state so that we can achieve success together.”

Sites are reporting data to the state, and the data is reported through a dashboard. “You can look at our outcomes and analyze them in aggregate, or stratify them by hospital, race, ethnicity, payer status or by certain comorbidities,” says Dr. Lappen. “It’s a comprehensive dashboard that allows sites to track their data and progress in real time.”

Tracking process measures

Change in primary and secondary process measures.

The first wave of participants joined the project in fall 2020 and reported three months of data to serve as a baseline marker. Sites then are asked to submit data every month afterward. Fifty-five hospitals around the state are currently participating in the project and submitting data.

“Our primary objective is to reduce maternal morbidity and mortality, and to reduce disparities, related to hypertensive disorders of pregnancy by 2024,” says Dr. Lappen.

While reaching these outcomes will take time, the project team is evaluating early progress through tracking of process measures. Process measures are indicators that reflect adherence to accepted recommendations for clinical practice, or to the clinical practice processes the project is striving to achieve.