AT ACOG 2016
WASHINGTON (FRONTLINE MEDICAL NEWS) – Is it time to reconsider the standard prenatal care model of 12-14 in-office prenatal visits?
As pregnant women increasingly use digital technology, and as the array of available health monitoring tools grows larger and smarter, the question looms.
Research findings reported at the annual meeting of the American College of Obstetricians and Gynecologists suggest that women with low-risk pregnancies have equivalent outcomes but are more satisfied with models that reduce the number of office visits and utilize remote monitoring.
At the Mayo Clinic in Rochester, Minn., 300 women deemed to have low-risk pregnancies were randomized to either 12 planned office visits with a physician or midwife, or to the clinic’s “OB Nest” model of care consisting of 8 planned clinic visits with a physician or midwife, 6 virtual visits with a nurse (by phone or email), home monitoring with an automatic blood pressure cuff and a hand-held fetal Doppler monitor, and access to an online prenatal care community.
The clinic’s OB Nest model “was born out of concern that the traditional model no longer met the needs of our patients,” said Dr. Yvonne S. Butler Tobah , a senior associate consultant to the department of obstetrics and gynecology at Mayo.
The goal, she said, is to “shift our prenatal clinic’s culture … to a wellness care model and to strengthen the autonomy, confidence, self-awareness and empowerment of our patients.”
Patients in the OB Nest group were encouraged to get blood pressure readings once a week, and weekly Doppler readings of fetal heart rate between weeks 12 and 28. They could use the cuff and monitor anytime they chose, however.
Values were recorded in a pregnancy journal – along with weight – and reported during the scheduled virtual visits. The patients could send in concerning readings or otherwise communicate with dedicated OB Nest nurses at any time they chose by phone or via an online portal. Emergencies were to be reported immediately.
The online prenatal care community is an invitation-only, Mayo-specific social platform, monitored by the OB Nest nurses, which gave patients the opportunity to share and discuss issues.
Patient satisfaction, as measured at 36 weeks with a 16-item validated satisfaction scale, was significantly higher in the OB Nest group; these patients had a mean score of 93.9 on a 1-100 point scale, compared with a mean score of 78.9 in the usual care group.
Levels of pregnancy-related stress – measured at three points in time with a 9-item prenatal maternal stress survey – were also significantly lower at 14 weeks and lower at 36 weeks in the OB Nest group compared with usual care. Stress levels were similar in both groups at 24 weeks.
Perceived quality of care was assessed at 36 weeks using a modified version of a prenatal processes-of-care scale that addressed communication and decision making, and no differences were observed.
“OB Nest significantly improved patient satisfaction with care and reduced maternal stress,” Dr. Tobah said. “And it did this while maintaining perceived quality of care and maintaining [safe] outcomes.”
The study was not sufficiently powered to detect statistically significant differences in clinical outcomes, which were the study’s secondary outcomes. However, there were no differences observed in maternal-fetal events or delivery outcomes, with the exception of a 4.5% rate of gestational diabetes in the OB Nest group, compared with none in the usual care group, Dr. Tobah explained.
Of the 150 patients randomized to each group, 19 and 20 were lost to follow-up in the OB Nest group and usual care group, respectively. Patients in the study had a mean age of 29, and the majority were white and married. “It was a highly educated, low-risk group,” she said. “Patients said [at the end] that they liked the general accessibility and consistent communication with a provider on an ongoing basis.”
While patients in the OB Nest group ultimately had 3.4 fewer in-office appointments than did usual care patients, they required more out-of-office nursing time and the length of in-office visits was significantly higher, Dr. Tobah noted.
In another study of remote prenatal care monitoring reported at the ACOG meeting, low-risk patients assigned to an alternative prenatal care schedule of 8 in-office visits supplemented with digital monitoring of blood pressure and weight similarly had higher patient satisfaction scores than did low-risk patients assigned to 14 prenatal visits.
Patient satisfaction was measured several times during pregnancy. Scores were significantly higher at 20 weeks in the 49-patient alternative care group “and evened out [with the 41-patient usual-care group] at the tail end of pregnancy,” said Dr. Nihar Ganju of George Washington University, Washington. “And there was no difference in pregnancy outcomes.”
This study used the Babyscripts mobile app connected to a wireless weight scale and a wireless blood pressure cuff. Patients were instructed to check their weight and blood pressure at least once a week.
They were “highly engaged,” Dr. Ganju said, checking their blood pressure a mean of 1.4 times weekly and their weight almost twice weekly. Providers received “four notifications of abnormal values,” he said.
Dr. Ganju and his colleagues are hopeful that the digital health tool “can really be effective in addressing the issue of excessive weight gain,” he said at the ACOG meeting. They are also beginning a study on remote monitoring for patients with chronic hypertension.
Findings on the effectiveness of remote personalized weight management are also expected to come from the soon-to-be-completed LIFE-Moms study , a national project looking at how overweight and obese women can best manage weight gain in pregnancy and improve their maternal and fetal outcomes.
Dr. Ganju reported having no disclosures. Two coauthors reported a nonfinancial advisory relationship with 1Eq Inc., the mobile app company that developed Babyscripts and helped fund the study. Another author is an employee of 1Eq. Dr. Tobah reported that she had no disclosures.