Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
Center for Women's Health Research and Innovation, University of Pittsburgh, Pittsburgh, Pennsylvania.
JAMA Netw Open. 2021 Oct 1;4(10):e2130804. doi: 10.1001/jamanetworkopen.2021.30804.
Preeclampsia is a leading preventable cause of maternal morbidity and mortality. Initiation of low-dose aspirin (LDASA) treatment at or before 16 weeks' gestation may prevent preeclampsia onset for patients with specific risk factors.
To assess potential underuse of LDASA and reasons for underuse using data from a prenatal care smartphone app.
DESIGN, SETTING, AND PARTICIPANTS: In this prospective cohort study, English-speaking pregnant patients aged 18 years or older from the UPMC health care system received an invitation to use the MyHealthyPregnancy app at their first prenatal appointment. Use of the app was voluntary. The study took place between September 23, 2019, and August 31, 2020, as part of a quality-improvement initiative.
The app offered educational information, monitoring tools, and routine screenings tailored to patient-entered gestational age and demographic and clinical characteristics. App-based questions included LDASA eligibility based on US Preventive Services Task Force criteria for preeclampsia risk and a monthly prompt about LDASA recommendations from the patient's health care practitioner.
The primary outcomes were the receipt of LDASA recommendations from a practitioner and adherence to any such recommendation, as self-reported on the app. Patients' medical records were examined to cross-reference their self-reports of an LDASA recommendation. Multivariable logistic regression was used to model patient-perceived recommendation as a function of factors associated with preeclampsia.
The patient cohort consisted of 2563 patient participants (2036 [79%] White; mean [SD] age, 30 [5.2] years) with 2567 pregnancies; 1882 pregnancies (73.3%) were among women with private or employer-based insurance, and 1246 (48.5%) were among nulliparous patients. At least 1 factor associated with high risk for preeclampsia was reported in 316 pregnancies (12.3%), and 2 or more factors associated with moderate risk were reported in 1051 (40.9%). Of the 1015 pregnancies for which patients answered voluntary questions about aspirin use, 124 (12.2%) met at least 1 criterion for highest risk of preeclampsia. In 57 (46.0%) of these pregnancies, the patient indicated that their practitioner recommended LDASA; after examination of the medical records, 90 pregnancies (72.6%) had evidence of an LDASA recommendation and 34 (27.4%) did not. Of the 90 pregnancies with a documented LDASA recommendation, 33 patients (36.7%) were unaware of it. Prior preeclampsia (28 weeks' gestation: odds ratio, 20.1; 95% CI, 11.0-36.9) and chronic hypertension (28 weeks' gestation: odds ratio, 17.4; 95% CI, 6.3-48.2) were the primary high-risk factors associated with recommendation of LDASA.
In this cohort study, only 46.0% of prenatal care app users who met the criteria for highest preeclampsia risk reported receiving an LDASA recommendation from their practitioner, and medical records suggested that there may have been frequent miscommunication between patients and practitioners about LDASA use. Digital tools such as the MyHealthyPregnancy app might offer an opportunity to improve identification of patients at risk for preeclampsia and communication with these patients about aspirin use.
子痫前期是导致产妇发病率和死亡率的主要可预防原因。在特定风险因素的患者中，在 16 周妊娠或之前开始低剂量阿司匹林（LDASA）治疗可能预防子痫前期的发生。
使用来自产前保健智能手机应用程序的数据评估潜在的 LDASA 未充分利用和未充分利用的原因。
设计、设置和参与者：在这项前瞻性队列研究中，来自 UPMC 医疗保健系统的 18 岁或以上的英语孕妇在第一次产前预约时收到使用 MyHealthyPregnancy 应用程序的邀请。使用该应用程序是自愿的。该研究于 2019 年 9 月 23 日至 2020 年 8 月 31 日进行，作为质量改进计划的一部分。
该应用程序提供了针对患者输入的孕龄和人口统计学及临床特征量身定制的教育信息、监测工具和常规筛查。基于美国预防服务工作组子痫前期风险标准的 LDASA 资格和每月一次关于患者保健医生 LDASA 建议的应用程序提示包括在应用程序内的问题中。
主要结果是从医生那里收到 LDASA 建议和对任何此类建议的依从性，如患者在应用程序上自行报告。检查患者的病历以交叉参考他们对 LDASA 建议的自我报告。使用多变量逻辑回归来模拟患者感知的建议作为与子痫前期相关的因素的函数。
患者队列包括 2563 名患者参与者（2036 [79%]为白人；平均[SD]年龄为 30[5.2]岁），共 2567 次妊娠；1882 次妊娠（73.3%）发生在有私人或雇主为基础保险的女性中，1246 次妊娠（48.5%）发生在初产妇中。在 316 次妊娠（12.3%）中报告了至少一种与子痫前期高风险相关的因素，在 1051 次妊娠（40.9%）中报告了两种或两种以上与中度风险相关的因素。在 1015 次回答关于阿司匹林使用自愿问题的妊娠中，有 124 次（12.2%）符合子痫前期最高风险的至少一个标准。在这些妊娠中的 57 次（46.0%）中，患者表示其医生建议使用 LDASA；在检查病历后，有 90 次妊娠（72.6%）有 LDASA 建议的证据，34 次妊娠（27.4%）没有。在有记录的 LDASA 建议的 90 次妊娠中，有 33 名患者（36.7%）不知道该建议。既往子痫前期（28 周妊娠：比值比，20.1；95%CI，11.0-36.9）和慢性高血压（28 周妊娠：比值比，17.4；95%CI，6.3-48.2）是与 LDASA 推荐相关的主要高风险因素。
在这项队列研究中，只有 46.0%的符合子痫前期最高风险标准的产前保健应用程序用户报告从他们的医生那里收到 LDASA 建议，并且病历表明，患者和医生之间关于 LDASA 使用的沟通可能经常存在误解。像 MyHealthyPregnancy 这样的数字工具可能有机会改善对子痫前期风险患者的识别，并与这些患者沟通阿司匹林的使用。
