Assistant Professor of Medicine, Tamar Krishnamurti, talks about the importance of pregnant women taking baby aspirin to prevent pre-eclampsia and a new app that will help them through their pregnancy journey.
Interview conducted by Ivanhoe Broadcast News in December 2021.
I want to start by asking you what’s happening when someone is preeclamptic.
PROF KRISHNAMURTI: Pre-eclampsia is a complication that can occur after about 20 weeks of pregnancy. It’s characterized by new onset, high blood pressure and protein in the urine. And it’s something that has certain risk factors associated with it. But actually, if you take a low dose in a baby aspirin, you can decrease the risk of developing pre-eclampsia because that aspirin is an anticoagulant.
What is it about taking a low dose of the baby aspirin that can help?
PROF KRISHNAMURTI: So the low dose baby aspirin, if it’s taken routinely, can decrease that risk of high blood pressure onset. But in a low enough dose, there are really no risks to the mother or fetus from taking it.
Is this a fairly new recommendation for pregnant women? Or is this something that most women would know or would have heard of from previous pregnancies?
PROF KRISHNAMURTI: The recommendation to take low dose baby aspirin has been evaluated multiple times by the United States Preventive Services Task Force but it’s still not necessarily a common practice for people to take it universally during pregnancy. And there are some risk factors that physicians could use to identify patients that would most benefit from taking that aspirin.
Doctors are suggesting to specific patients who would benefit?
PROF KRISHNAMURTI: That’s right.
But you’re finding not everyone’s following?
PROF KRISHNAMURTI: In order to be able to really make a recommendation and have somebody follow through with it for any health behavior, first of all, you have to identify accurately those people that would benefit from it. Then, they have to understand their eligibility for taking the medication, and then they have to also be able to be adherent to that medication.
Who would benefit? Which women in particular?
PROF KRISHNAMURTI: There is a set of specific risk factors whereby, if you have at least one of these risk factors, you’re considered high risk. And those can be things like having a history of high blood pressure or pre-eclampsia in a previous pregnancy. And then there are other risk factors where, if you have multiple of those risk factors, you might be at higher risk. And so they range of things from clinical risk factors to kind of social determinants of health.
And about what percentage of women do not comply?
PROF KRISHNAMURTI: Well, I can tell you a little bit about our study and how we determined that. There are different studies with different numbers in terms of compliance. But what we were doing already was using a smartphone app to support people during their pregnancy. It’s called the My Healthy Pregnancy app. And it’s prescribed to patients, and then they can use it throughout the course of their pregnancy. They can enter information into it each day, and it will give them information back about risks that are identified, offers education, connection to resources, either in the health care system or in the community. And so, it’s really serving as a complement to their routine prenatal care. We use the opportunity of testing this app out here at UPMC in a quality improvement initiative to see if we could also ask patients about their risk factors for developing pre-eclampsia later in the pregnancy. As the first use the app, we ask them questions that were informed by the USPSTF guidelines for pre-eclampsia risk, and then we determined whether they were at high risk or moderate risk of pre-eclampsia based on those responses. And then throughout the course of pregnancy, we prompted them through the app with some questions about whether or not they’d been prescribed aspirin by their doctor, and if they had been prescribed aspirin, whether they were taking it routinely. And so, from all of this information that we were collecting, we were able to see both if the people that were at risk for pre-eclampsia were being prescribed it by their provider, but also, if they were being prescribed it, if they were taking it.
Were you able to determine the appropriate women being prescribed? And what was the compliance?
PROF KRISHNAMURTI: Yeah, so we were able to take a look both at the self-reports through the app and at their charts. And what we discovered is that the majority of the highest risk patients were being prescribed or recommended aspirin. We could look and see what, of the risk factors that they had, were most commonly associated with being prescribed aspirin. And that allowed us also to identify that smaller group of patients that may not be routinely prescribed aspirin but are eligible for it. And then what we found, which was particularly interesting, was that about 37% of those patients who were prescribed aspirin appropriately were not aware that they were being prescribed aspirin. So, they really didn’t know, even though it was documented in their chart and prescribed to them, they really didn’t know that they should be taking it routinely. For the people that did know they should be taking it routinely, they were mostly adherent. What we identified was really a communication gap around aspirin eligibility and use.
Were researchers able to determine why the disconnect or the gap with women who weren’t aware that they should be taking aspirin?
PROF KRISHNAMURTI: Yeah, that’s something that we’re looking into now. So that’s kind of our next step is how can we understand the kind of underlying mental model and understanding around aspirin, if there are psychological barriers, concerns that we would want to address, if it’s just a communication gap or some specific information that’s needed. And then we’re hoping to be able to leverage the same app platform to be able to deliver that education, support continued adherence for those patients.
Is there something on the app now that prompts women? And are you seeing increased compliance with that part of the app?
PROF KRISHNAMURTI: So, our first step has been to revise the education that we have around both pre-eclampsia and aspirin and stay tuned for the results on whether or not people are looking at that information and how they’re integrating it into their behavior. But I’m hopeful that that kind of continued support will make a change.
Were some of the women concerned about the potential risks? Were they concerned that there were risks to the baby?
PROF KRISHNAMURTI: You know what? We haven’t actually done that level of study yet, but it’s definitely a next step. We’ll really need to sit down and speak face to face. One of the changes that we’ve made in the system, though, is to be able to prompt providers when an eligible patient comes in. And we’re also sending messaging from the app to an onsite clinical care team. So, when a patient who has these risk criteria for pre-eclampsia is using the app, we can notify their provider that they would be eligible for aspirin.
What are the implications of having a tool like this for both clinicians and for patients?
PROF KRISHNAMURTI: Yeah, so I think that it’s one opportunity for creating an additional touchpoint with patients. If we’re identifying that they’re eligible for some things, assuming that their provider agrees with that recommendation, we can kind of continue to reach out to them, stay connected with them through a tool like this. And it also gives us some information, with the patient’s permission, about patients’ specific needs, who is adherent, who isn’t, and we can then share that back with their provider, so we can really support the in-person communication when they have those prenatal care appointments.
Have you had other hospital systems looking at this as a model? Is there any indication that this could have a national rollout or could be used by other systems nationwide?
PROF KRISHNAMURTI: Yeah, absolutely. So, it was a mobile health platform that was developed here in Pittsburgh. It’s now a company, Naima Health, has the app, and that’s a spin-out company from Carnegie Mellon University and the University of Pittsburgh. And we are testing the tool out in other health care systems and also have a Spanish language version that we’ve developed.
What are the risks to both the mother and the baby if someone has pre-eclampsia?
PROF KRISHNAMURTI: It’s probably the leading preventable cause of maternal mortality – also a leading, preventable cause of preterm birth. And there are long-term health implications for the mother as well of developing pre-eclampsia in pregnancy. So, it’s not something that ends with delivery, but has ongoing implications for cardiovascular health.
END OF INTERVIEW
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