In 2019, Christina (Tina) D. Yarrington, MD, FACOG, was asked become the director of Labor and Delivery for BMC's Department of Obstetrics and Gynecology. This opportunity motivated her to pose a question, prompted by common cases that arose in her clinical practice: What exactly causes the high readmission rates of postpartum hypertension patients at BMC?

In her new role, Yarrington aimed to find the answer.
"When mothers need to be readmitted after delivery due to hypertension, it’s very traumatic," Yarrington, division chief of Maternal-Fetal Medicine, elaborates. "Though they can have their baby with them, it completely disrupts the natural course of having a baby, bonding [with] family, causing more anxiety in a new mother. It’s a big bump in the road for a new mother and the baby’s family."

In addition, Yarrington notes the grave clinical implications: "Hypertension is a big factor in postpartum mortality, and it has to be taken seriously. Adding to the complications, most patients are not aware of or educated on the seriousness of postpartum hypertension."  

Finding a path forward when "best practice" doesn't work

Best practice says care for postpartum hypertension involves scheduling the new mother for routine visits at both three and eight days after delivery. However, the clinic found that most mothers skipped these appointments, in part due to the hectic environment of having a new baby.

Thinking of these missed appointments, an alternative care path could be to send nurses directly to the mother's home — but the clinic found that some insurers wouldn't cover these visits, some mothers were uncomfortable with unfamiliar care providers in their homes, and some providers wouldn't service certain zip codes.

"This presented a lot of disparity, complications, and, most importantly, it created barriers to monitoring and treating a new mother with hypertension," Yarrington said. 

A mother herself, Yarrington understood the obstacles of treating hypertension in postpartum patients and was determined to find a better path. She researched the current medical device market for remote hypertension monitoring devices and found many options. But because she was committed to addressing the need for equitable solutions, she narrowed her search to devices that would not add extra burden to postpartum patients. Specifically, she sought options that had an easy user interface and did not require broadband or WiFi connectivity.
Only one monitor met Yarrington’s equity requirements. Deploying cellular-enabled technology, this innovative device collected blood pressure readings that were relayed directly into the patient’s medical record. By simply pressing a button, the patient could send the data via cell towers through an encrypted HIPAA-compliant, web-based portal directly to their clinician. The clinician then can easily consult the record and keep the data for reference or take further action, if needed.  

BMC’s Research Operations and hospital leaders connect and commit 

Soon, BMC matched Yarrington with a donor who found the promise of remote postpartum monitoring intriguing and agreed to fund the purchasing of the devices. Although it took some time to get the project underway, Yarrington's careful preparation paid off. In March 2020, COVID-19 hit Boston, changing both the landscape of care and its urgency; the remote blood pressure monitoring program needed to be launched within days, not months. Yarrington sprung to action alongside her department's nurses and medical student volunteers to expedite registration and assignment of the devices to patients.

The challenge of COVID also resulted in the need for more funding — and fast. Soon, the program would run out of donor money, just when BMC patients needed the monitors most.

Meanwhile, as COVID raged through Boston, the world, and BMC, the hospital's clinicians, support staff, and administrators moved mountains. They united in unprecedented ways, taking their already deep commitment to equity to a new place.

One instance of their success? The financial plight of Yarrington’s remote care initiative came to the attention of Research Operations, the department tasked with supporting BMC’s sponsored programs. In collaboration with BMC leadership, the department secured the necessary gap funding. The emergency rollout could continue, and postpartum hypertensive patients could stay at home and still receive appropriate care. 

Project outcomes include a new career direction

The funding enabled Yarrington to collect the data of more than a thousand patients by spring 2021, which in turn served as the catalyst to a promising research career. Yarrington began to envision herself as a clinician-researcher, while subsequent events, occurring in short order, proved to be downright auspicious.

Through a mentor from the Boston University School of Public Health, she met epidemiologist Samantha Parker Kelleher, PhD, a BU SPH assistant professor investigating perinatal outcomes related to cardiovascular disease. Together they submitted a proposal, based on Yarrington’s initial data analysis, for an R01 award, one of the most prestigious and highly sought-after National Institutes of Health investigator-initiated research project awards, and won. Viewed by many as making an investigator’s career, the awarded proposal included granular data obtained by following postpartum patients remotely for the first six weeks along with data related to hospitalizations, utilization outcomes, and morbidity outcomes. The start date of the R01 project was August 1, 2021, 17 months from the start date of COVID-19 at BMC.

Under Institutional Review Board oversight, Parker and Yarrington are now analyzing quantitative and qualitative data to build simulation models that incorporate patient care, qualitative measures of self-efficacy, and healthcare use. Through qualitative and quantitative lenses, the duo seeks to improve equitable outcomes for patients with postpartum hypertension, at BMC and beyond.

The doctors also submitted proposals for and were awarded two other projects:

  • The recently created HHS Hypertension Innovator Award Competition, sponsored by the federal Office of Women’s Health: The proposal used their write-up of Yarrington’s original data analysis and the resulting award provides her with additional pilot funding to launch an expansion program and supplement a nursing role in postpartum hypertension.
  • An award sponsored by the American Heart Association (AHA): As BMC principal investigator, commencing in July 2022, Yarrington focuses on understanding how health-related social needs intersect with home blood pressure monitoring and postpartum healthcare utilization, in particular in connection to primary care.

Cross-campus research collaborations advance equitable health outcomes  

Through her partnership, Dr. Yarrington has learned how beneficial it is for clinicians to collaborate with non-clinicians because they have a different perspective on research. She credits such collaboration with her swift success as an investigator.
When asked if she could make any specific recommendations about cross-campus engagement, Yarrington pointed to the work being done at BU Chobanian & Avedisian School of Medicine, specifically at the Charles River Campus. There, she notes, health care researchers can avail themselves of complex informatics and artificial intelligence modalities, which she firmly believes can help clarify and address BMC's clinical questions.

"We should aim at encouraging everyone to reach out to resources for collaboration," Yarrington says. "It’s key to the development of the next generation of doctors and research scientists."

Her next proposal underscores that collaboration conviction; it aims to cultivate and support pre-doctoral students with health equity front and center. 

Overall, Yarrington appreciates Boston Medical Center's mission to support health equity-based initiatives, including her remote blood pressure monitoring program — and also the hospital's role in fostering her research career.

"At BMC, we are all trying to figure out for our patients how to bridge the mine fields of social barriers they have to navigate every day," Yarrington says. "An important milestone for me was that, because of BMC’s support and sustainability of this clinical program, my research career was launched…The research since then, linking the results of thousands of patients’ blood pressure data to other electronic health data, will hopefully further improve outcomes for our patients.”   

Want to read more about maternal hypertension, health inequity, and remote monitoring? Check out WBRU’s February 6 report, featuring BMC patient Kennise Nevers, Dr. Yarrington, and BMC nurse Megan O’Brien here.

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