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Developing Cardiovascular Screening Measures for Pregnant and Postpartum Women

Cardiovascular Screening Toolkit and Algorithm »

Cardiovascular Maternal Mortality

Cardiovascular disease (CVD) is the leading cause of death in pregnant and postpartum women in the US, primarily due to lack of suspicion and delays in diagnosis.  CVD is also responsible for maternal morbidity including longer length of hospital stay, intensive care unit (ICU) admissions, and future pregnancy risks. CVD is defined as abnormal cardiac structure or function demonstrated by echocardiogram or other imaging studies (systolic dysfunction, diastolic dysfunction, ventricular/septal hypertrophy or dilation, pulmonary hypertension, valve disease), or an arrhythmia.  Unfortunately, diagnosis of CVD is challenging, as symptoms of cardiovascular disease are often mistaken for normal symptoms of pregnancy. Accurate diagnosis of CVD varies widely among pregnant and postpartum women that may either result in a lack of follow up of women who are at risk, or may lead to unnecessary testing that burdens the resources in women who are not at risk. Early identification of CVD risk allows to engage in preventive measures after delivery which may prevent the onset of CVD in the future.

Cardiovascular Screening Toolkit and Algorithm

CVD Toolkit

A screening algorithm is used for standardized identification of individuals with suspected disease, or suspected high risk for disease. A screening test should distinguish individuals with a high probability for disease by analyzing several variables indicated by the algorithm. Among individuals who screen positive for risk of disease, additional diagnostic testing and clinical testing are necessary to establish a diagnosis. A multitude of screening algorithms are used throughout a variety of specialties in medicine and are crucial in identifying high-risk individuals, so they can receive an appropriate diagnosis and/or treatment early. Early treatment and diagnosis of disease are vital to help reduce negative effects of disease in individuals.

For cardiovascular screening in pregnant and postpartum women, a reliable clinical screening approach that monitors the hospital and clinician performance is lacking. Timely identification of women at risk of CVD and follow-up may improve maternal health outcomes, i.e. maternal morbidity and mortality and lifetime onset of CVD.

The California Maternal Quality Care Collaborative (CMQCC) is a multi-stakeholder organization with the goal to end preventable morbidity, mortality, and racial disparities in California maternal care. Dr. Afshan Hameed led the Cardiovascular Disease in Pregnancy and Postpartum Task Force which developed the CMQCC Cardiovascular disease in pregnancy toolkit to encourage obstetric and other healthcare providers to retain a high index of suspicion for CVD.  It includes resources for providers, infographics for patients on signs and symptoms of CVD, future CVD risk and long-term health issues, contraception options and planning a pregnancy with known CVD. The toolkit also includes a discussion on racial and ethnic disparities in CVD prevention and diagnosis. 

A clinical decision tool was created as part of the CMQCC Cardiovascular Disease in Pregnancy Toolkit to identify pregnant and postpartum women with CVD or risk of developing CVD. The screening algorithm also includes follow-up recommendations for women who screen positive for CVD risk. This screening algorithm is intended for all pregnant and postpartum women as a guide to diagnosing CVD. With improved detection of disease, appropriate treatment may improve the outcomes of women and their pregnancies.

For more information about the Toolkit and Algorithm, please see the resources below:

CMQCC Cardiovascular Disease in Pregnancy Toolkit

CMQCC Cardiovascular Disease Screening Algorithm


The screening tool was pilot tested at a sample of hospital departments at UCI, California, and Montefiore Medical Center, New York.

The heart of the matter: Initial application of the California cardiovascular disease toolkit – Article | PDF Poster

Heart of the matter: preliminary-analysis of the California maternal quality care collaborative cardiovascular disease toolkit – Article | PDF Poster

Blumenthal E, Crosland BA,  Senderoff D, Saturnino K, Garg N, Bernstein, M, Wolfe D, Hameed A. California cardiovascular screening tool - findings from initial implementation Journal: American Journal of Perinatology Reports. Accepted for Publication, May 2020.

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Developing Measures »

In January 2020, the University of California, Irvine Department of Obstetrics and Gynecology received funding from the Gordon and Betty Moore Foundation. This funding is part of the Moore Foundation Diagnostic Excellence Initiative. The goal of this initiative is to help develop and validate new measures for diagnostic performance. They acknowledge that quality and safety of care is a crucial topic in healthcare, and is a moral prerogative for public health.  This initiative advocates for emphasis on diagnostic excellence, supporting growth, and assessing new technologies to improve diagnostic performance.

The grant: Diagnosis of Cardiovascular Disease in Pregnant and Postpartum Women will be used to develop two quality measures and implement them at three health systems: University of California, Irvine, Medical Center Health Systems, University of California, San Diego, Medical Center Health Systems, and University of Tennessee, St. Thomas Health Systems. The aim of this project is to support the development of clinical quality measures to improve the diagnosis of cardiovascular disease in pregnant and postpartum women. 

Currently, there is a lack of HEDIS indicators for pregnant/postpartum women that monitor or mandate cardiovascular (CVD) detection and/or CVD risk screening using a validated tool. These proposed measures target women in reproductive age who access the health care system for maternity services to identify women with CVD or increased risk of developing CVD. The proposed measures offer an innovative approach for universal CVD screening in the pregnancy and postpartum period.

The Two Measures

  1. CVD screening: The proportion of pregnant/postpartum women that receive screening for cardiovascular risk using CVD tool by CMQCC
  2. Follow-up to women who screened positive: The proportion of women who screened positive for cardiovascular risk who receive follow-up care within two months


We aim to demonstrate the feasibility to calculate meaningful and actionable measures using data from the hospital wide network as well as explore whether the system wide administration of the measure will produce a similar yield to that of the pilot studies.

More information on this project can be found here.

Co-Investigator Team

The tool will be implemented and the two measures developed at three sites: University of California, Irvine, Medical Center Health Systems, University of California, San Diego, Medical Center Health Systems, and University of Tennessee, St. Thomas Health Systems.

Afshan Hameed, MD, FACOG, FACC, Principal Investigator
University of California, Irvine, Department of Obstetrics and Gynecology
Dr. Hameed is a Maternal Fetal Medicine Specialist and Cardiologist at UCI. Her background and training combining focuses as an Internist, Cardiologist, and Maternal Fetal Medicine Specialist will serve the purposes of cardiovascular screening of pregnant and postpartum women. She serves on the California Maternal Quality Care Collaborative (CMQCC) Pregnancy Associated Mortality Review Advisory Committee (PAMR) to identify gaps in care at the provider and patient level and to outline quality improvement opportunities. Dr. Hameed chairs the cardiovascular disease in pregnancy and postpartum task force at the CMQCC which developed the provider toolkit.

Heike Thiel de Bocanegra, PhD, MPH, Co-Investigator
University of California, Irvine, Department of Obstetrics and Gynecology
Dr. Thiel de Bocanegra is an Associate Professor, health services research, Professor with Obstetrics and Gynecology at UCI. She has 20+ years of experience in health service research and program evaluation as well as development and measurement of health indicators. Dr. Thiel de Bocanegra is member of the national task force that submitted the Developmental Contraceptive Use Measures to the National Quality Forum.

Maryam Tarsa, MD, Co-Investigator
University of California, San Diego, Department of Obstetrics and Gynecology
Dr. Tarsa is a Specialist in Maternal Fetal Medicine and a Professor of Obstetrics, Gynecology, and Reproductive Sciences and Perinatologist at the University of California, San Diego (UCSD).She is the lead co-investigator at the UC San Diego sub-site.

Cornelia Graves, MD, Co-Investigator
University of Tennessee, Division of Maternal Fetal Medicine
Dr. Graves is Director of Obstetrical Critical Care, Director of the Maternal section of the Division of Maternal-Fetal Medicine, the Division Director of Maternal-Fetal Medicine and the Assistant Dean for Diversity. She is the lead co-investigator at the University of Tennessee sub-site.

Brian Adam Crosland, MD
University of California, Irvine, Department of Obstetrics and Gynecology

Dr. Crosland is a current fellow that led the pilot study at UCI, including the implementation of the algorithm, and participated in advising other clinic sites in the implementation of the CVD screening tool.

Technical Expert Panel

The Technical Expert Panel is made up of a diverse group of experts on content that is relevant to our project such as: performance measurement, clinical content (cardiology/maternal fetal medicine), clinical IT, and patient representative. Members provide insight and feedback to the investigator team on measure development.

Laith Alshawabkeh, MD
University of California, San Diego, Department of Cardiology

Dr. Alshawabkeh is Associate Professor in Adult Congenital Heart Disease, at UCSD. He is the lead investigator on multiple sites that impact the care of adults with congenital heart disease. He is a cardiovascular disease specialist and Director of the Adult Congenital Heart Program.

Sean Currigan, MPH
American College of Obstetricians and Gynecologists

Mr. Currigan is a Quality and Safety Officer at the American College of Obstetricians and Gynecologists (ACOG). He advises on measure development and requirements for submission to the National Committee for Quality Assurance. Mr. Currigan also worked previously for the American College of Cardiology.

Stacy Davis, MD
University of Tennessee, St. Thomas Health, Department of Cardiology

Dr. Davis is an Assistant Professor of Cardiology at University of Tennesee. She specializes in advanced heart failure, cardiology, and internal medicine in Nashville, TN. She is co-director of the Collaborative Perinatal Cardiac Center along with Dr. Connie Graves.
Related Links: Nashville doctors link heart health to prenatal care

Brianna Harris-Henderson
LetsTalkPPCM non-profit organization

This patient representative is a peripartum cardiomyopathy (PPCM) survivor. She provides invaluable input to the panel on the patient experience regarding maternal cardiovascular disease. She is also the founder of a non-profit organization: LetsTalkPPCM, that focuses on bringing awareness to PPCM.

Tamera Hatfield, MD
University of California, Irvine, Department of Obstetrics and Gynecology

Dr. Hatfield is a Clinical Informatics Specialist and is the department liaison for electronic health record-related items. She is a specialist in Maternal-Fetal Medicine with the Department of Obstetrics and Gynecology at UCI. She advises on electronic health record algorithm builds.

Marni Jacobs, PhD
University of California, San Diego, Department of Obstetrics, Gynecology, and Reproductive Sciences

Dr. Jacobs is a Clinical IT expert and advises on technical issues with the CVD Screening algorithm as well as data collection. Dr. Jacobs is an Epidemiologist and Assistant Adjunct Professor at UCSD. As it pertains to public health, she is interested in aspects of intervention od health disparities.

Daphne Yvette LaCoursiere, MD
University of California, San Diego, Department of Obstetrics and Gynecology

Dr. LaCoursiere is an Associate Clinical Professor in Obstetrics and Gynecology at UCSD. Dr. LaCoursiere's special interest is in caring for patients with maternal obesity. She began the Maternal Weight and Wellness Program at UC San Diego Health one of only a few in the nation, which specializes in providing complete, compassionate care for overweight women before, during, and after pregnancy.

Jeannette Lin, MD
University of California, Irvine and University of California,  Los Angeles, Department of Cardiology

Dr. Lin is an Assistant Clinical Professor of Cardiology at UCI and UCLA specializing in Congenital Heart Disease. She also specializes in adult cardiology and cardiovascular issues in pregnancy.

Elliot Main, MD
California Maternal Quality Care Collaborative and Stanford University

Dr. Main is a Clinical Professor of Obstetrics and Gynecology at Stanford University, and Medical Director of the California Maternal Quality Care Collaborative (CMQCC) where he has led multiple state and national quality improvement projects. He is also the Chair of the California Pregnancy-Associated Mortality Review Committee since its inception in 2006. Dr. Main is a Maternal-Fetal Medicine specialist with a focus on maternal health.

Patient Representative
This second patient representative gives us appreciated insight to the patient experience in developing these measures. Our patient opinions are taken with the utmost respect and gratitude to give the team instrumental feedback.