NCHR Comments on AHRQ’s Review on Schedule of Visits and Televisits for Routine Antenatal Care

March 15, 2022


National Center for Health Research’s Comments on Agency for Healthcare Research and Quality’s Draft Systematic Review on the Schedule of Visits and Televisits for Routine Antenatal Care 

We are writing to express our views on the Agency for Healthcare Research and Quality’s (AHRQ) draft systematic review on the schedule of visits and televisits for routine antenatal care.

The National Center for Health Research (NCHR) is a nonprofit think tank that conducts, analyzes, and scrutinizes research on a range of health issues, with particular focus on which prevention strategies and treatments are most effective for which patients and consumers. We do not accept funding from companies that make products that are the subject of our work, so we have no conflicts of interest.

We agree with the review that the overall assessment of the available evidence is inconclusive regarding the adequacy of a reduced number of antenatal visits or replacing some routine antenatal visits with telehealth appointments. We are particularly concerned with several of the overall limitations of the data, as stated in the review:

  • This report draws on very few studies. For example, only 2 RCTs were evaluated with regards to replacing some routine antenatal visits with telehealth appointments. In addition, many of the studies in the report seem outdated, with several published in the 1990s. Some of the research cited was conducted in Sweden and the United Kingdom, both of which have different healthcare systems than the United States. These broad limitations impede the ability to make generalizations for a contemporary US patient population.
  • Cross-study comparisons are difficult, as the data provided are based on different models of care and outcomes have been reported inconsistently across the included studies.
  • The majority of participants across all studies were White and none of the included studies evaluating the impact of replacing routine antenatal visits with televisits provided demographic subgroup analyses. This means that the review cannot provide any guidance on how changes to antenatal visits could affect different groups of patients, depending for example on patients’ race, age, socioeconomic status, or their access to the internet.

Regarding studies of a reduced schedule of antenatal visits, there was insufficient evidence for several of the stated outcomes of interest, such as maternal anxiety, satisfaction with antenatal care, preterm birth, and low birth weight. Further, as the review states, most participants were low-risk patients, the number of scheduled visits varied across the included studies, and there was no evaluation of whether specific types of patients had better or worse outcomes.

The report acknowledges that there is even less evidence on replacing some routine antenatal visits with telehealth appointments, with insufficient data on most of the outcomes of interest including quality of life, maternal health, breastfeeding and lost work time. Important information is not available, such as patients’ pregnancy risk factors and baseline morbidities, and potential differences in rates of NICU admissions and the rates of preterm births in patients who received routine visits vs. hybrid visits. There are also no available data on whether the results of the two included studies conducted during the COVID-19 pandemic will be generalizable to post-pandemic healthcare.

We therefore agree with the report that more research is needed, both on how changes to routine care as well as how replacing some of those visits with televisits could affect patients, particularly those who already suffer from inequalities in access to healthcare services. In particular, there is an urgent need for studies that evaluate more patient-reported outcomes, instead of relying mostly on provider or clinic responses.

The report discusses these gaps in research and the fact that evidence is insufficient or inconclusive, but it also states that the report’s intent is to “help healthcare decision makers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of healthcare services.” Unfortunately, the shortcomings of the research undermine the goal of helping decision makers. We therefore urge AHRQ to more explicitly explain how the shortcomings of available evidence affect the review’s implications for clinical practice. It is not enough that the authors acknowledge that “it is likely that many providers and patients would prefer to opt out of such care until there is better evidence that the alternative models do not cause harm.” Since the report is intended to help patients and clinicians make well-informed decisions, the limitations of the available evidence regarding changes to the schedule of visits and televisits for routine antenatal care need to be more prominently discussed.

The National Center for Health Research can be reached at info@center4research.org or at (202) 223-4000.