Title: Developing a question prompt tool to prevent and manage early cardiovascular disease
after hypertensive pregnancy: Qualitative interviews with women and clinicians
Version: 1 Date: 28 Apr 2023
Reviewer's report:
Overview:
This article addresses a significant and underexplored aspect of women’s health – the lack of
communication and follow-up with Canadian women diagnosed with hypertensive disorders
of pregnancy regarding their subsequent risk of developing cardiovascular disease. It is well
written and draws on solid qualitative methods. There are some major and minor issues that, if
addressed, would greatly strengthen the quality and clarity of the manuscript. The main issue
is further justification and explanation for the QPT as an appropriate strategy to address this
complex issue.
Major Issues:
- It would be helpful if the authors could provide more information about how women with HDP
are typically treated postnatally in Canada, if this data is available. More specifically, on page 4,
lines 18-20, the authors include a startling statistic that suggests only 17% of Canadian women
who are referred to a cardiologist schedule a visit. Does the study provide information about
how many women with HDP are referred to cardiologists, in general? It would also be useful
to provide more information about this study, given the gravity of the statistics cited, as well
as any explanation offered by the authors about why women do not to follow-up on referrals
to cardiology or cardiac rehab.
- On page 5, the authors provide justification for developing the QPT given previous research
that suggests tools be developed to facilitate communication regarding CVD risk. However,
there seems to be a disconnect between this justification in reference to the statistic cited on
page 4 that indicates 50% of Canadian family physicians, obstetricians, and cardiologists are
unaware of HDP-related CVD risk. Since half of relevant Canadian providers are not aware/
knowledgeable about this issue, it’s a little unclear how the QPT will address this gap in care. It
would be helpful if the authors could address this discrepancy and provide a clearer justification
for QPT development, given these statistics. It seems that many women would be in the position
of initiating a conversation about CVD with a provider who is not educated on the topic.
- Related to the previous comment, I would like to see the authors acknowledge other possible
modalities other than the QPT for educating women and clinicians on CVD risk. How does
this method compare to, for example, designing a pamphlet for women who experience HDP
during pregnancy regarding their future risks? Is there a specific benefit to engaging directly
with a practitioner (who might have limited expertise, since the authors state that clinicians are
often poorly informed about the risks)? If the QPT will be shared with patients by physicians,
why is a list of possible discussion topics preferable to materials that include evidence-based
information? As well, if the tool is likely to be distributed by healthcare providers, it’s not clear
why it is designed for women to ask questions of their care providers, rather than the other way
around. This seems to place a disproportionate burden on patients.
- While the authors discuss the potential logistical challenges with distributing the QPT, it is
still not clear how patients could become aware of this tool without the involvement of their
healthcare provider. Are there examples of QPTs that have become ubiquitous to the point that
patients are aware that they are available without involvement of the healthcare provider?
Minor Issues:
- Page 2 Line 8: Please add the abbreviation for hypertensive disorders of pregnancy in brackets.
- Page 3 Lines 3 & 4: Both lines have closed brackets that do not seem to correspond to any
open bracket
- Page 4 Line 4-5: It might be preferable to state “Persons with a first pregnancy at age # 40, who
are obese, or of non-Hispanic Black, Filipino, and South Asian descent,” assuming this captures
all relevant race categories, rather than “of visible minorities”
- Page 4 Line 11: Move “(henceforth, women)” immediately after “persons.” Also, it would be
helpful to clarify why the authors have specified “young” persons here, as this is a somewhat
vague term.
- Page 5 Lines 9:10: Please clarify the statement, “Simple one-page QPTs alone appear to achieve
these positive outcomes [17].” Do you mean that only one-page QPTs are linked to positive
outcomes? Or are you comparing QPTs to other strategies?
- Page 7 Line 4: Could you clarify what is meant by “when North American lifestyle influences
health [24]”?
- There are some issues with comma usage throughout; please review carefully