Primary care engagement improved by enhanced postpartum transition support

Short- and long-term health in pregnant patients can be improved by the implementation of postpartum transition support, according to a recent study published in JAMA Network Open.¹

A significant and increasing prevalence of chronic disease burden has been observed in US pregnancies, but transition to primary care management after delivery is uncommon among patients with chronic conditions. Conditions impacting pregnancy include diabetes, hypertension, or obesity in over 30% of pregnancies and anxiety or depression in 11% to 22%.

In a serial cross-sectional analysis, a significant increase in identification of at least 1 chronic condition in the United States was observed.² The rate rose from 66.9 per 1000 delivery hospitalizations in 2005 to 2006 to 91.8 per 1000 delivery hospitalizations in 2013 to 2014.

While careful monitoring is often utilized for pregnant patients with chronic conditions, routine care remains lacking after pregnancy.¹ Multiple guidelines encourage transition to primary care during the postpartum period, but patient administrative burden remains a significant barrier to accessing care.

To increase patient engagement in primary care during the immediate postpartum period, investigators conducted a randomized clinical trial. Eligibility criteria included having obesity, anxiety or depressive mood disorder, type 1 or 2 diabetes, gestational diabetes, chronic hypertension, or pregnancy-related hypertension.¹

Patients with high risk of hypertensive disorders of pregnancy were prioritized for inclusion. Participants were also pregnant or recently postpartum, prenatal care recipients, enrolled in the study institution’s electronic health record (EHR) patient portal, aged at least 18 years, primarily speaking English or Spanish, and not linked to fetal demise at enrollment.

Two variables were used for stratification of the assignment sequence: a primary care physician (PCP) visit within 3 years before the estimated due date (EDD) and prenatal care size. After giving consent, patients were assigned to receive the study intervention or standard care.¹

The goal of the intervention was to increase the rate of primary care visit completion within 4 months after EDD. This was accomplished through an introduction message highlighting the need to visit a PCP after delivery, with information that a study staff member would set up an appointment for them.

Patients who had already seen their PCP within the past year were scheduled for the visit when next eligible. Appointment reminders were delivered to participants through the EHR patient portal and text messages.¹

Completion of a primary care visit within 4 months of EDD was reported as the primary outcome. Secondary outcomes included obstetric tirage visit, emergency department or urgent care use, and readmission within 4 months after delivery.

There were 180 patients in the intervention group and 173 in the control group, with 97.7% receiving study-related messages through the online patient portal. Of patients in the intervention group, 76.1% had appointments scheduled by study staff, with 4.4% not presenting. Online electronic survey completion 5 months after EDD was reported by 61.8% of participants.¹

Patients were aged a mean 34.1 years with a median gestational age of 36.3 weeks at enrollment. Anxiety or depression was reported in 75.4%, chronic or pregnancy-related hypertensive disorder in 16.1%, preexisting gestational diabetes in 19.5%, and obesity in 40.8%.

Achievement of the primary outcome was met by 40% of the intervention group vs 22% of the control group. Obstetric tirage visits and emergency department or urgent care use did not differ between groups, but postpartum readmissions were reduced in the intervention group, at 1.7% vs 5.8% in the control group.¹

PCP visits with a weight screening, blood pressure screening, mood screening, and documented mental health plan were all more common in the intervention group. Treatment effect heterogeneity was reported across health conditions, demographic characteristics, and baseline physical and mental health.

These results indicated significant improvements in postpartum primary care visit completion among patients with common comorbidities through an intervention for transitions to primary care. Investigators recommended follow-up research to assess condition-specific management and long-term health outcomes.¹

References

1. Clapp MA, Ray A, Liang P, James KE, Ganguli I, Cohen JL. Postpartum primary care engagement using default scheduling and tailored messaging: A randomized clinical trial. JAMA Netw Open. 2024;7(7):e2422500. doi:10.1001/jamanetworkopen.2024.22500
2. Admon LK, Winkelman TNA, Moniz MH, Davis MM, Heisler M, Dalton VK. Disparities in chronic conditions among women hospitalized for delivery in the United States, 2005-2014. Obstet Gynecol. 2017;130(6):1319-1326. doi: 10.1097/AOG.0000000000002357