Abstract
Background:
Gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP) are risk factors for future cardiovascular disease, yet few individuals receive postpartum care with primary care clinicians (PCP). To facilitate transitions of care to PCPs and improve cardiovascular health monitoring within the first 13 months postpartum, we developed and piloted an enhanced postpartum referral pathway for patients with GDM or HDP.
Methods:
Eligible patients included those who received perinatal care at a large, urban, academic medical center, experienced GDM or HDP during their most recent pregnancy, and lacked an existing PCP. Resident, faculty, and advanced practitioners referred patients during antenatal, delivery-related, or postpartum visits. A dedicated scheduler contacted patients to schedule an appointment with a women’s health-focused resident or faculty PCP. The percent of patients who attended a postpartum PCP visit, who had an HbA1c and cholesterol panel checked within the first 13 months postpartum, were compared between patients referred and not referred to the program using adjusted odds ratios (aOR).
Results:
Of 129 individuals referred, 48.1% attended a PCP visit, 31.8% completed cholesterol screening, and 41.9% completed HbA1c screening within 13 months postpartum. After adjusting for age, parity, insurance, and referral indication, referred individuals had greater odds for each outcome (PCP visit: aOR = 6.0, 95% CI 4.0–9.0; cholesterol: aOR = 2.4, 95% 1.6-3.9; HbA1c: aOR = 2.5, 95% CI 1.7–3.7) compared with nonreferred individuals in the same time period.
Discussion:
A enhanced postpartum PCP referral pathway pilot for birthing individuals was associated with improved follow-up in the first year postpartum.
Keywords: adverse pregnancy outcomes, postpartum care, primary care, care transitions
Introduction
Adverse pregnancy outcomes (APOs) such as gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP) are associated with a twofold higher risk of cardiovascular disease up to a decade after delivery.1,2 For individuals with APOs, the American College of Obstetricians and Gynecologists and the American Heart Association recognize the postpartum period as a critical time for cardiovascular disease risk factor screening and optimization of cardiovascular health (CVH) to mitigate future risk of heart disease.3 Consistent follow-up with a continuity care provider is essential for risk factor assessment, monitoring, and counseling. However, most individuals with APOs do not attend a primary care outpatient visit during the first year postpartum.4 In addition, less than 60% of individuals receive counseling to support CVH optimization at their postpartum visit.5
Previous programs utilizing transition clinics, patient navigators, and/or home visits have shown some success in improving postpartum follow-up and care among individuals with cardiometabolic complications of pregnancy.6–11 However, these programs require substantial infrastructure and resources for successful implementation. Postpartum programs that can be inexpensively and sustainably integrated into existing health care settings or systems are needed to improve postpartum care and CVH monitoring in diverse populations in the United States. Therefore, we created and piloted an enhanced postpartum primary care referral program that leveraged existing health care resources to encourage follow-up with primary care and laboratory-based CVH monitoring for individuals with cardiometabolic complications of pregnancy.
Materials and Methods
Program setting
The program was implemented at an academic medical center that serves an economically, racially, and ethnically diverse patient population in a large, metropolitan area. Eligible patients included pregnant or postpartum individuals with a pregnancy complicated by an International Classification of Diseases, Ninth Revision or Tenth Revision code-based diagnosis of GDM or HDP (gestational hypertension, preeclampsia, or superimposed preeclampsia) who did not have a self-reported source of primary care prior to pregnancy and who received antenatal and delivery care at the academic medical center. Given the pilot nature of this program and the necessity for shared electronic health records (EHR), it was only implemented in the ambulatory offices of the academic faculty practices in the Department of Obstetrics and Gynecology at this large birthing hospital (>11,500 births/year). These practices provide care to both publicly and privately insured birthing individuals who seek care from obstetricians and gynecologists, maternal-fetal medicine subspecialists, and advanced practice practitioners, including resident and fellow physician trainees.
Program description
Between 2018 and 2022, we developed and piloted an enhanced postpartum referral pathway from obstetrics to primary care at the academic medical center with goals of reducing any interruption in cardiometabolic care and eliminating organizational barriers such as scheduling appointments between two departments. Prior to program initiation, usual care was variable, and pregnant and postpartum individuals were advised to schedule an appointment for long-term primary care at the discretion of the obstetrician. The responsibilities of identifying a primary care clinic and calling for an appointment were delegated to the patient. No formal warm hand-off or record transfer was conducted unless by the request of primary care or the patient.
In this program, eligible patients received a referral to the Division of General Internal Medicine (Department of Medicine) at the academic medical center during routine antenatal, delivery-related, or postpartum care with clinicians in the Department of Obstetrics and Gynecology. The obstetrics team sent the lead program physician in primary care a direct staff message via the EHR regarding the referral. The scheduler at the general medicine practice was informed of the referral and called the patient to schedule an appointment. New patient appointments were scheduled for in person, 40-minute visits with a primary care physician (PCP) who was board-certified in internal medicine and/or medical residents in the Women’s Health Track of the Internal Medicine Residency at the general medicine practice. Follow-up visits could be completed either in person or, after the onset of the COVID-19 health crisis, via telehealth. Given the need to expand awareness of and capacity for the care of individuals following an APO, resident physicians in both departments participated in separate, brief educational sessions regarding the long-term health implications of APOs, the goals of postpartum primary care, and the processes for the enhanced referral program. Obstetricians were additionally encouraged to discuss the long-term risks of pregnancy complications with patients as an indication for primary care referral. Faculty leads in obstetrics/gynecology and general medicine provided regular programmatic support, reminders, and education to their faculty and resident colleagues. Screening and preventive care services provided were based on best practices for preventive care described by the United States Preventive Task Force, the Women’s Preventive Services Initiative, and the American College of Obstetricians and Gynecologists.12–14 Approval was obtained from the Northwestern University Institutional Review Board for use of EHR data for program evaluation.
Program evaluation
We evaluated the program’s feasibility to promote primary care attendance and laboratory-based CVH monitoring (cholesterol and glycated hemoglobin [HbA1c]) within the first 13-month postpartum. Using a two-group, posttest only comparison design, we compared program outcomes among those referred and not referred to the program in its initial years, from 2018 to 2021. The independent variable was program referral status (referred vs. not referred). During the study, investigators maintained a list of patients referred to the program. The usual care group included patients identified from the EHR data warehouse who met program eligibility criteria but were not referred to the program over the same time period. Dependent variables that included primary care visit attendance (percent attending at least 1 primary care visit and percent attending more than 1 primary care visit) and laboratory-based CVH monitoring (percent with cholesterol panel or HbA1c drawn) were compared between all patients referred to the program and the usual care group. Adjusted odds ratios (aOR) estimated the odds of each outcome among individuals referred to the program, after adjusting for the following covariates: maternal age at delivery, parity, insurance status, and referral indication. Covariates were chosen based on maternal characteristics associated with either the independent or dependent variables. The odds of completing laboratory-based CVH monitoring based on referral status were also calculated among the subgroup of patients who attended a primary care visit to evaluate if differences in CVH monitoring were observed between groups of patients who attended PCP visits after program referral or self-referral. Of those who attended a primary care visit, we secondarily determined the percent who attended a first PCP visit within 3, 6, 9, and 13 months postpartum by program referral status. Finally, we conducted a subgroup analysis to determine (1) if outcomes differed by maternal demographic and clinical characteristics and (2) if the outcomes of program referral were similar within each of these subgroups. Specifically, using Pearson chi-square tests, PCP visit attendance and CVH monitoring were compared between referral groups within the following demographic and clinical subgroups: parity, self-identified race/ethnicity, insurance type, and referral indication. Analysis was conducted using Stata, Version 14.15
Results
Of the 129 individuals referred, the average age at delivery was 33.4 years (SD 5.7 years), 30.2% had Medicaid funding during pregnancy, and a majority identified as minoritized racial or ethnic groups (18.6% Hispanic, 10.1% non-Hispanic Asian/Pacific Islander, 34.9% non-Hispanic Black, and 26.4% non-Hispanic White) (Table 1). In this population, 31.0% had GDM, 51.8% had HDP, and 10.9% had both referral indications. Compared with individuals referred to the program, the 1,750 individuals not referred to the program were similar in age (33.5 years [SD 5.3. years]), less likely to be enrolled in Medicaid during pregnancy (21.0%), more likely to identify as non-Hispanic White (35.3%), and more likely to have a pregnancy complicated by GDM (75.3%).
Table 1.
Characteristics of Participants by Program Referral Status
| Not referred | Referred | |
|---|---|---|
| N | 1,750 | 129 |
| Mean age (SD) | 33.5 (5.3) | 33.4 (5.7) |
| Nulliparous (%) | 54.6 | 57.4 |
| Race or ethnicity (%) | ||
| Hispanic | 17.3 | 18.6 |
| Non-Hispanic Asian-Pacific Islander | 16.0 | 10.1 |
| Non-Hispanic Black | 18.2 | 34.9 |
| Non-Hispanic White | 35.3 | 26.4 |
| Other Racial or Ethnic groupa | 3.6 | 3.9 |
| Declined to answer | 9.7 | 6.2 |
| Medicaid (%) | 21.0 | 30.2 |
| Adverse pregnancy outcome (%) | ||
| Hypertensive disorder of pregnancy only | 17.3 | 58.1 |
| Gestational diabetes only | 75.3 | 31.0 |
| Both hypertensive disorders of pregnancy and gestational diabetes | 7.4 | 10.9 |
Race or ethnicity indicated as “other” by patient in electronic medical record or as non-Hispanic American Indian/Alaskan Native. SD,
Within the first 13 months after delivery, a total of 48.1% (SE 4.4%) of individuals referred to the program attended a PCP visit, compared with 13.9% (SE 0.8%) of those not referred (aOR 6.0 [4.0, 9.0]) (Table 2). The majority of patient encounters were conducted in person for both those referred (154 of 159 encounters) and those not referred to the program (644 of 689 encounters). Referred individuals were more likely to attend >1 visit with a PCP (aOR 3.9 [95% CI 2.5, 6.0]), to have a cholesterol panel checked (aOR 2.4 [95% CI 1.6, 3.9]), and to have a HbA1c checked (aOR 2.5 [95% CI 1.7, 3.7]). Among the subgroup of individuals who attended a primary care visit, individuals referred to the program were more likely to attend a primary care visit within the first 3 months postpartum (61.3%) compared with those not referred (25.1%) (Table 3). Odds of cholesterol (aOR 1.0 [95% CI 0.5, 2.0]) and HbA1c monitoring (aOR 1.5 [95% CI 0.8, 3.0]) were similar by referral status among those who attended a primary care visit.
Table 2.
Frequency and Adjusted Odds of Primary Care Outcomes within 13 Months of Delivery by Program Referral Status
| Program outcomes | Not referred (n = 1,750) | Referred (n = 129) | Adjusteda odds ratio (95% CI) |
|---|---|---|---|
| Attended at least one primary care visit | 13.9 | 48.1 | 6.0 (4.0, 5.0) |
| Attended greater than one primary care visit | 12.3 | 34.9 | 3.9 (2.5, 6.0) |
| Cholesterol checked | 16.2 | 31 | 2.4 (1.6, 3.9) |
| Glycated hemoglobin checked | 23.0 | 41.9 | 2.5 (1.7, 3.7) |
Adjusted for maternal age, parity, medicaid enrollment status during pregnancy, and referral indication.
Table 3.
Percent of Individuals with First Primary Care Visit within 3, 6, 9, and 13 Months Postpartum by Referral Status
| Program referral status | ||
|---|---|---|
| Not referred | Referred | |
| Total number who attended a primary care visit within 13 months postpartum | 243 | 62 |
| Months postpartum (%) | ||
| 0–3 months | 25.1 | 61.3 |
| 4–6 months | 31.3 | 30.6 |
| 7–9 months | 21.4 | 6.5 |
| 10–13 months | 22.2 | 1.6 |
In subgroup analyses, primary care visit attendance, cholesterol, and HbA1c monitoring were higher among individuals referred to the program than among those not referred in each demographic and clinical subgroup (parity, race/ethnicity, Medicaid enrollment status, referral indication) (Table 4). PCP visit attendance was lowest among individuals who self-identified as Hispanic or non-Hispanic Black or who were enrolled in Medicaid, regardless of referral status.
Table 4.
Association between Program Referral Status and Primary Care Visit Attendance and Cardiovascular Health Monitoring by Maternal Demographic and Clinical Characteristics
| Demographic/clinical subgroup | Number attending primary care visit/number in subgroup (%)a,b | Number with cholesterol checked/Number in subgroup (%)a,b | Number with glycated hemoglobin checked/Number in subgroup (%)a,c | |||
|---|---|---|---|---|---|---|
| Not referred | Referred | Not referred | Referred | Not referred | Referred | |
| Parity | ||||||
| Nulliparous | 139/956 (14.5) | 40/74 (54.1) | 172/956 (18.0) | 26/74 (35.1) | 237/956 (24.8) | 42/74 (43.2) |
| Multiparous | 104/794 (13.1) | 22/55 (40.0) | 112/794 (14.1) | 15/55 (27.3) | 166/794 (20.9) | 22/55 (40.0) |
| Race or Ethnicity | ||||||
| Hispanic | 38/302 (12.6) | 9/24 (37.5) | 51/302 (16.9) | 8/24 (33.3) | 79/302 (26.2) | 11/24 (45.8) |
| Non-Hispanic Asian-Pacific Islander | 46/280 (16.4) | 8/13 (61.5) | 51/280 (18.2) | 7/13 (53.9) | 66/280 (23.6) | 8/13 (61.5) |
| Non-Hispanic Black | 38/318 (11.9) | 20/45 (44.4) | 41/318 (12.9) | 12/45 (26.7) | 66/318 (20.8) | 15/45 (33.3) |
| Non-Hispanic White | 91/618 (14.7) | 20/34 (58.8) | 111/618 (18.0) | 11/34 (32.4) | 154/618 (24.9) | 16/34 (47.1) |
| Medicaid enrollment status | ||||||
| Enrolled | 16/367 (4.4) | 17/39 (43.6) | 31/367 (8.4) | 19/39 (23.1) | 60/367 (16.3) | 15/39 (38.5) |
| Not Enrolled | 227/1379 (16.50) | 45/90 (50.0) | 253/1379 (8.3) | 32/90 (35.6) | 343/1379 (24.9) | 39/90 (43.3) |
| Referral indication | ||||||
| HDPd Only | 43/303 (14.2) | 37/75 (49.3) | 50/303 (16.5) | 21/75 (28.0) | 66/303 (21.8) | 26/75 (34.7) |
| GDMe Only | 180/1317 (13.7) | 16/40 (40.0.5) | 211/1317 (16.0) | 13/40 (32.5) | 304/1317 (23.0) | 20/40 (50.0) |
| HDPd and GDMe | 20/130 (15.4) | 9/14 (64.3) | 23/130 (17.7) | 7/14 (50.0) | 33/130 (25.4) | 8/14 (57.1) |
“Number in subgroup” (denominator) refers to number of participants in each demographic/clinical x-referral group. For example, n = 956 (column 2, row 4), represents the total number of nulliparous individuals not referred to the program. The numerator represents the number of individuals in the demographic/clinical x referral group with the outcome (e.g., attending primary care visit).
p < 0.05 for Chi-square tests comparing primary care visit attendance and cholesterol monitoring between those referred and not referred to the program within all subgroups.
p < 0.05 for Chi-square tests comparing glycated hemoglobin monitoring between those referred and not referred to the program within all subgroups except among self-identified non-Hispanic Black individuals (p = 0.058).
Hypertensive disorders of pregnancy.
Gestational diabetes.
HDP, hypertensive disorders of pregnancy; GDM, Gestational diabetes mellitus.
Discussion
This pilot postpartum referral pathway from obstetrics to primary care was associated with a six-times higher likelihood of attending a primary care visit and a two-times higher likelihood of completing laboratory-based CVH monitoring within the first 13 months postpartum in a socio-demographically diverse population with a recent history of GDM or HDP. Higher rates of PCP follow-up and CVH monitoring were observed in each racial and ethnic subgroup and among those who were enrolled in Medicaid during pregnancy. However, only 50% of the individuals referred attended a PCP visit, and 30% completed an HbA1c or cholesterol panel. Furthermore, differences by maternal demographic and clinical characteristics (e.g., race, ethnicity, Medicaid status) persisted, highlighting the need for additional systems-level and public health interventions to address remaining gaps in postpartum care among high-risk individuals.
Compared with previous programs, this strategy utilized existing health care resources to reduce barriers to scheduling postpartum primary care follow-up and thus did not incur additional cost or substantial burden to the health care system. Therefore, we propose that this program could reasonably be implemented across various health care settings with limited resources. However, additional strategies are necessary to fully promote primary care follow-up and CVH monitoring among patients with cardiometabolic complications of pregnancy. Although this pilot program was associated with substantially higher rates of follow-up with primary care, less than 50% of individuals attended a primary care visit in the first-year postpartum. Prior interventions that have had success in improving postpartum follow-up among individuals with cardiometabolic complications of pregnancy have utilized patient navigators and postpartum transition clinics.6,10,16 Although these interventions are more resource-intensive, they are associated with better follow-up compared with this program. Thus, evaluation and future implementation of multiple strategies in addition to enhanced referral pathways are necessary.
Special attention is additionally needed in areas with primary care shortages where results from our pilot program may not be generalizable. By 2034, the Association of American Medical Colleges projects national shortages of up to 48,000 primary care physicians.17 Furthermore, gaps in access to a primary care workforce have been widening between rural and urban areas.18 In areas with these shortages, further efforts are needed to promote postpartum preventive care, such as implementation of primary care telehealth, utilization of community health workers, and/or engagement of other clinicians who can also deliver preventive cardiovascular care. Wider implementation and dissemination of multi-level, resource-intensive strategies will require revision of existing public health policies and health care systems, as well as funding for postpartum health promotion programs.
Targeted efforts are also needed to reduce differences in postpartum care by maternal demographic and clinical characteristics. Although referral to the program was associated with higher primary care follow-up and laboratory-based CVH monitoring in each racial and ethnic subgroup, disparities persisted with approximately 40% of self-identified Hispanic and non-Hispanic Black individuals attending a PCP visit, compared with approximately 60% of non-Hispanic White and Asian/Pacific Islander individuals. Barriers to care that may amplify health care disparities in the postpartum period include poor access to care, difficulty navigating a fragmented health care system, challenges identifying reliable childcare and transportation, and the many sequelae of historical and structural racism.16,19 Telehealth visits and remote CVH monitoring have shown previous success in mitigating some barriers to access to care and reducing disparities in postpartum monitoring.20 Consistently providing patients a telehealth option could offer an opportunity to further reduce disparities in access to primary care; however, these strategies will also require reduction in barriers to digital health care.21 Future work must also assess other health services, behavioral, and clinical interventions to equitably improve long-term health outcomes such as incident hypertension, diabetes, or cardiovascular disease in individuals with APOs.
Strengths of this study include implementation of a low-cost intervention utilizing existing health care resources. In addition, study outcomes were objective, specific, and observable using EHR data. This study had several limitations. First, selection bias was present given the small referral group. To mitigate selection bias, maternal demographic and clinical characteristics were included in multivariable models. Given that data were not available on all social determinants of health (e.g., distance lived from the health care center), unmeasured confounding may exist. Second, this study did not formally assess program implementation processes. Third, additional staff were not available to encourage postpartum primary care follow-up beyond those already embedded in the health care system. Fourth, data from other health care institutions where patients may have sought postpartum primary care were not available. Fifth, our study may not be generalizable to areas with PCP shortages. Finally, this study only investigated laboratory-based CVH monitoring. Future studies are needed to determine the rates and quality of counseling on CVD-prevention strategies (e.g., diet, physical activity, postpartum weight loss) as part of comprehensive preventive care. Therefore, we may have underestimated the prevalence of primary care follow-up and CVH monitoring.
Conclusions
In conclusion, this proof-of-concept model with initial data from an enhanced postpartum referral program from obstetrics to primary care was associated with improvements in primary care visit attendance and laboratory-based CVH monitoring within the first 13 months postpartum among individuals with cardiometabolic complications of pregnancy. Despite observed improvements in program outcomes among those referred to the program, less than half of individuals attended a postpartum primary care visit, and differences by race and ethnicity persisted. Enhanced postpartum referral pathways may be an important first step; however, multicomponent interventions are needed to fully promote equitable and effective transitions of care during the postpartum period.
Authors’ Contributions
N.A.C.: Conceptualization, methodology, software, formal analysis, and writing—original draft; H.B.: Formal analysis; C.M.N., R.M., and E.D.: Conceptualization, investigation, and writing—review and editing; L.M.Y. and B.M.D.: Conceptualization, methodology, investigation, writing—review and editing, and supervision.
Author Conflicts of Interest
No competing financial interests exist.
Funding Information
No funding was received for this article.
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