Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston.
Harvard Medical School, Boston, Massachusetts.
JAMA Netw Open. 2024 Jul 1;7(7):e2422500. doi: 10.1001/jamanetworkopen.2024.22500.
More than 30% of pregnant people have at least 1 chronic medical condition, and nearly 20% develop gestational diabetes or pregnancy-related hypertension, increasing the risk of future chronic disease. While these individuals are often monitored closely during pregnancy, they face major barriers when transitioning to primary care following delivery, due in part to a lack of health care support for this transition.
To evaluate the impact of an intervention designed to improve postpartum primary care engagement by reducing patient administrative burden and information gaps.
DESIGN, SETTING, AND PARTICIPANTS: An individual-level randomized clinical trial was conducted from November 3, 2022, to October 11, 2023, at 1 hospital-based and 5 community-based outpatient obstetric clinics affiliated with a large academic medical center. Participants included English- and Spanish-speaking pregnant or recently postpartum adults with obesity, anxiety, depression, diabetes, chronic hypertension, gestational diabetes, or pregnancy-related hypertension and a primary care practitioner (PCP) listed in their electronic health record.
A behavioral economics-informed intervention bundle, including default scheduling of postpartum PCP appointments and tailored messages.
Completion of a PCP visit for routine or chronic condition care within 4 months of delivery was the primary outcome, ascertained directly by reviewing the patient's electronic health record approximately 5 months after their estimated due date. Intention-to-treat analysis was conducted.
A total of 360 patients were randomized (control, 176; intervention, 184). Individuals had a mean (SD) age of 34.1 (4.9) years and median gestational age of 36.3 (IQR, 34.0-38.6) weeks at enrollment. The distribution of self-reported race and ethnicity was 6.8% Asian, 7.4% Black, 68.6% White, and 15.0% multiple races or other. Most participants (75.4%) had anxiety or depression, 16.1% had a chronic or pregnancy-related hypertensive disorder, 19.5% had preexisting or gestational diabetes, and 40.8% had a prepregnancy body mass index of 30 or greater. Medicaid was the primary payer for 21.2% of patients. Primary care practitioner visit completion within 4 months occurred in 22.0% (95% CI, 6.4%-28.8%) of individuals in the control group and 40.0% (95% CI, 33.1%-47.4%) in the intervention group. In regression models accounting for randomization strata, the intervention increased PCP visit completion by 18.7 percentage points (95% CI, 9.1-28.2 percentage points). Intervention participants also had fewer postpartum readmissions (1.7% vs 5.8%) and increased receipt of the following services by a PCP: blood pressure screening (42.8% vs 28.3%), weight assessment (42.8% vs 27.7%), and depression screening (32.8% vs 16.8%).
The findings of this randomized clinical trial suggest that the current lack of support for postpartum transitions to primary care is a missed opportunity to improve recently pregnant individual's short- and long-term health. Reducing patient administrative burdens may represent relatively low-resource, high-impact approaches to improving postpartum health and well-being.
ClinicalTrials.gov Identifier: NCT05543265.
超过 30%的孕妇至少患有 1 种慢性疾病，近 20%的孕妇患有妊娠糖尿病或与妊娠相关的高血压，这增加了未来患慢性疾病的风险。虽然这些人在怀孕期间通常会得到密切监测，但在分娩后过渡到初级保健时，他们会面临重大障碍，部分原因是缺乏对这一过渡的医疗保健支持。
评估旨在通过减少患者行政负担和信息差距来改善产后初级保健参与度的干预措施的影响。
设计、地点和参与者：一项个体水平的随机临床试验于 2022 年 11 月 3 日至 2023 年 10 月 11 日在一家医院附属和五家社区门诊妇产科诊所进行，这些诊所隶属于一家大型学术医疗中心。参与者包括英语和西班牙语母语的肥胖、焦虑、抑郁、糖尿病、慢性高血压、妊娠糖尿病或与妊娠相关的高血压孕妇或产后不久的成年人，以及他们电子健康记录中列出的初级保健医生（PCP）。
包括默认安排产后 PCP 预约和定制信息的行为经济学干预包。
产后 4 个月内完成 PCP 就诊以进行常规或慢性疾病护理是主要结果，大约在预计预产期后 5 个月左右通过查看患者的电子健康记录来确定。采用意向治疗分析。
共有 360 名患者被随机分配（对照组，176 名；干预组，184 名）。参与者的平均（SD）年龄为 34.1（4.9）岁，中位妊娠年龄为 36.3（IQR，34.0-38.6）周。自我报告的种族和民族分布为 6.8%为亚洲人，7.4%为黑人，68.6%为白人，15.0%为多种族或其他。大多数参与者（75.4%）有焦虑或抑郁，16.1%有慢性或妊娠相关的高血压疾病，19.5%有孕前或妊娠糖尿病，40.8%有孕前体重指数为 30 或更高。21.2%的患者主要由医疗补助支付。对照组中有 22.0%（95%CI，6.4%-28.8%）的个体在产后 4 个月内完成了 PCP 就诊，干预组中有 40.0%（95%CI，33.1%-47.4%）的个体完成了就诊。在考虑随机分层的回归模型中，干预措施使 PCP 就诊完成率提高了 18.7 个百分点（95%CI，9.1-28.2 个百分点）。干预组的患者产后再入院率也较低（1.7% vs 5.8%），并增加了以下由 PCP 提供的服务：血压筛查（42.8% vs 28.3%）、体重评估（42.8% vs 27.7%）和抑郁筛查（32.8% vs 16.8%）。
这项随机临床试验的结果表明，目前缺乏对产后过渡到初级保健的支持，这是改善近期孕妇短期和长期健康的一个错失的机会。减少患者行政负担可能代表着改善产后健康和幸福感的相对低资源、高影响方法。
ClinicalTrials.gov 标识符：NCT05543265。
